Standardised ginseng extract G115® potentiates the antidepressant-like properties of fluoxetine in the forced swim test

OBJECTIVE

Ginsenosides, biologically active components of the root of Panax ginseng, have been reported to have therapeutic benefits in a number of disease states including psychiatric conditions such as major depressive disorder. Our objective was to determine if a standardised commercial ginseng extract, G115®, could reduce the signs of behavioural despair commonly observed in animal models of depression either alone or in combination with the selective serotonin reuptake inhibitor (SSRI) fluoxetine.

METHODS

Male Sprague-Dawley (SD) rats (N = 51) were divided into four groups: vehicle control, G115® ginseng root extract, fluoxetine and fluoxetine plus G115®. Rats were trained to voluntarily consume treatments twice daily for 14 days and were then tested in an open field (OF), elevated plus maze (EPM) and forced swim test (FST). Post-mortem hippocampal and prefrontal cortex tissue was analysed for expression of brain-derived neurotrophic factor (BDNF) and tropomyosin receptor kinase B (TrkB) by western blot.

RESULTS

One-way Analysis of Variance revealed no significant group differences in the OF or plus-maze performance on any variable examined. In the FST, fluoxetine significantly reduced immobility time and increased latency to immobility. The effects of fluoxetine were further significantly potentiated by co-administration of G115®. Post-mortem tissue analysis revealed significant group differences in BDNF expression in the left hippocampus and left prefrontal cortex without any accompanying changes in TrkB expression.

CONCLUSIONS

We conclude that oral G115® significantly potentiates the antidepressant-like effect of fluoxetine in the FST in the absence of potentially confounding effects on locomotion and anxiety.

The ginseng pimple: an inflammatory papule following ginseng consumption

Ginseng is a popular herbal remedy derived from the plant roots of the Panax genus and has been used in traditional Asian medicine for thousands of years. In the United States, it has become increasingly popular and is taken for many conditions, including as an immune enhancer. Cutaneous adverse effects have been reported to occur following ginseng consumption, although detailed clinical descriptions are limited. A 60-year-old woman who repeatedly developed inflammatory papules following ginseng consumption is described and the characteristics of ginseng use in healthcare are reviewed.

Subchronic oral toxicity study of Korean red ginseng extract in Sprague-Dawley rats with a 4-week recovery period

Ginseng is a major herbal remedy used in Asian countries for thousands of years and known to restore and enhance vital energy. Korean red ginseng, which is processed by steaming and drying fresh Panax ginseng, is most popular and contains unique ginsenosides, which have anticancer and anti-inflammatory properties. The present study was carried out to evaluate the repeated oral dose toxicity of Korean red ginseng extract. The test article was administered orally once a day to male and female Sprague-Dawley rats at dose levels of 0, 500, 1000, or 2000 mg/kg/day for 13 consecutive weeks (15 animals/sex/group in the vehicle control and 2000 mg/kg/day groups, and 10 animals/sex/group in the 500 and 1000 mg/kg/day groups). Ten animals per group were sacrificed at the end of the 13-week treatment period, and the remaining rats were sacrificed after a 4-week recovery period. Administration of Korean red ginseng extract did not result in any toxicologically significant changes in mortality, body weight, food consumption, ophthalmoscopy, hematology, serum biochemistry, gross pathological findings, absolute/relative organ weights, or histopathology. It was established that the no observed adverse effect level (NOAEL) of the test article was 2000 mg/kg/day for both sexes in this study.

Clinical judgement perplexed by initially undisclosed use of herbal medicine and unexpected cross-reactivity of immunoassay

We report a case of symptomatic bradycardia caused by consumption of a Chinese herbal medicine which was initially undisclosed to the attending emergency physician. The scientific name of the herb is Panax japonicus. Electrocardiogram revealed sinus bradycardia. Laboratory tests were normal except for the detection of a high serum digoxin level. Further interrogation of the patient eventually disclosed ingestion of the herb which, however, did not contain any digoxin. Other active ingredients in the herb include various types of ginsenoside. These are digoxin-like substances that had caused the observed false-positive detection of digoxin by fluorescence polarization immunoassay due to cross-reactivity. Our case-report provides an important insight about a blind-spot in the field of laboratory medicine (clinical pathology), namely, the false positive detection of digoxin due to crossreactivity in the immunoassay when we come across digoxin-like substances in clinical scenarios, which has barely received attention in the medical literature. It also conveys a clear educational message that with full understanding of the laboratory methodology and its mechanistic rationale there are actually some tricks-of-the-trade that allow us to optimize the specificity of the biochemical tests and the treatment of digoxin-like substances overdose.

Traditional uses, botany, phytochemistry, pharmacology and toxicology of Panax notoginseng (Burk.) F.H. Chen: A review

ETHNOPHARMACOLOGICAL RELEVANCE

Panax notoginseng (Burk.) F.H. Chen is a widely used traditional Chinese medicine known as Sanqi or Tianqi in China. This plant, which is distributed primarily in the southwest of China, has wide-ranging pharmacological effects and can be used to treat cardiovascular diseases, pain, inflammation and trauma as well as internal and external bleeding due to injury.

AIMS OF THE REVIEW

This paper provides up-to-date information on investigations of this plant, including its botany, ethnopharmacology, phytochemistry, pharmacology and toxicology. The possible uses and perspectives for future investigation of this plant are also discussed.

MATERIALS AND METHODS

The relevant information on Panax notoginseng (Burk.) F.H. Chen was collected from numerous resources, including classic books about Chinese herbal medicine, and scientific databases, including Pubmed, SciFinder, ACS, Ebsco, Elsevier, Taylor, Wiley and CNKI.

RESULTS

More than 200 chemical compounds have been isolated from Panax notoginseng (Burk.) F.H. Chen, including saponins, flavonoids and cyclopeptides. The plant has pharmacological effects on the cardiovascular system, immune system as well as anti-inflammatory, anti-atherosclerotic, haemostatic and anti-tumour activities, etc.

CONCLUSIONS

Panax notoginseng is a valuable traditional Chinese medical herb with multiple pharmacological effects. This review summarizes the botany, ethnopharmacology, phytochemistry, pharmacology and toxicology of P. notoginseng, and presents the constituents and their corresponding chemical structures found in P. notoginseng comprehensively for the first time. Future research into its phytochemistry of bio-active components should be performed by using bioactivity-guided isolation strategies. Further work on elucidation of the structure-function relationship among saponins, understanding of multi-target network pharmacology of P. notoginseng, as well as developing its new clinical usage and comprehensive utilize will enhance the therapeutic potentials of P. notoginseng.

Electrocardiographic and blood pressure effects of energy drinks and Panax ginseng in healthy volunteers: A randomized clinical trial

BACKGROUND

Energy drink usage has been linked to emergency room visits and deaths. The objective of the study is to assess the electrocardiographic and blood pressure effects of energy drinks, Panax ginseng and placebo in healthy individuals.

METHODS

This was a randomized, double blinded, placebo controlled, crossover study. Young healthy volunteers with no comorbid conditions consumed 32oz of an energy drink, control drink with 800mg of Panax ginseng or matching placebo-control drink over 45min. Primary endpoints were QTc interval and systolic blood pressure. Secondary endpoints included QT interval, PR interval, QRS duration, heart rate, and diastolic blood pressure. All endpoints were assessed at baseline, 1, 2, 3.5, and 5.5h.

RESULTS

A significant increase in QTc interval 2h post energy drink consumption was evident when compared to placebo (3.37±10.7ms and -3.19±11.8ms respectively; p=0.030). Similarly, systolic blood pressure 2h post energy drink consumption increased when compared to placebo (2.00±6.37mmHg and -2.67±5.83mmHg respectively; p=0.014). The PR interval significantly reduced over a 2h period post energy drink use in a clinically non-meaningful manner. Heart rate at 2h was not significantly higher in the energy drink group when compared to others. The QT interval, QRS interval and diastolic blood pressure were not impacted at any time point.

CONCLUSIONS

Certain energy drinks consumed at a high volume significantly increase the QTc interval and systolic blood pressure by over 6ms and 4mmHg respectively. Panax ginseng does not have a significant impact on ECG or blood pressure parameters.

Ginseng for cognition

BACKGROUND

Ginseng is a herbal medicine in widespread use throughout the world. Its effect on the brain and nervous system has been investigated. It has been suggested, on the basis of both laboratory and clinical studies, that it may have beneficial effects on cognitive performance.

OBJECTIVES

To evaluate the efficacy and adverse effects of ginseng given to improve cognitive performance in healthy participants, participants with cognitive impairment or dementia.To highlight the quality and quantity of research evidence available.

SEARCH STRATEGY

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources were searched on 24 February 2009 using the following terms: ginseng* OR panax OR ginsan OR "Jen Shen"OR shinseng OR Renshen OR schinseng OR ninjin OR gingilone OR panaxoside* OR ginsenoside* OR protopanaxa* OR protopanaxadiol OR protopanaxatriol OR panaxagin OR ginsenol OR ginsenine and terms for dementia and cognition. The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many clinical trials registries and grey literature sources.

SELECTION CRITERIA

All double-blind and single-blind randomized, placebo controlled trials assessing the effects of ginseng on cognitive function were eligible for inclusion. Interventions were considered to be ginseng if they were compounds containing ginseng or active agents of the Panax genus as the major component.

DATA COLLECTION AND ANALYSIS

Characteristics of each included trial were extracted independently by two reviewers using a self-developed data extraction form and entered into RevMan 5.0 software. Authors of identified trials were contacted for additional information and unpublished data. The effects of ginseng in healthy participants, participants with cognitive impairment or dementia were addressed independently.

MAIN RESULTS

Nine randomized, double-blind, placebo controlled trials meeting the inclusion criteria were identified. Eight trials enrolled healthy participants, and one was of subjects with age-associated memory impairment (AAMI).Only five of the identified trials had extractable information and were included in the analysis. Four studies investigated the effects of ginseng extract and one assessed the efficacy of ginseng compound HT008-1. All of these trials investigated the effects of ginseng on healthy participants. Pooling the data was impossible owing to heterogeneity in outcome measures, trial duration, and ginseng dosage. Results of the analysis suggested improvement of some aspects of cognitive function, behavior and quality of life. No serious adverse events associated with ginseng were found.

AUTHORS' CONCLUSIONS

Currently, there is a lack of convincing evidence to show a cognitive enhancing effect of Panax ginseng in healthy participants and no high quality evidence about its efficacy in patients with dementia. Randomized, double-blind, placebo-controlled, parallel group trials with large sample sizes are needed to further investigate the effect of ginseng on cognition in different populations, including dementia patients.

Four common herbs seen in dental practice: properties and potential adverse effects

The use of herbal supplements in North America is steadily growing and raises concerns about safety, efficacy, and how they affect safe patient care. The most notable and direct health risks associated with herbal supplements include hypertension, prolonged bleeding, and the potential for drug-herb interactions, which is of particular concern for patients undergoing anesthesia, both general and local anesthesia. In this article, four of the most commonly used herbs today in North America will be discussed: garlic, gingko, ginseng, and ginger. The pharmacology, benefits, and possible side effects of these herbs will be presented. Awareness of the rising use of herbs is important to prevent, recognize, and treat potential problems that can arise from herbal preparations taken alone or in conjunction with prescription medications.

Korean ginseng-induced occupational asthma and determination of IgE binding components

A number of case reports on occupational asthma caused by herbal medicines have been issued, for example, on Sanyak, Chunkung, Banha, and Brazilian ginseng. Recently, cases of occupational asthma induced by Sanyak and Korean ginseng have been reported, but the pathogenic mechanisms involved are unknown. This study was carried out to evaluate the immunologic mechanism underlying Korean ginseng-induced occupational asthma. A patient engaged in Korean ginseng wholesale was referred for recurrent dyspnea, wheezing, and nasal symptoms, which were aggravated at work. Allergen bronchial provocation testing to Korean ginseng extract showed a typical immediate response, and skin prick testing to Korean ginseng extract also showed a strong positive response. Moreover, serum-specific IgE levels to Korean ginseng extract were significantly higher than in controls. Enzyme-linked immunosorbent assay (ELISA) inhibition tests showed a dose-dependent inhibition by Korean ginseng, but not by Dermatophagoides farinae, wheat flour, or Chinese balloon flower. Sodium dodecylsulfate-poly-acrylamide gel electrophoresis (SDS-PAGE) and immunoblotting revealed four specific Immunoglobulin E (IgE) binding components at 26, 30, 47, and 60 kDa, which were not bound by control sera. These results strongly suggest that occupation asthma induced by Korean ginseng is induced via an IgE-mediated mechanism.

An examination of the bleeding complications associated with herbal supplements, antiplatelet and anticoagulant medications

Dental professionals routinely treat patients taking prescription, nonprescription, and herbal medications that are known or have the potential to alter bleeding. Prescription anticoagulant and antiplatelet medications, as well as over-the-counter drugs such as aspirin, are typically taken to reduce the risk of thromboembolic events, including stroke. Herbal supplements are widely used for a variety of indications, and both patients and health care practitioners are often unaware of the anticoagulant and antiplatelet effects that occur as either predictable pharmacologic effects or adverse side effects of herbal medicines. In addition, patient use of these herbal supplements is usually undisclosed to health care providers. The purpose of this literature review is to examine the mechanisms of action of drugs and herbs that alter bleeding, and to educate dental professionals as to the proper care and management of patients using these medications. Decision-making strategies, including interpretation of laboratory tests, and when to discontinue the use of these medications are discussed. Patients undergoing routine dental and dental hygiene procedures do not need to discontinue the use of anticoagulant and antiplatelet medications. However, alterations in drug use may be required for those patients undergoing invasive surgical procedures. It is recommended that herbal supplements must be discontinued 2 weeks prior to receiving invasive surgical procedures. Dental practitioners must learn to weigh the risks of discontinuing drug therapy against the potential risks to patients, and implement risk reduction strategies to minimize adverse bleeding complications associated with dental treatment.

Panax ginseng induces human Type I collagen synthesis through activation of Smad signaling

Skin aging appears to be principally related to a decrease in levels of Type I collagen, the primary component of the dermal layer of skin. It is important to introduce an efficient agent for effective management of skin aging; this agent should have the fewest possible side effects and the greatest wrinkle-reducing effect. In the course of screening collagen production-promoting agents, we obtained Panax ginseng C.A. Meyer. This study was designed to investigate the possible collagen production-promoting activities of Panax ginseng C.A. Meyer root extract (PGRE) in human dermal fibroblast cells. As a first step to this end, human COL1A2 promoter luciferase assay was performed in human dermal fibroblast cells. In this assay, PGRE activated human COL1A2 promoter activity in a concentration-dependent manner. Human Type I procollagen synthesis was also induced by PGRE. These results suggest that PGRE promotes collagen production in human dermal fibroblast cells. Additionally, we have attempted to characterize the mechanism of action of PGRE in Type I procollagen synthesis. PGRE was found to induce the phosphorylation of Smad2, an important transcription factor in the production of Type I procollagen. When applied topically in a human skin primary irritation test, PGRE did not induce any adverse reactions. Therefore, based on these results, we suggest the possibility that PGRE may be considered as an attractive, wrinkle-reducing candidate for topical application.

Herbal medicines used during the first trimester and major congenital malformations: an analysis of data from a pregnancy cohort study

BACKGROUND

Major congenital malformations place a considerable burden on the affected child, the family and society. Any kind of medicine used during pregnancy might have a harmful impact; therefore, such practice has raised concerns. The objective of the current study was to explore the relationship between the use of herbal medicines by pregnant women during the first trimester of pregnancy and the risk of major congenital malformation in their live born infants.

METHODS

This was a cross-sectional analysis of data from a prospective pregnancy cohort, which was established between 1984 and 1987. To assemble the cohort, pregnant women of >or=26 weeks of gestation who came to the Taipei Municipal Maternal and Child Hospital in Taiwan for prenatal care were enrolled in the study and interviewed using a structured questionnaire. Detailed information, including herbal medicine use during different periods of pregnancy, was obtained during the interview. Past medical history, current obstetric data and details on conventional medicines used during pregnancy were abstracted from medical records. Data on birth weight, gestational duration and characteristics of live born infants were gathered from the Taiwan national birth register. Congenital malformation information was obtained from multiple sources: the newborn examination record (1984-7); the national death register (1984-2003); and Taiwan National Health Insurance data (1996-2000). Multiple logistic regression was used to estimate the odds ratio [OR] of major congenital malformation by herbal medicines used during the first trimester.

RESULTS

A total of 14,551 live births were analysed. After adjustment for confounding factors, taking huanglian during the first trimester of pregnancy was found to be associated with increased risk of congenital malformations of the nervous system (adjusted OR 8.62, 95% CI 2.54, 29.24). An-Tai-Yin was associated with an increased risk of congenital malformations of the musculoskeletal and connective tissues (adjusted OR 1.61, 95% CI 1.10, 2.36) and the eye (adjusted OR 7.30, 95% CI 1.47, 36.18).

CONCLUSION

We found evidence for a possible link between the use of specific herbal medicines during the first trimester of pregnancy and increased risks of specific groups of congenital malformations. We could not investigate whether the adverse effects were related to direct toxicity from the herbal medicines, or were from misuse, contamination or uncontrolled confounding. Nonetheless, we would advise caution regarding use of herbal medicines during pregnancy, and we suggest that further investigation of these findings is warranted.

Potential drug–herb interaction with antiplatelet/anticoagulant drugs

This is a cross-sectional survey evaluating the use of herbal medicines in medical wards patients that may interfere with the effect of antiplatelet or anticoagulant therapy. Among the 250 patients participated, 42.4% (n=106) were taking herbs with 76 patients (71.7%) using herbs for the past 12 months. Overall, almost 31% (n=23, N=76) of patients were taking one or more of the specified herbal medicines [ginseng (Panax ginseng), garlic (Allium sativum), ginkgo (Gingko biloba) thought to interact with antiplatelet or anticoagulant therapy. The study showed that 21% (n=16, N=76) of patients co-ingested specified herbs with antiplatelet or anticoagulant therapy, of which half of them were at risk of potential drug-herb interactions. A large proportion of respondents involved in potential drug-herb interaction were elderly people (62.5%, n=5). However, more than 90% of herbal users did not disclose the use of herbal medicine to their health professionals. It is thus prudent for all care givers to be aware of the possibility of drug-herb interaction and inquire about herbal use from patients.

Ginseng

In athletics today, there is no shortage of participants looking for an extra edge in competition. In addition, there is no shortage of nutritional supplements for athletes to use with hopes of reaping ergogenic benefits. Ginseng is and will continue to be one of these supplements consumed by athletes despite little or no scientific data to support its ergogenicity. Multiple different types of ginseng can be consumed; the most studied and most common types are Siberian, Chinese, and American. Although related, each has different active compounds, and likely, different effects on the body. There do not appear to be significant adverse effects when used for short periods, but further studies are needed to confirm this. Similarly, more studies are needed to address the ergogenic potential of ginseng. At this time, ginsengs cannot be recommended to improve athletic performance, but there may be some utility for athletes by preventing viral upper respiratory infection and improving cognition. This review evaluates recently published literature on ginseng use in athletes.

Herbal Supplements: Facts and Myths—Talking to Your Patients About Herbal Supplements

The use of herbal supplements in the United States is steadily growing and raises concerns about safety, efficacy, and how they affect safe patient care. The direct health risks associated with herbal supplements include hypertension, prolonged bleeding, and the potential for drug-herb interactions. These potential drug interactions are of particular concern for patients undergoing anesthesia. This article provides a review of literature on the 10 most popular herbal supplements and addresses the herbal supplements' reported use, possible adverse effect(s), patient teaching, possible drug interaction(s), and recommendations regarding discontinuation before surgery.

Herbs and dietary supplement use in patients with stage 5 chronic kidney disease

Herbal products and dietary supplements are complementary and alternative medicine (CAM) therapies that have grown faster than any other CAM treatments. Little information is available about the use of these products in the stage 5 chronic kidney disease (CKD) population. Information on the use, safety, efficacy, adverse effects, and recommended dosages in the nondialysis population are summarized in this article.

Complimentary and alternative medicine use among patients starting warfarin

The use of complimentary and alternative medicines (CAM) among the UK population is on the increase. For patients requiring warfarin therapy, it is important to maintain an adequate and safe level of anticoagulation. As some forms of CAM can interact with warfarin, it is imperative that any patient considered for warfarin, is asked about their use of CAM. Our report describes the incidence and type of CAM usage among patients about to start or recently commenced on warfarin therapy attending our outpatient anticoagulant clinic. All patients attending clinic for the first time were seen by a pharmacist. A retrospective analysis of the pharmaceutical care plans for all patients seen during 2003 were analysed regarding the degree of CAM usage. Of 631 care plans reviewed, 170 (26.9%) patients were taking some form of CAM. Ninety-nine (58% of all CAM users) were taking a CAM that could interact with warfarin; the commonest forms were cod-liver oil capsules and garlic capsules. We conclude that many patients new to warfarin therapy were significant users of CAM, many of which had the potential to interact with warfarin. By taking a full drug history, potential CAM/warfarin interactions could be avoided.

North American ginseng exerts a neutral effect on blood pressure in individuals with hypertension

An early observational study suggested that ginseng could elevate blood pressure. This caused concern because 4.5% of American adults use ginseng, with a popular choice being North American ginseng. To date, North American ginseng lacks hemodynamic evaluation; therefore, we conducted a randomized, double-blinded, controlled trial to investigate its effect on blood pressure in 16 hypertensive individuals (mean+/-SD age 61.1+/-8.1 years; systolic/diastolic blood pressure 132.4+/-12.8/83.3+/-8.1 mm Hg; 13 on antihypertensives). We used 6 batches of North American ginseng root that varied in quality and ginsenoside content, representing the spectrum of this ginseng on the market. On 8 mornings, each participant was fitted with an ambulatory blood pressure monitor, which measured blood pressure during a 30-minute baseline period. Each participant then consumed in a randomized and double-blind fashion 3 g of encapsulated treatment: placebo (on 2 mornings) or powdered North American ginseng (on 6 mornings). After treatment, blood pressure was measured every 10 minutes for 160 minutes, and its change at each post-treatment time point relative to baseline was determined per individual and averaged, and the mean was obtained for the overall 160-minute period. None of the North American ginsengs or their mean differed from placebo in their effect on overall (160 minutes) mean blood pressure change. None affected blood pressure versus placebo at the 10-minute intervals; but their mean versus placebo increased systolic and diastolic blood pressure at 140 and 160 minutes, respectively, and lowered diastolic blood pressure at 100 minutes. The findings together suggested that North American ginseng exerts a neutral acute effect on blood pressure in hypertensive individuals.

Menometrorrhagia and tachyarrhythmia after using oral and topical ginseng

Widespread and uncontrolled use of ginseng has raised the question of its side effects and drug interactions. A 39-year-old female patient experienced menometrorrhagia. Her complaints had started 5 months earlier. The laboratory tests revealed follicle-stimulating hormone (FSH) and estradiol levels to be 10 mIU and 90 mIU, respectively. Endometrial biopsy was planned for the diagnosis of abnormal uterine bleeding. During the preoperative evaluation, the patient stated that she had been using both oral and topical ginseng for cosmetic reasons. The ECG revealed sinus tachycardia with occasional atrial premature beats. The procedure was postponed for 2 weeks so that the patient would stop taking ginseng, smoking, and drinking coffee. Arrhythmia stopped 10 days later. Tachycardia continued during the procedure but did not require treatment, as it did not cause any hemodynamic instability. An endometrial biopsy specimen showed a disordered proliferative pattern. The patient was advised to stop using oral and topical ginseng. During a follow-up visit, she had no sign of menometrorrhagia or tachyarrhythmia and her hemoglobin levels were in the normal range. Smoking and coffee consumption, along with ginseng use, can be responsible for arrhythmogenic effects. Abnormal uterine bleeding can cause tachycardia secondary to anemia. The clinical progress of this patient is consistent with our hypothesis that ginseng is responsible for menometrorrhagia, although this could be coincidental. Patients should always be asked prior to surgery if they use herbal medications, food supplements, or cosmetics as well as prescription drugs. This is of great importance for both diagnosis and avoidance of drug interactions and side effects during anesthesia.

Cancer prevention and therapeutics: Panax ginseng

Panax ginseng has been used as a medicinal plant in China for thousands of years. Current use in Western countries has been diverse, with focused research on cancer therapeutics. P. ginseng apparently mitigates cancer through anti-inflammatory, antioxidant, and apoptotic mechanisms to influence gene expression. Additional mechanisms of investigation include influence on neurotransmission and immunosurveillance. Low toxicity and positive studies in concomitant use with other chemotherapeutic agents is promising. Although there is no conclusive evidence of P. ginseng curing cancer, research has continually found tumor inhibition, especially in the promotion and progression phases.

Brief communication: American ginseng reduces warfarin's effect in healthy patients: a randomized, controlled Trial

BACKGROUND

People using prescription medication often concurrently take herbal supplements. In a case report, the anticoagulant effect of warfarin decreased after patients consumed ginseng.

OBJECTIVE

To evaluate the interactions between American ginseng and warfarin.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

General Clinical Research Center, University of Chicago, Chicago, Illinois.

PARTICIPANTS

20 healthy patients.

INTERVENTION

In this 4-week study, 20 patients received warfarin for 3 days during weeks 1 and 4. Beginning in week 2, patients were assigned to receive either American ginseng or placebo.

MEASUREMENTS

International normalized ratio (INR) and plasma warfarin level.

RESULTS

The peak INR statistically significantly decreased after 2 weeks of ginseng administration compared with placebo (difference between ginseng and placebo, -0.19 [95% CI, -0.36 to -0.07]; P = 0.0012). The INR area under the curve (AUC), peak plasma warfarin level, and warfarin AUC were also statistically significantly reduced in the ginseng group as compared with the placebo group. Peak INR and peak plasma warfarin level were positively correlated.

LIMITATIONS

The study sample consisted of young, healthy volunteers in a research setting rather than patients taking therapeutic doses of warfarin.

CONCLUSIONS

American ginseng reduces warfarin's anticoagulant effect. When prescribing warfarin, physicians should ask patients about ginseng use.

[Potential risks, adverse effects and drug interactions associated with herbal medicine in dental patients]

Herbal medicine is an increasingly common form of alternative therapy in the United States. Most herbal products are considered dietary supplements and thus are not regulated as medicines. They are marketed without prior approval of their efficacy and safety by the Food and Drug Administration (FDA). Some herbal medications have potentially harmful side effects as well as adverse interactions with conventional drugs. The adverse reactions involve all systems, age groups and severity. It is important for dentists and other health care providers to obtain adequate information as to what herbal medications their patients are taking. It is also necessary for professionals to acquire knowledge regarding herbal medications as to their use and to educate their patients about the risk-benefit and potential interactions these medications may have with over-the-counter and prescription drugs. The purpose of this article was to review the literature on the potential risks of commonly used herbal medications: Ginkgo Biloba, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, Garlic, Kava and Ephedra.

Drug-herb interaction among commonly used conventional medicines: a compendium for health care professionals

The objective of the review was to consolidate the clinical and pharmacologic aspects of drug-herb interactions to develop a compendium of information to provide prescribers with a measure of the risk of interactions, a description of the clinical consequences, and an assessment of the quality (ie, validity) of evidence. A variety of electronic databases and hand-searched references were used to identify documentation of interactions between herbal products and drugs from the most commonly used therapeutic classes. MEDLINE, Allied and Complementary Medicine Database, CINHAL, HealthSTAR, and EMBASE were searched from 1966 to the present. One hundred sixty-two citations were identified. Only 22 citations met the inclusion criteria. Using a matrix of 165 possible drug-herb interaction pairs (15 therapeutic drug classes by 11 herbal products), we identified 51 (31%) interactions discussed in the literature. Twenty-two of these 51 drug-herb pairs (43%) were supported by randomized clinical trials, case-control studies, cohort studies, case series, or case studies. The remaining interaction pairs reflected theoretic reasoning in the absence of clinical data. Most interactions were pharmacokinetic, with most actually or theoretically affecting the metabolism of the affected product by way of the cytochrome p450 enzymes. In this review, warfarin was the most common drug and St. John's wort was the most common herbal product reported in drug-herb interactions. To create a comprehensive and valid list of herb-drug interactions would require a substantial increase in research activities in this area. Improvements in the quality of methodology used are also necessary.

[Herbal preparations have both effects and side effects. Widespread usage dictates knowledge among physicians]

The article gives a clinically oriented overview of the efficacy and safety of Ginkgo biloba, St. John's wort, ginseng, Echinacea, saw palmetto and kava based on American experiences. Clinical data support the efficacy for some of these drugs. None of them is free of adverse effects. Generally speaking, trials of herbal medicinal products have been too few, too small and too short. The lack of long-term studies is especially unfortunate since many of the drugs are used for a long time. The difference between American and Swedish legislation on herbal medicine products is described.

[Herbal medicines--evidence and drug interactions in clinical practice]

We present an evidence-based literature review of five commonly used herbs in Denmark: St John's wort, ginkgo biloba, valerian, garlic, and ginseng. Various drug interactions are associated with the intake of some herbal medicines, and may result in many clinical conditions. We bring this to the attention of clinical practitioners. Attention to clinical practice and recommendations for discontinuation of the five herbs are given before surgery. Physicians should be aware of and report potential drug interactions and adverse effects, so as to throw more light on this subject.

The peri-operative implications of herbal medicines

An increasing number of patients are taking herbal medicines such as echinacea, garlic, ginkgo biloba, ginseng, St John's Wort, valerian, ephedra, kava, grapefruit juice and ginger. Although these herbal medications are considered 'natural' products that may have some benefits, adverse effects such as increased bleeding tendencies and drug interactions are associated with their use. Surgeons and anaesthetists may be unaware of their patients' use of these medications because it is common for patients not to disclose their use of this form of medication, and both surgeons and anaesthetists often fail to enquire about their use. Anaesthetists and surgeons must be familiar with the effects of herbal medicines and should specifically enquire about the use of herbal medicines during pre-operative assessment. Currently available data suggest that all herbal medicines should be ceased 2 weeks before surgery.

Panax ginseng: a systematic review of adverse effects and drug interactions

Panax ginseng C. A. Meyer is a perennial herb native to Korea and China and has been used as an herbal remedy in eastern Asia for thousands of years. Modern therapeutic claims refer to vitality, immune function, cancer, cardiovascular diseases, improvement of cognitive and physical performance and sexual function. A recent systematic review of randomised controlled trials found that the efficacy of ginseng root extract could not be established beyond doubt for any of these indications. In order to obtain a balanced assessment of the therapeutic value of P. ginseng it is also necessary to consider the safety profile. In view of the extremely widespread use of P. ginseng it seems important to ask whether this herbal medicine involves health risks for the consumer. This review was conducted as a systematic attempt to document and evaluate all the available safety data on P. ginseng root extracts. Systematic searches were performed in five electronic databases and the reference lists of all papers located were checked for further relevant publications. All articles containing original data on adverse events and drug interactions with P. ginseng were included. Information was also requested from 12 manufacturers of ginseng preparations, the spontaneous reporting schemes of the WHO and national drug safety bodies. No language restrictions were imposed. Data from clinical trials suggest that the incidence of adverse events with ginseng monopreparations is similar to that with placebo. The most commonly experienced adverse events are headache, sleep and gastrointestinal disorders. The possibility of more serious adverse events is indicated in isolated case reports and data from spontaneous reporting schemes; however, causality is often difficult to determine from the evidence provided. Combination products containing ginseng as one of several constituents have been associated with serious adverse events and even fatalities. Interpretation of these cases is difficult as ingredients other than P. ginseng may have caused the problems. Possible drug interactions have been reported between P. ginseng and warfarin, phenelzine and alcohol. Collectively, these data suggest that P. ginseng monopreparations are rarely associated with adverse events or drug interactions. The ones that are documented are usually mild and transient. Combined preparations are more often associated with such events but causal attribution is usually not possible.

Complementary herbal and alternative drugs in clinical practice

TOPIC

Complementary and alternative medicine agents (CAMs).

PURPOSE

To summarize the current empirical data about the major CAMs purporting to have psychotherapeutic value.

SOURCES OF INFORMATION

Extant literature.

CONCLUSIONS

Available evidence indicates that CAMs, while generally safe, are not risk free. While CAM use grows, nurses and other health professionals have a limited knowledge base about the action, side effects, and interactions of common CAM agents. Nurses need to increase their knowledge base about CAMs in order to help patients in decision making regarding the use of these agents to treat common psychiatric symptoms.

Effects of Panax ginseng on quality of life

OBJECTIVE

To assess the time-dependent effects of Panax ginseng on health-related quality of life (HRQOL) by use of a general health status questionnaire.

METHODS

Subjects were randomized in a double-blind manner to P. ginseng 200 mg/d (n = 15) or placebo (n = 15) for 8 weeks. The Short Form-36 Health Survey version 2 (SF-36v2), a validated general health status questionnaire, was used to assess HRQOL at baseline and at 4 and 8 weeks. HRQOL between the groups was compared by use of repeated-measures analysis of covariance. A p value <0.05 was considered statistically significant.

RESULTS

There were no significant differences in baseline demographics and SF-36v2 scores between the groups. After 4 weeks of therapy, higher scores in social functioning (P. ginseng 54.9+/-4.6 vs. placebo 49.2+/-6.5; p = 0.014), mental health (P. ginseng 52.2+/-7.7 vs. placebo 47.2+/-7.3; p = 0.075), and the mental component summary (P. ginseng 51.3+/-7.4 vs. placebo 44.3+/-8.3; p = 0.019) scales were observed in patients randomized to P. ginseng; these differences did not persist to the 8-week time point. The incidence of adverse effects was 33% in the P. ginseng group compared with 17% in the placebo group (p = 0.40). Subjects given P. ginseng (58%) were more likely to state that they received active therapy than subjects given placebo (17%; p < 0.05).

CONCLUSIONS

P. ginseng improves aspects of mental health and social functioning after 4 weeks of therapy, although these differences attenuate with continued use.

Interactions between herbal medicines and prescribed drugs: a systematic review

Despite the widespread use of herbal medicines, documented herb-drug interactions are sparse. We have reviewed the literature to determine the possible interactions between the seven top-selling herbal medicines (ginkgo, St John's wort, ginseng, garlic, echinacea, saw palmetto and kava) and prescribed drugs. Literature searches were performed using the following databases: Medline (via Pubmed), Cochrane Library, Embase and phytobase (all from their inception to July 2000). All data relating to herb-drug interactions were included regardless of whether they were based on case reports, case series, clinical trials or other types of investigation in humans. In vitro experiments were excluded. Data were extracted by the first author and validated by the second author. 41 case reports or case series and 17 clinical trials were identified. The results indicate that St John's wort (Hypericum perforatum) lowers blood concentrations of cyclosporin, amitriptyline, digoxin, indinavir, warfarin, phenprocoumon and theophylline; furthermore it causes intermenstrual bleeding, delirium or mild serotonin syndrome, respectively, when used concomitantly with oral contraceptives (ethinylestradiol/desogestrel), loperamide or selective serotonin-reuptake inhibitors (sertaline, paroxetine, nefazodone). Ginkgo (Ginkgo biloba) interactions include bleeding when combined with warfarin, raised blood pressure when combined with a thiazide diuretic and coma when combined with trazodone. Ginseng (Panax ginseng) lowers blood concentrations of alcohol and warfarin, and induces mania if used concomitantly with phenelzine. Garlic (Allium sativum) changes pharmacokinetic variables of paracetamol, decreases blood concentrations of warfarin and produces hypoglycaemia when taken with chlorpropamide. Kava (Piper methysticum) increases 'off' periods in Parkinson patients taking levodopa and can cause a semicomatose state when given concomitantly with alprazolam. No interactions were found for echinacea (Echinacea angustifolia, E. purpurea, E. pallida) and saw palmetto (Serenoa repens). In conclusion, interactions between herbal medicines and synthetic drugs exist and can have serious clinical consequences. Healthcare professionals should ask their patients about the use of herbal products and consider the possibility of herb-drug interactions.

The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava

Because use of herbal remedies is increasing, a risk-benefit profile of commonly used herbs is needed. This article provides a clinically oriented overview of the efficacy and safety of ginkgo, St. John's wort, ginseng, echinacea, saw palmetto, and kava. Wherever possible, assessments are based on systematic reviews of randomized clinical trials. Encouraging data support the efficacy of some of these popular herbal medicinal products, and the potential for doing good seems greater than that for doing harm. The published evidence suggests that ginkgo is of questionable use for memory loss and tinnitus but has some effect on dementia and intermittent claudication. St. John's wort is efficacious for mild to moderate depression, but serious concerns exist about its interactions with several conventional drugs. Well-conducted clinical trials do not support the efficacy of ginseng to treat any condition. Echinacea may be helpful in the treatment or prevention of upper respiratory tract infections, but trial data are not fully convincing. Saw palmetto has been shown in short-term trials to be efficacious in reducing the symptoms of benign prostatic hyperplasia. Kava is an efficacious short-term treatment for anxiety. None of these herbal medicines is free of adverse effects. Because the evidence is incomplete, risk-benefit assessments are not completely reliable, and much knowledge is still lacking.

Herbal products and serious side effects: a case of ginseng-induced manic episode

OBJECTIVE

Ginseng root extract is a widely used herbal product not devoid of side effects. This report describes the development of manic symptoms after ginseng consumption in a patient with affective disorder. Other potentially harmful side effects of ginseng are also reviewed.

METHOD

A single case report.

RESULTS

A 56-year-old woman with previous affective disorder presented a manic episode during ginseng intake. Symptoms disappeared rapidly with low doses of neuroleptics and benzodiazepines after ginseng suppression.

CONCLUSION

Ginseng may produce manic symptoms. A special risk situation seems to be affective patients under antidepressant medication. The case emphasizes the lack of harmlessness of herbal products. Patients should be routinely asked about the use of herbal products and diet supplements.

[The safety of herbal medicines in the psychiatric practice]

The use of alternative medicines is increasing world-wide and in Israel. These drugs, considered by the Ministry of Health as food supplements, are to be obtained at pharmacies and health stores and are being sold freely, without any professional advice. Many of the herbs are used by patients to treat psychiatric disorders. These herbs have a pharmacological activity, adverse effects and interactions with conventional drugs, which can produce changes in mood, cognition, and behavior. We present the most commonly used herbal drugs, and discuss their safety and efficacy in psychiatric practice. Hypericum--used as an antidepressant and as an antiviral medicine, was reported in 23 randomized clinical trials reviewed from the MEDLINE. It was found to be significantly more effective than placebo and had a similar level of effectiveness as standard antidepressants. Recent studies almost clearly prove that this herb, like most of the conventional antidepressants, can induce mania. Valerian--is used as an anti-anxiety drug, and reported to have sedative as well as antidepressant properties. In contrast to the significant improvement in sleep that was found with the use of valerian, compared to placebo, there are several reports on the valerian root toxicity. This includes nephrotoxicity, headaches, chest tightness, mydriasis, abdominal pain, and tremor of the hands and feet. Ginseng--another plant that is widely used as an aphrodisiac and a stimulant. It has been associated with the occurrence of vaginal bleeding, mastalgia, mental status changes and Stevens-Johnson syndrome after it's chronic administration. It has interactions with digoxin, phenelzine and warfarin. Ginkgo--in clinical trials the ginkgo extract has shown a significant improvement in symptoms such as memory loss, difficulties in concentration, fatigue, anxiety, and depressed mood. Long-term use has been associated with increased bleeding time and spontaneous hemorrhage. Ginkgo should be used cautiously in patients receiving aspirin, NSAIDs, anticoagulants or other platelet inhibitors. Health care professionals can no longer ignore the widespread use of alternative medicines and cannot continue with the "don't ask, don't tell" policy. Clinicians should ask the patients about their use of herbs in a non-judgmental way, and should document the patient's use of these drugs. Finally, we must be more aware of the side effects and the potential drug interactions of these herbs, and advise our patients to avoid long term use of these drugs due to lack of information regarding the safety of these medicines.

Herbal medicines and perioperative care

CONTEXT

Widespread use of herbal medications among the presurgical population may have a negative impact on perioperative patient care.

OBJECTIVES

To review the literature on commonly used herbal medications in the context of the perioperative period and provide rational strategies for managing their preoperative use.

DATA SOURCES

The MEDLINE and Cochrane Collaboration databases were searched for articles published between January 1966 and December 2000 using the search terms herbal medicine, phytotherapy, and alternative medicine and the names of the 16 most commonly used herbal medications. Additional data sources were obtained from manual searches of recent journal articles and textbooks.

STUDY SELECTION

We selected studies, case reports, and reviews addressing the safety and pharmacology of 8 commonly used herbal medications for which safety information pertinent to the perioperative period was available.

DATA EXTRACTION

We extracted safety, pharmacodynamic, and pharmacokinetic information from the selected literature and reached consensus about any discrepancies.

DATA SYNTHESIS

Echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian are commonly used herbal medications that may pose a concern during the perioperative period. Complications can arise from these herbs' direct and pharmacodynamic or pharmacokinetic effects. Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effect of anesthetics by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St John's wort.

CONCLUSIONS

During the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation.