Cardiovascular pharmacotherapy and herbal medicines: the risk of drug interaction

Phytotherapeutic approach for conquering menopausal syndrome and osteoporosis

Women face a significant change in their reproductive health as menopause sets in. It is marred with numerous physiological changes that negatively impact their quality of life. This universal, transition phase is associated with menopausal and postmenopausal syndrome, which may spread over 2-10 years. This creates a depletion of female hormones causing physical, mental, sexual and social problems and may, later on, manifest as postmenopausal osteoporosis leading to weak bones, causing fractures and ultimately morbidity and mortality. Menopausal hormone therapy generally encompasses the correction of hormone balance through various pharmacological agents, but the associated side effects often lead to cessation of therapy with poor clinical outcomes. However, it has been noticed that phytotherapeutics is trusted by women for the amelioration of symptoms related to menopause and for improving bone health. This could primarily be due to their reduced side effects and lesser costs. This review attempts to bring forth the suitability of phytotherapeutics/herbals for the management of menopausal, postmenopausal syndrome, and menopausal osteoporosis through several published research. It tries to enlist the available botanicals with their key constituents and mechanism of action for mitigating symptoms associated with menopause as well as osteoporosis. It also includes a list of a few herbal commercial products available for these complications. The article also intends to collate the findings of various clinical trials and patents available in this field and provide a window for newer research avenues in this highly important yet ignored health segment.

Potential Drug-Nutrient Interactions of 45 Vitamins, Minerals, Trace Elements, and Associated Dietary Compounds with Acetylsalicylic Acid and Warfarin-A Review of the Literature

In cardiology, acetylsalicylic acid (ASA) and warfarin are among the most commonly used prophylactic therapies against thromboembolic events. Drug-drug interactions are generally well-known. Less known are the drug-nutrient interactions (DNIs), impeding drug absorption and altering micronutritional status. ASA and warfarin might influence the micronutritional status of patients through different mechanisms such as binding or modification of binding properties of ligands, absorption, transport, cellular use or concentration, or excretion. Our article reviews the drug-nutrient interactions that alter micronutritional status. Some of these mechanisms could be investigated with the aim to potentiate the drug effects. DNIs are seen occasionally in ASA and warfarin and could be managed through simple strategies such as risk stratification of DNIs on an individual patient basis; micronutritional status assessment as part of the medical history; extensive use of the drug-interaction probability scale to reference little-known interactions, and application of a personal, predictive, and preventive medical model using omics.

Clinically Relevant Herb-Drug Interactions: A 30-Year Historical Assessment

The Dietary Supplement Health and Education Act, a legislative measure ushering in a novel class of complementary healthcare products known as dietary supplements, will mark its 30th anniversary in October 2024. Over this 30-year period, dietary supplement usage evolved from a few hundred products made up mostly of vitamins, minerals, and select botanical extracts to more than 75,000 single- and multi-ingredient products that are now regular staples in the American healthcare system and used by half of all U.S. consumers. One of the fastest-growing segments of the dietary supplement market during this 3-decade interval has been those products formulated with botanical extracts. Coincident with the growing popularity of botanical dietary supplements (BDS) has been their concomitant ingestion with conventional prescription medications. BDS are complex mixtures of phytochemicals oftentimes exhibiting complex pharmacology. Formulated as concentrated phytochemical extracts, BDS are vehicles for a host of plant secondary metabolites rarely encountered in the typical diet. When taken with prescription drugs, BDS may give rise to clinically significant herb-drug interactions (HDI). Pharmacodynamic HDI describe interactions between phytochemicals and conventional medications at the drug receptor level, while pharmacokinetic HDI stem from phytochemical-mediated induction and/or inhibition of human drug metabolizing enzymes and/or transporters. This review summarizes BDS identified over the last 30 years that pose clinically relevant HDI and whose mechanisms are either pharmacodynamically or pharmacokinetically mediated.

Integrated traditional herbal medicine in the treatment of gastrointestinal disorder: the pattern of use and the knowledge of safety among the Eastern Region Saudi population

BACKGROUND

Herbal medicine is commonly integrated with conventional medicine in Saudi Arabia, especially for the management of digestive disorders. However, the majority of Saudis use herbal remedies without prior consultation with a physician, which raises concerns about their appropriate and safe use. The aim of this study was to assess the level of awareness among the Saudi population regarding the proper utilization and potential adverse effects of frequently used herbs for the treatment of gastrointestinal (GI) diseases.

METHODS

A cross-sectional survey was conducted in Saudi Arabia from January to March 2021. An electronic self-administered questionnaire was distributed.

RESULTS

A total of 543 participants from different age groups, educational levels, and cities across Saudi Arabia completed the study questionnaire. The most commonly used herbs at home by the participants were: myrrh, parsley, black seed, chamomile, mint, anise, clove, and green tea. 57.7% of the participants perceived herbs as safer than conventional medicines; 27.3% reported that using herbal remedies over conventional medicine was a family tradition, and 21.4% used herbs because they were cheaper than conventional medicines.

CONCLUSION

Herbal remedies, including myrrh, parsley, blackseed, chamomile, mint, and anise, are commonly employed for the treatment of gastrointestinal disorders in Saudi Arabia. However, the knowledge level of participants regarding potential side effects and drug-herb interactions was found to be deficient. As such, there is a pressing need for educational campaigns and community awareness programs to elucidate the proper usage of herbal remedies and to caution against their potential adverse effects.

Effect of St. John's Wort (Hypericum perforatum L.) on Male Sexual and Reproductive Health: A Narrative Review

BACKGROUND

Hypericum species are widely acknowledged for their biological attributes, with notable attention being paid to Hypericum perforatum, commonly known as St. John's wort (SJW) within the Hypericum section of the Hypericaceae family. This species is among the most thoroughly investigated herbal medicines, particularly in terms of its application in the management of mild to moderate depression. SJW is used to treat depression, menopausal symptoms, attention-deficit hyperactivity disorder (ADHD), somatic symptom disorder, obsessive-compulsive disorder, and skin conditions, such as wounds and muscle pain. However, the usefulness and effectiveness of SJW for male sexual and reproductive health (SRH) are not well known.

OBJECTIVE

To assess the current evidence in the literature on the effect of SJW on male SRH.

METHODS

This narrative review followed a predetermined protocol and used MEDLINE and PubMed to identify articles published in English on the effects of SJW on male SRH. The search used various keywords, such as "Hypericum Perforatum", "St. John's Wort", and terms related to sexual and reproductive health issues. Articles published between the inception of the database and August 2023 were included.

RESULTS

We identified 12 articles published from 1999 to 2019, the majority of which were experimental and conducted on animals. These studies demonstrate variability in terms of design, sample size, type of SJW extract used, the dosage administered, and duration of treatment. Studies have indicated potential sexual dysfunction (SD) due to SJW, which includes reduced libido, delayed ejaculation, delayed orgasm, and erectile dysfunction. Additionally, reproductive toxicity has been suggested, as evidenced by spermicidal effects through the inhibition of sperm motility, abnormal spermatozoa, chromosomal aberrations, and DNA denaturation. Furthermore, some studies have reported potential adverse events during maternal exposure, inhibition of fertilization, and disruption of reproductive parameters.

CONCLUSIONS

Our review suggests that the safety and efficacy of SJW in the treatment of human SRH remain unclear. Further comprehensive, well-designed studies with larger samples, longer exposure periods, and specific dosages are needed to clarify SJW's effects of SJW. Therefore, consultation with healthcare professionals before using herbal remedies or supplements is crucial.

Healthcare Professionals and Undergraduate Students' Knowledge Toward Drug-Food Interactions in the Eastern Region of Saudi Arabia

Introduction

Drug and Food Interactions (DFI) arise when particular nutrients in food interact with drugs when consumed concurrently, consequently resulting in alterations in the pharmacokinetics, pharmacodynamics, and therapeutic effectiveness of the drug. This study aimed to evaluate the information and understanding of healthcare providers (HCPs) about common DFI.

Methods

A cross-sectional study was achieved by a self-administered online-based questionnaire to gather data from HCPs in eastern region of Saudi Arabia between Sep. to Oct. 2022. The questionnaire integrated questions related to HCP demographic features and knowledge of DFI. The DFI section included questions that assessed the general knowledge of DFI and knowledge of specific food and drug interactions.

Results

A total of 401 participants completed the study questionnaire; 41.4% were undergraduate students, 37.2% were pharmacists, 10.5% were nurses, and 9.5% were doctors. Unfortunately, HCPs are unable to recognize several food types that may interact with medications, which may lead to undesirable consequences associated with an enormous financial burden. For instance, only 27.9% of the HCPs stated that patients on monoamine oxidase inhibitors should avoid cheese. In addition, only approximately 11% of HCPs knew that patients on levothyroxine should avoid cauliflower, those taking digoxin should avoid wheat bran, those taking lithium should avoid cola, and those on heparin should avoid calcium-rich food. Overall knowledge was significantly higher among pharmacists and others HCPs with more than 5 years of experience.

Discussion and Conclusion

This study demonstrated a low level of knowledge regarding specific food and drug interactions among healthcare providers in the eastern region of Saudi Arabia.

A dual-modal graph learning framework for identifying interaction events among chemical and biotech drugs

Drug-drug interaction (DDI) identification is essential to clinical medicine and drug discovery. The two categories of drugs (i.e. chemical drugs and biotech drugs) differ remarkably in molecular properties, action mechanisms, etc. Biotech drugs are up-to-comers but highly promising in modern medicine due to higher specificity and fewer side effects. However, existing DDI prediction methods only consider chemical drugs of small molecules, not biotech drugs of large molecules. Here, we build a large-scale dual-modal graph database named CB-DB and customize a graph-based framework named CB-TIP to reason event-aware DDIs for both chemical and biotech drugs. CB-DB comprehensively integrates various interaction events and two heterogeneous kinds of molecular structures. It imports endogenous proteins founded on the fact that most drugs take effects by interacting with endogenous proteins. In the modality of molecular structure, drugs and endogenous proteins are two heterogeneous kinds of graphs, while in the modality of interaction, they are nodes connected by events (i.e. edges of different relationships). CB-TIP employs graph representation learning methods to generate drug representations from either modality and then contrastively mixes them to predict how likely an event occurs when a drug meets another in an end-to-end manner. Experiments demonstrate CB-TIP's great superiority in DDI prediction and the promising potential of uncovering novel DDIs.

Safety Concerns Related to the Simultaneous Use of Prescription or Over-the-Counter Medications and Herbal Medicinal Products: Survey Results among Latvian Citizens

The use of herbal medicines is increasing worldwide. While the safety profile of many herbal medicines is promising, the data in the literature show important interactions with conventional drugs that can expose individual patients to high risk. The aim of this study was to investigate the experience of the use of herbal medicines and preparations and the risks of interactions between herbal and conventional medicines among Latvian citizens. Data were collected between 2019 and 2021 using a structured questionnaire designed for pharmacy customers in Latvia. Electronic databases such as Drugs.com, Medscape, and European Union herbal monographs were reviewed for the risk of drug interactions and potential side effects when herbal medicines were involved. The survey included 504 respondents. Of all the participants, 77.8% used herbal preparations. Most of the participants interviewed used herbal remedies based on the recommendation of the pharmacist or their own initiative. A total of 38.3% found the use of herbal remedies safe and harmless, while 57.3% of respondents regarded the combination of herbal and regular drugs as unsafe. The identified herbal medicines implicated in the potential risk of serious interactions were grapefruit, St. John's wort, and valerian. As the risks of herb-drug interactions were identified among the respondents, in the future, both pharmacy customers and healthcare specialists should pay more attention to possible herb-drug interactions of over-the-counter and prescription medications.

Patterns of natural health product use at an outpatient heart function clinic

Background:

Natural health product (NHP) use is common among Canadians, but the NHPs used by outpatients with cardiovascular conditions such as atrial fibrillation and heart failure have not been identified.

Objectives:

Describe NHP use among outpatient cardiac patients, assess drug interactions and their potential implications and determine NHP documentation by health care providers.

Methods:

Telephone interviews were conducted by the main researcher with patients who attended the Cardiac Clinics at the Royal Columbian Hospital. Medication reconciliation was performed to elicit information regarding NHP use and clinic charts were used to supplement demographic information.

Results:

There were 119 successful interviews. Most patients were approximately 65 years old and male, were diagnosed with atrial fibrillation, had 2 to 3 queried comorbidities and took 2 cardiovascular medications. It was found that 62% of patients use NHPs, and 239 individual NHPs were identified. The most common NHPs used were vitamins and minerals (63%), especially vitamin D (13%), multivitamins (8%) and omega-3s (8%). Interactions between cardiac medications and NHPs occurred in 86% of patients. NHP use was completely documented by health care providers in 24% of patients.

Conclusion:

NHP use is common among patients who attend outpatient cardiac clinics. Interactions between NHPs and cardiovascular medications are prevalent and may carry specific individual patient risks. NHP documentation by health care providers is often incomplete.

Changes in Pharmacokinetics and Pharmacodynamics of Losartan in Experimental Diseased Rats Treated with Curcuma longa and Lepidium sativum

The current study investigated “pharmacodynamics and pharmacokinetics interactions” of losartan with Curcuma longa (CUR) and Lepidium sativum (LS) in hypertensive rats. Hypertension was induced by oral administration of L-NAME (40 mg/kg) for two weeks. Oral administration of CUR or LS shows some substantial antihypertensive activity. The systolic blood pressure (SBP) of hypertensive rats was decreased by 7.04% and 8.78% 12 h after treatment with CUR and LS, respectively, as compared to rats treated with L-NAME alone. LS and CUR display the ability to potentiate the blood pressure-lowering effects of losartan in hypertensive rats. A greater decrease in SBP, by 11.66% and 13.74%, was observed in hypertensive rats treated with CUR + losartan and LS + losartan, respectively. Further, both the investigated herbs, CUR and LS, caused an increase in plasma concentrations of losartan in hypertensive rats. The AUC0-t, AUC0-inf and AUMC0-inf of losartan were increased by 1.25-fold, 1.28-fold and 1.09-fold in hypertensive rats treated with CUR + losartan. A significant (p < 0.05) increase in AUC0-t (2.41-fold), AUC0-inf (3.86-fold) and AUMC0-inf (8.35-fold) of losartan was observed in hypertensive rats treated with LS + losartan. The present study affirms that interactions between CUR or LS with losartan alter both “pharmacokinetics and pharmacodynamics” of the drug. Concurrent administration of losartan with either CUR or LS would require dose adjustment and intermittent blood pressure monitoring for clinical use in hypertensive patients. Additional investigation is necessary to determine the importance of these interactions in humans and to elucidate the mechanisms of action behind these interactions.

Pharmacy practitioners' practice, awareness and knowledge about herbal products and their potential interactions with cardiovascular drugs

Background: Herbal medicine use is widespread among patients, as community pharmacies may provide such products. Therefore, pharmacy practitioners should be aware of potential herbal products' adverse effects and herb-drug interactions, particularly with medications for comorbid diseases, such as cardiovascular drugs, in which pharmacy practitioners need to have good knowledge to provide patients with relevant advice to get optimal and safe therapeutic outcomes. Accordingly, the study is designed to assess the knowledge and awareness of pharmacy practitioners regarding herbal product dispensing and cardiovascular drug interaction in Jordan and view their role in patients' counselling to set up safe and effective drug use. Methods: A cross-sectional study was conducted in Jordan using an online formatted questionnaire distributed to pharmacy practitioners working in community pharmacies. Descriptive and analytical statistics were performed for the responses using the Statistical Package for the Social Sciences (SPSS) software, version 26. Results: Out of 508 participants, 41.7% had medium knowledge of herbal products pertaining mainly to university education (68.1%); 55.1% of participants dispensed herbal products without prescriptions for obesity and weight reduction (72.8%) and gastrointestinal problems (70.9%); this is because respondents agreed that herbal remedies are safe (28.5%) and effective (38.4%). Whilst the knowledge level of respondents about herbal medicine interaction with cardiovascular medication was medium, with a mean of 1.94, as this interaction may result in potentially serious consequences, 40.7% of respondents strongly agreed to gain more knowledge about the side effects of herbal products and medicine interactions through educational courses. Conclusions: The pharmacy practitioners had medium knowledge of herbal products; however, more attention should be paid to herb-drug interactions in the pharmacy educational curriculum. Additionally, pharmacy practitioners need to refresh their knowledge by attending periodic educational courses and by using reliable resources for information about herbal products in order to provide effective and competent pharmaceutical care.

Concurrent use of Chinese herbal medicine and anticoagulants may reduce major bleeding events

Background

This retrospective cohort study investigated the risk of major bleeding events during the concurrent use of Chinese herbal medicine (CHM) and anticoagulants in clinical practice.

Methods

A total of 4,470 patients receiving anticoagulant drugs were selected from Taiwan’s National Health Insurance Research Database (NHIRD). Half (n = 2,235) were also using CHMs (CHM cohort); the other half were not (non-CHM cohort). Each cohort was matched 1:1 using the propensity score. Chi-square testing and the Student’s t-test were used to examine differences between two cohorts. Cox proportional hazard regression analysis assessed the risks for major bleeding events in each cohort, as well as bleeding risks associated with specific CHM formulas and herbs. Cumulative incidence curves for major bleeding events were calculated using Kaplan-Meier analysis.

Results

Compared with the non-CHM cohort, the CHM cohort had a lower risk of overall bleeding events (p < 0.001) including hemorrhagic stroke (p = 0.008), gastrointestinal (GI) bleeding (p < 0.001), urogenital bleeding (p ≤ 0.001) and nasal/ear/eye bleeding (p = 0.004). Single herbs, such as Glycyrrhiza uralensis et Rhizoma, Panax notoginseng, Panax ginseng, Platycodon grandiflorum, Eucommia ulmoides Oliver and formulas, such as Shu Jing Huo Xue Tang, Shao Yao Gan Cao Tang and Ji Sheng Shen Qi Wan were associated with a lower risk of major bleeding events.

Conclusion

Using CHMs with anticoagulants appeared to decrease the risk of major bleeding, especially CHMs products containing Glycyrrhiza uralensis et Rhizoma, Panax notoginseng, Panax ginseng, Platycodon grandiflorum and Eucommia ulmoides Oliver. Further investigations are needed to determine whether CHM can maintain the therapeutic efficacy of anticoagulants while simultaneously reducing potential side effects.

Attitude, Beliefs, and Use of Herbal Remedies by Patients in the Riyadh Region of Saudi Arabia

Background: The consumption of herbal medicines (HMs) is increasing worldwide, especially in developing countries. This study attempts to investigate and evaluate the patient’s perception with regard to the security of HMs, their attitudes towards the concomitant use of HMs with modern medicines, and counseling about their use. Design: Self-administered questionnaire-based cross-sectional survey study. Setting: A self-administered structured questionnaire was administered to 200 patients who received HMs from four different government and private hospitals in the Riyadh region of Saudi Arabia, over a period of three months. Results: The response rate was 74.5%. Out of these, 76.83% of respondents reported using HMs in some form for a variety of conditions. There was no statistically significant relationship between various demographic characteristics and the use of herbs. The majority of the respondents (76.72%) reported using HMs without any professional supervision. This exposes them to the risk of harmful side effects and drug interactions. Conclusions: Physicians and pharmacists should work to provide evidence-based information about HMs to patients about effectiveness and side effects and be vigilant while writing prescriptions and dispensing drugs to them. Patient counseling and education about medication use are required to augment their awareness about their use.

Bioactive Foods and Medicinal Plants for Cardiovascular Complications of Type II Diabetes: Current Clinical Evidence and Future Perspectives

Cardiovascular diseases (CVDs) are the main cause of mortality in type 2 diabetes mellitus (T2DM); however, not all patients are fully satisfied with the current available treatments. Medicinal plants have been globally investigated regarding their effect in CVD, yet the field is far from getting exhausted. The current paper aims to provide an evidence-based review on the clinically evaluated medicinal plants and their main therapeutic targets for the management of CVD in T2DM. Electronic databases including PubMed, Cochrane, Embase, Scopus, and Web of Science were searched from 2000 until November 2019, and related clinical studies were included. Lipid metabolism, glycemic status, systemic inflammation, blood pressure, endothelial function, oxidative stress, and anthropometric parameters are the key points regulated by medicinal plants in T2DM. Anti-inflammatory and antioxidant properties are the two most important mechanisms since inflammation and oxidative stress are the first steps triggering a domino of molecular pathological pathways leading to T2DM and, subsequently, CVD. Polyphenols with potent antioxidant and anti-inflammatory effects, essential oil-derived compounds with vasorelaxant properties, and fibers with demonstrated effects on obesity are the main categories of phytochemicals beneficial for CVD of T2DM. Some medicinal plants such as garlic (Allium sativum) and milk thistle (Silybum marianum) have strong evidences regarding their beneficial effects; however, others have low level of evidence which reveals the need for further clinical studies with larger sample sizes and longer follow-up periods to confirm the safety and efficacy of medicinal plants for the management of CVD in T2DM.

Berberine Attenuates MPP+-Induced Neuronal Injury by Regulating LINC00943/miR-142-5p/KPNA4/NF-κB Pathway in SK-N-SH Cells

Berberine plays a neuro-protective role in neurodegenerative diseases, including Parkinson's disease (PD). Long non-coding RNAs (lncRNAs) play critical roles in PD pathogenesis. The purpose of this study was to investigate whether LINC00943 was involved in the role of berberine in PD. 1-methyl-4-phenyl-1, 2, 3, 6-tetrahydropyridine (MPTP) or 1-methyl-4-phenyl pyridine (MPP⁺) were used to construct PD mouse and cell models, respectively. Cell proliferation was evaluated by Cell Counting Kit-8 (CCK-8) and 5-Ethynyl-2'-deoxyuridine (Edu) assays. Inflammation and cell apoptosis were assessed by enzyme-linked immunosorbent assay (ELISA) and flow cytometry, respectively. Quantitative real-time PCR (qRT-PCR) was employed to test the expression of LINC00943, microRNA (miR)-142-5p, and karyopherin subunit alpha 4 (KPNA4) mRNA. The protein levels of NF-κB pathway-related markers and KPNA4 were measured by western blot. Oxidative stress level was assessed by corresponding kits. The interaction between miR-142-5p and LINC00943 or KPNA4 was determined via dual-luciferase reporter and RNA immunoprecipitation (RIP) assays. Berberine inhibited MPP⁺-induced injury in SK-N-SH cells by promoting cell proliferation and suppressing inflammation, apoptosis, and oxidative injury. LINC00943 and KPNA4 were upregulated and miR-142-5p was downregulated in PD mouse and cell models. LINC00943 (or KPNA4) overexpression or miR-142-5p inhibition abated the neuro-protective role of berberine in PD cell model. Moreover, miR-142-5p was a target of LINC00943, and KPNA4 could specially bind to miR-142-5p. Additionally, berberine inhibited NF-κB pathway by regulating LINC00943/miR-142-5p/KPNA4 axis. Berberine protected SK-N-SH cell from MPP⁺-induced neuronal damage via regulating LINC00943/miR-142-5p/KPNA4/NF-κB pathway, highlighting novel evidence for the neuro-protective role of berberine in PD.

Community burden of hypertension and treatment patterns: An in-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

BACKGROUND

This study aimed to describe the burden, treatment patterns and, age threshold for predicting hypertension among rural adults in Nyive in the Ho Municipality of the Volta Region, Ghana.

METHODS

A population-based cross-sectional study design was employed. A total of 417 adults aged 20 years and above were randomly selected from households within the Nyive community. The WHO STEPwise approach for non-communicable diseases risk factor surveillance (STEPS) instrument was used to obtain socio-demographic and clinical information including age, gender, educational background, marital status, and occupation as well as hypertension treatment information. Blood pressure was measured using standard methods. The risk of hypertension and the critical age at risk of hypertension was determined using binary logistic regression model and the receiver-operator characteristics (ROC) analysis.

RESULTS

The direct and indirect age-standardized hypertension prevalence was higher in males (562.58/487.34 per 1000 residents) compared to the females (489.42/402.36 per 1000 residents). The risk of hypertension among the study population increased by 4.4% (2.9%-5.9% at 95% CI) for one year increase in age while the critical age at risk of hypertension was >39 years among females and >35 years among males. About 64(46.72%) of the hypertensive participants were not on treatment whereas only 42(30.66%) had their blood pressure controlled.

CONCLUSION

Rural hypertension is high among adults in Nyive. The critical age at risk of hypertension was lower among males. The estimated annual increase of risk of hypertension was 4.7% for females and 3.1% for males. High levels of undiagnosed and non-treatment of hypertension and low levels of blood pressure control exist among the rural folks.

From Bush Medicine to Modern Phytopharmaceutical: A Bibliographic Review of Devil's Claw (Harpagophytum spp.)

Devil's claw (Harpagophytum spp., Pedaliaceae) is one of the best-documented phytomedicines. Its mode of action is largely elucidated, and its efficacy and excellent safety profile have been demonstrated in a long list of clinical investigations. The author conducted a bibliographic review which not only included peer-reviewed papers published in scientific journals but also a vast amount of grey literature, such as theses and reports initiated by governmental as well as non-governmental organizations, thus allowing for a more holistic presentation of the available evidence. Close to 700 sources published over the course of two centuries were identified, confirmed, and cataloged. The purpose of the review is three-fold: to trace the historical milestones in devil's claw becoming a modern herbal medicine, to point out gaps in the seemingly all-encompassing body of research, and to provide the reader with a reliable and comprehensive bibliography. The review covers aspects of ethnobotany, taxonomy, history of product development and commercialization, chemistry, pharmacology, toxicology, as well as clinical efficacy and safety. It is concluded that three areas stand out in need of further investigation. The taxonomical assessment of the genus is outdated and lacking. A revision is needed to account for intra- and inter-specific, geographical, and chemo-taxonomical variation, including variation in composition. Further research is needed to conclusively elucidate the active compound(s). Confounded by early substitution, intermixture, and blending, it has yet to be demonstrated beyond a reasonable doubt that both (or all) Harpagophytum spp. are equally (and interchangeably) safe and efficacious in clinical practice.

The effect of Guanxin Shutong capsule on alleviating the myocardial fibrosis in heart failure rats

ETHNOPHARMACOLOGICAL RELEVANCE

Guanxin Shutong (GXST) capsule is a renowned traditional Chinese medicine widely used for the treatment of cardiovascular diseases in the clinic. However, no pharmacological experimental studies of GXST has been reported on the treatment of pressure overload-induced heart failure. This study aimed to investigate the effects of GXST capsule on ameliorating myocardial fibrosis conditions in pressure overload-induced heart failure rats.

MATERIAL AND METHODS

Rats were randomly divided into 6 groups: Normal group, Model group, GXST-treated group at a dose of 0.5 g/kg, 1 g/kg, 2 g/kg, respectively, and digoxin positive control group at a dose of 1 mg/kg. After 4 weeks of administration, cardiac function was evaluated by echocardiography. Cardiac injury and fibrotic conditions were evaluated by H&E staining, Masson staining, and Sirius Red staining. Myocardial fibrosis was evaluated by immunohistochemistry staining and Western blot.

RESULTS

GXST significantly inhibited cardiac fibrosis, reduced the excessive deposition of collagen, and finally improved cardiac function. GXST reversed ventricular remodeling might be through the TGF-β/Smad3 pathway.

CONCLUSION

GXST capsule demonstrated a strong anti-fibrosis effect in heart failure rats by inhibiting the TGF-β/Smad3 signaling pathway.

Quantitative and qualitative analyses of herbal medication use among Ghanaian stroke survivors

BACKGROUND

Herbal medicines are not regulated by regulatory authorities and are often not of proven safety and efficacy. Anecdotal reports suggest widespread use of traditional herbal medicine (THM) for treatment of stroke in Africa, but verifiable data are limited in published literature.

OBJECTIVE

To assess the frequency and reasons for THM use among Ghanaian stroke survivors.

METHODS

We conducted a cross-sectional survey of 106 consecutive stroke survivors presenting for care at a tertiary medical center in Kumasi, Ghana between June and October 2020. Information on demographic, clinical, vascular risk factors and use of THM were collected in a non-judgmental manner and analyzed.

RESULTS

Among the cohort, 46 (43.4%) reported use of any THM for their stroke management. There was a trend towards fewer women who reported use of THM 34.8% vs 53.3%, p = 0.06. Of those reporting use of THM, 78% had blood pressure > 140/90 mmHg vs. 56% among those not exposed to THM (p = 0.02). Top reasons proffered for use of THM were: expecting them to aid faster recovery from stroke (n = 30), expecting them to cure stroke (n = 18), and expecting them to be of superior effectiveness compared to approved conventional medications of proven efficacy/safety (n = 1).

CONCLUSION

Almost half the individuals in this contemporary sample of Ghanaian stroke survivors reported use of THM with expectations for improved outcomes. More counseling is required to inform patients about potential safety issues with THM use, and more research is needed to explore risk/benefit of promising THMs to improve stroke outcomes.

The use of complementary and alternative medicine among hypertensive and type 2 diabetic patients in Western Jamaica: A mixed methods study

BACKGROUND

The simultaneous or intermittent use of alternative treatments and prescription medications for hypertension and type 2 diabetes mellitus can have adverse health effects.

OBJECTIVES

To identify beliefs and practices associated with the use of alternative treatments for hypertension and type 2 diabetes mellitus among patients.

METHODS

A mixed-methods study including an investigator-administered survey and focus group discussion sessions using convenience sampling was conducted among patients aged ≥18 years during May to August 2018. Descriptive statistics were used to describe and compare demographic characteristics among groups of survey participants using JMP Pro 14.0. Thematic analysis was conducted to analyze the qualitative data using NVivo.

RESULTS

Most study participants (87-90%) were on prescription medication for their condition. Of survey participants, 69% reported taking their medication as prescribed and 70% felt that prescription medicine was controlling their condition. Almost all participants (98%) reported using alternative treatments, mainly herbal medications, and 73-80% felt that herbal medicines controlled their conditions. One-third believed that herbal medicines are the most effective form of treatment and should always be used instead of prescription medication. However, most participants (85%) did not believe that prescription and herbal treatments should be used simultaneously. Most (76-90%) did not discuss herbal treatments with their healthcare providers. Four themes emerged from the focus group sessions: 1) Simultaneous use of herbal and prescription medicine was perceived to be harmful, 2) Patients did not divulge their use of herbal medicine to healthcare providers, 3) Alternative medicines were perceived to be highly effective, and 4) Religiosity and family elders played key roles in herbal use.

CONCLUSIONS

This study provides useful insights into perceptions and use of alternative treatments by patients that can be used by healthcare providers in developing appropriate interventions to encourage proper use of prescription medicines and alternative medicines resulting in improved management of these chronic diseases.

Potential herb-drug interactions in community-dwelling older adults in China: the Shanghai Aging Study

BACKGROUND

Potential herb-drug interactions (pHDIs) often go unrecognized, and little is known about the prevalence of pHDIs in older adults.

AIMS

This study aimed to investigate the prevalence of pHDIs in community-dwelling older adults in Shanghai and identify patterns and factors associated with pHDIs.

METHODS

Baseline data from the Shanghai Aging Study, which was designed to establish a prospective community-based cohort of older adults in Shanghai, were analyzed regarding pHDIs with Lexi-Interact Online software.

RESULTS

Among 1227 participants who used any combination of drug-herb or herb-herb, 43.3% were exposed to at least one pHDI. A total of 1641 different pHDIs were identified among the study samples. Only seven (0.4%) pHDIs were rated as risk category X, indicating that the combinations were contraindicated and should be avoided. Worryingly, 876 (53.4%) pHDIs were rated as risk category D, indicating that significant interactions may occur and therapeutic modification should be considered. Of particular concern is that 99.8% of pHDIs in risk category D involve herbs with anticoagulant/antiplatelet properties. Individuals with stroke (odds ratio [OR] 2.02), hyperlipidemia (OR 1.51) or heart diseases (OR 1.42) and the number of herbs (2.66), number of drugs (OR 1.21), and age (OR 1.02) were significantly associated with the risk of pHDIs.

CONCLUSION

43.3% of community-dwelling older adults who used any combination of drug-herb or herb-herb was exposed to pHDIs, and more than half of pHDIs were related to herbs with anticoagulant/antiplatelet properties. Awareness of the patterns and high-risk groups of these pHDIs may contribute to increased patient safety.

Guanxinshutong capsule ameliorates cardiac function and architecture following myocardial injury by modulating ventricular remodeling in rats

Guanxinshutong capsule (GXST), which consists of five traditional Chinese medicines, has been used for a long time in China for the treatment of cardiovascular diseases, such as coronary artery disease and myocardial infarction. However, the effects on GXST on myocardial injury (MI) have not been studied in detail. In these experiments, we found that GXST administration decreased MI-associated ventricular remodeling (VR) with a reduction in interventricular septal thickness in diastole (IVSd), left ventricular posterior wall diameter in systole (LVPWs), and left ventricular posterior wall diameter in diastole (LVPWd) to ameliorate cardiac function and architecture, as measured by echocardiography. Furthermore, histological analysis showed that GXST could ameliorate pathological alterations in the myocardium. And Sirius red staining, wheat germ agglutinin staining and inflammation-related immunohistochemistry results showed that GXST ameliorated the fibrosis areas, cardiac hypertrophy and inflammation (IL-6 and TNF-α). In addition, GXST upregulated intercellular junction proteins (N-cad and Cx-43) and downregulated the angiogenesis-related proteins (PDGF and VEGFA), myocardial fibrosis-related proteins (TGF-β1), and matrix metalloproteinase (MMP-2 and MMP-9). We also found that GXST medium-dose group (1 g/kg/d) dosage was the most efficacious. In conclusion, GXST protected cardiac tissues against MI by reducing VR, thus indicating the potential application of GXST in the treatment of MI.

Utilization trends in traditional Chinese medicine for acute myocardial infarction

ETHNOPHARMACOLOGICAL RELEVANCE

Among heart diseases, acute myocardial infarction (AMI) is the most serious and life-threatening emergency. In Taiwan, heart disease has consistently ranked second among the top 10 leading causes of death since 2007, second only to malignant tumors; however, population-based studies on the use of traditional Chinese medicine (TCM) in AMI cases are limited.

AIM OF THE STUDY

This study investigated the characteristics of TCM users and prescriptions of TCM, and their differences between two cohorts of patients with AMI, identified 10 years apart.

MATERIALS AND METHODS

A cross-sectional study was conducted using the Taiwan National Health Insurance claims database. From among two random sample of 1 million beneficiaries selected from the claims database, we identified two cohorts of patients with first hospitalization for AMI in between 2000-2001 and 2010-2011. Patients who had received TCM therapy within one year after hospital discharge were defined as TCM users, whereas, all the other patients with AMI were considered non-users of TCM. We compared the characteristics of TCM use and the patterns of prescriptions between the two cohorts.

RESULTS

The proportion of patients receiving TCM care was similar between the two AMI cohorts; 20% (85/418) of the patients were diagnosed in 2000-2001 and 21% (169/817) in 2010-2011. In the 2010-2011 AMI cohort, the proportion of men was smaller among TCM users than non-users, and TCM users were less likely to have hyperlipidemia. Among TCM users, the most frequently prescribed herb was Dan-shen (Salvia miltiorrhiza Bunge, Salvia root) in both cohorts. The most commonly used Chinese herbal formulations were Xue-Fu-Zhu-Yu-Tang (Blood Mansion Dispel Stasis) for the 2000-2001 cohort and Zhi-Gan-Cao-Tang (Honey-Fried Licorice Decoction) for the 2010-2011 cohort.

CONCLUSIONS

This study revealed the differences in the prescription frequency of Chinese herbal formulation among the two cohort of patients with AMI, suggesting that the practice of prescribing TCM has evolved from post-antique formula to classical remedies during the 10 years evaluated. Further investigations are needed to evaluate if the change in the utilization of Chinese herbal formulations impacts the effectiveness of the treatment.

Antihypertensive Indigenous Lebanese Plants: Ethnopharmacology and a Clinical Trial

Hypertension is highly prevalent among the Lebanese adult population and is indeed the major cause of mortality in Lebanon. Traditional use of antihypertensive medicinal plants has long been practiced. The aim of this study is to document this traditional knowledge and clinically test the antihypertensive capacity of three of the most commonly used wild plant species Mentha longifolia, Viola odorata and Urtica dioica. Ethno-pharmacological data was collected by personal interviews with herbalists and traditional healers using a semi structured survey questionnaire and assessing relative frequency of citation (RFC). The clinical study was conducted by a randomized, blind, placebo-controlled trial in 29 subjects with mild hypertension distributed in four groups, three plant extract treatments and one placebo. Systolic (SBP) and diastolic blood pressures (DBP) as well as mean arterial blood pressures (MAP) were monitored at weeks 4, 8, 12 and 16 during the treatment with 300 mL/day of plant extract. Results showed that M. longifolia, U. dioica and V. odorata exhibited the highest values of RCF (0.95) followed by Allium ampeloprasum (0.94), Apium graveolens (0.92) and Crataegus azarolus (0.90). The clinical trial revealed dose- and duration-dependent significant reductions in SBP, DBP and MAP of subjects treated with M. longifolia, U. dioica or V. odorata. Our findings indicate that extracts of these plants present an effective, safe and promising potential as a phyto-therapuetical approach for the treatment of mild hypertension. More research on the phytochemistry, pharmacological effects and the underlying mechanisms is necessary.

The efficacy of Xue Fu Zhu Yu prescription for hyperlipidemia: A meta-analysis of randomized controlled trials

Hyperlipidemia is rampant as a crucial risk factor for cardiovascular diseases. Xue Fu Zhu Yu (XFZY), a prescription formula in traditional Chinese medicine, is well-known for treating hyperlipidemia. Herein we conducted meta-analysis and assessed the efficacy of XFZY prescription as mono or adjunctive therapy in patients with hyperlipidemia. Databases including Medline, Cochrane Library, Embase, CNKI, Wanfang Data and VIP Information were comprehensively investigated via searching keywords "Xuefuzhuyu", "Xuefu Zhuyu", "Xue Fu Zhu Yu", "Xuefu-Zhuyu" or "XFZY" in combination with "hyperlipidemia" and "dyslipidemia". Efficacy, methodological quality, and publication bias of recruited trials on XFZY prescription were also assessed. Review Manager version 5.3 software was used for statistical analysis. Twelve trials involving 1305 participants all reported in Chinese were enrolled and, based on our analysis, significant increase of efficacy in XFZY prescription groups compared to control groups was observed, and there was either significance or non-significance of differences in regulating the levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C). This meta-analysis preliminarily demonstrated that XFZY prescription is effective for treating hyperlipidemia, but due to the poor methodological quality of most analyzed trials, conclusion should be cautiously summarized. Thoroughly designed, large-scale and multicenter trials are needed to estimate efficacy and safety of XFZY prescription for hyperlipidemia in the future.

Emerging Applications of Metabolomics in Traditional Chinese Medicine Treating Hypertension: Biomarkers, Pathways and More

Hypertension is a prevalent, complex, and polygenic cardiovascular disease, which is associated with increased mortality and morbidity. Across the world, traditional Chinese medicine (TCM) constituted by herbal medicine and non-pharmacological therapies is used to assist blood pressure management. Though widely accepted in daily practice, its mechanism remains largely unknown. Recent years saw a number of studies utilizing metabolomics technologies to elucidate the biological foundation of the antihypertensive effect of TCM. Metabolomics is a relatively "young" omics approach that has gained enormous attention recently in cardiovascular drug discovery and pharmacology studies of natural products. In this review, we described the use of metabolomics in deciphering TCM diagnostic codes for hypertension and in revealing molecular events that drive the antihypertensive effect. By corroborating the diagnostic rules, there's accumulating evidence showing that metabolic profile could be the signature of different syndromes/patterns of hypertension, which offers new perspectives for disease diagnosis and efficacy optimization. Moreover, TCM treatment significantly altered the metabolic perturbations associated with hypertension, which could be a crucial mechanism of the therapeutic effect of TCM. Not only significantly rebalances the dynamics of metabolic flux, TCM but also elicits metabolic network reorganization through restoring the functions of key metabolites, and metabolic pathways. The role of TCM in regulating metabolic perturbations will be informative to researchers seeking new leads for drug discovery. This review further envisioned the promises of employing metabolomics to explore network pharmacology, host-gut microbiota interactions and metabolic reprogramming in TCM, and possible herb-drug interactions in this field in future.

Pharmacokinetics of harpagoside in horses after intragastric administration of a Devil's claw (Harpagophytum procumbens) extract

Devil's claw is used for the treatment of inflammatory symptoms and degenerative disorders in horses since many years, but without the substantive pharmacokinetic data. The pharmacokinetic parameters of harpagoside, the main active constituent of Harpagophytum procumbens DC ex Meisn., were evaluated in equine plasma after administration of Harpagophytum extract FB 8858 in an open, single‐dose, two‐treatment, two‐period, randomized cross‐over design. Six horses received a single dose of Harpagophytum extract, corresponding to 5 mg/kg BM harpagoside, and after 7 days washout period, 10 mg/kg BM harpagoside via nasogastric tube. Plasma samples at certain time points (before and 0–24 hr after administration) were collected, cleaned up by solid‐phase extraction, and harpagoside concentrations were determined by LC‐MS/MS using apigenin‐7‐glucoside as internal standard. Plasma concentration‐time data and relevant parameters were described by noncompartmental model through PKSolver software. Harpagoside could be detected up to 9 hr after administration. C_max was found at 25.59 and 55.46 ng/ml, t_1/2 at 2.53 and 2.32 hr, respectively, and t_max at 1 hr in both trials. AUC_0–inf was 70.46 and 117.85 ng hr ml⁻¹, respectively. A proportional relationship between dose, C_max and AUC was observed. Distribution (V_z/F) was 259.04 and 283.83 L/kg and clearance (CL/F) 70.96 and 84.86 L hr⁻¹ kg⁻¹, respectively. Treatment of horses with Harpagophytum extract did not cause any clinically detectable side effects.

Interaction study between antiplatelet agents, anticoagulants, diabetic therapy and a novel delivery form of quercetin

BACKGROUND

In this pilot non-interference clinical study we evaluated possible interactions between Quercetin Phytosome® (Quercefit™), an innovative delivery form of quercetin, and antiplatelet agents, anticoagulants, and anti-diabetic therapy in otherwise healthy subjects.

METHODS

Interaction with antiplatelet therapy was assessed through the bleeding time (BT) test in 30 patients treated with acetylsalicylic acid, ticlopidine or clopidogrel before and after 10 days of supplementation with Quercetin Phytosome®. Interaction with anticoagulants was evaluated by measuring the International Normalized Ratio (INR) in 20 patients using warfarin or dabigatran before and after 20 days of supplementation with Quercetin Phytosome®. Lastly, glycaemia and glycated hemoglobin were measured in 12 diabetic patients treated with metformin and restricted diet before and after 20 days of supplementation with Quercetin Phytosome®.

RESULTS

After 10 days of supplementation no significant difference was observed in mean BT in patients treated with acetylsalicylic acid, ticlopidine or clopidogrel at standard dosages. Similarly, after 20 days of supplementation, the INR level among patients assuming warfarin or dabigatran was not statistically different from baseline. Lastly, no statistically significant difference in mean levels of glycaemia and glycated hemoglobin was reported before and after 20 days of complementary administration of Quercetin Phytosome® in diabetic patients treated with metformin and restricted diet.

CONCLUSIONS

Quercetin Phytosome® does not alter the antiplatelet activity of the most common antiplatelet agents, has no impact on the INR values in stable patients treated with warfarin or dabigatran, and does not influence the metabolic control of diabetic patient treated with metformin.

Inhibitory and inductive effects of Corydalis saxicola Bunting total alkaloids (CSBTA) on cytochrome P450s in rats

Corydalis saxicola Bunting, a well-known traditional Chinese medicine in south China, has been widely used for the treatment of various hepatic diseases. Its active ingredients are Corydalis saxicola Bunting total alkaloids (CSBTA), which primarily include dehydrocavidine, palmatine, and berberine. These representative alkaloids could be metabolized by hepatic CYP450s. Hence, it is necessary to investigate the potential influences of CSBTA on CYP450s to explore the possibility of herb-drug interactions. In present study, in vitro inhibition and in vivo induction studies were performed to evaluate the potential effects of CSBTA extract on CYP450s in rats. Inhibition assay illustrated that CSBTA exerted inhibitory effects on CYP1A2 (IC₅₀ , 38.08 μg/ml; K_i , 14.3 μg/ml), CYP2D1 (IC₅₀ , 20.89 μg/ml; K_i , 9.34 μg/ml), CYP2C6/11 (IC₅₀ for diclofenac and S-mephenytoin, 56.98 and 31.59 μg/ml; K_i, 39.0 and 23.8 μg/ml), and CYP2B1 (IC₅₀ , 48.49 μg/ml; K_i , 36.3 μg/ml) in a noncompetitive manner. Induction study showed CSBTA had obvious inhibitory rather than inductive effects on CYP1A2 and CYP2C6/11. Interestingly, neither inhibition nor induction on CYP3A was observed for CSBTA. In conclusion, CSBTA-drug interactions might occur through CYP450s inhibition, particularly CYP1A and CYP2D. Further studies are still needed to elucidate the underlying mechanisms of inhibition.

Which Benefits and Harms of Using Fenugreek as a Galactogogue Need to Be Discussed during Clinical Consultations? A Delphi Study among Breastfeeding Women, Gynecologists, Pediatricians, Family Physicians, Lactation Consultants, and Pharmacists

Background

Breastfeeding women with hypogalactia are commonly recommended to use fenugreek as a galactogogue. This study aimed to achieve formal consensus among breastfeeding women and healthcare providers on which potential harms and benefits of using fenugreek need to be communicated and discussed during clinical consultations.

Methods

A two-iterative round Delphi technique was used in two separate panels of breastfeeding women (n = 65) and healthcare providers (n = 56) to achieve formal consensus on a list of 24 and 16 items related to potential harms and benefits of fenugreek.

Results

About 70% of the healthcare providers recommended quite often herbal remedies for breastfeeding women and about 68% of the women had been recommended to use herbal remedies many times by their healthcare providers. Consensus was achieved on 21 potential harms and 14 potential benefits of using fenugreek to enhance human milk supply that need to be discussed with breastfeeding women during consultations.

Conclusion

Probably, potential harms and benefits of recommending fenugreek as herbal galactogogue for breastfeeding women seeking recommendations to increase their human milk supply need to be discussed during clinical consultations. Further observational studies are needed to assess what is being discussed in daily consultations when herbal remedies are recommended.

Efficacy and Safety of a Formulated Herbal Granula, Jiu Wei Zhen Xin, for Generalized Anxiety Disorder: A Meta-Analysis

BACKGROUND

The traditional Chinese medicine formula Jiu Wei Zhen Xin Granula (JWZXG) is prescribed to treat generalized anxiety disorder (GAD) in China. This study was to assess the efficacy and safety of JWZXG in patients with GAD.

METHOD

Data were pooled from 14 randomized controlled trials involving the assessment of mean changes of Hamilton Anxiety Rating Scale (HAMA) total scores, response rates, adverse event rates, quality, publication bias, and risk of bias.

RESULTS

Pooled analysis showed no significant difference in response rate (risk ratio 1.01, 95% CI [0.93-1.08]; Z test = 0.17, P = 0.86) and no significant difference between JWZXG group and azapirones group (RR 0.69, 95% CI [0.45, 1.06]; Z test = 1.69, P = 0.09) in rate of adverse events. Though no difference exists between JWZXG group and azapirones group in HAMA total score from baseline, JWZXG group was inferior to selective serotonin reuptake inhibitors (SSRIs) group (WMD -0.93, 95% CI [-1.64, -0.23]; Z test = 2.6, P = 0.009) which had more adverse events than JWZXG group (RR 0.64, 95% CI [0.46, 0.89]; Z test = 2.63, P = 0.009).

CONCLUSIONS

This meta-analysis preliminarily suggests that JWZXG is as effective as azapirones, though having the same possibility of suffering AEs. JWZXG was inferior to SSRIs but causes fewer AEs in the treatment of GAD.

Self-care of chronic musculoskeletal pain - experiences and attitudes of patients and health care providers

BACKGROUND

Self-care is often the first choice for people with chronic musculoskeletal pain. Self-care includes the use of non-prescription medications with no doctor's supervision, as well as the use of other modern and traditional treatment methods with no consultation of the health care provider. Self-care may have positive effects on the successful outcome of a multidisciplinary approach to treatment. The aim of this study was to investigate the experiences and attitudes of patients and health care providers to the self-care of chronic musculoskeletal pain.

METHODS

Qualitative Phenomenological study, where the data were collected by the method of an audio-taped interview in 15 patients at the outpatient clinic for pain management and in 20 health care providers involved in the treatment of those patients. The interviews were transcribed verbatim and analyzed by principles of Interpretative Thematic Analysis.

RESULTS

Topics identified in patients: a) positive aspects of self-care, b) a need for pain self-care, c) social aspects of pain self-care. Topics identified in health care providers: a) aspects of self-care, b) a need for self-care c) risks of self-care. Most of patients have positive attitude to self-care and this is the first step to pain management and to care for itself. The most frequent factors influencing decision about the self-care are heavy pain, unavailability of the doctor, long awaiting time for the therapy, or ineffectiveness of methods of conventional medicine. The health care providers believe that self-care of chronic musculoskeletal pain may be a patient's contribution to clinical treatment. However, good awareness of methods used is important in this context, to avoid adverse effects of self-care.

CONCLUSION

Patients understand the self-care of musculoskeletal pain as an individually adjusted treatment and believe in its effectiveness. Health care providers support self-care as an adjunction to clinical management only, and think that self-care of musculoskeletal pain acts as a placebo, with a short-lived effect on chronic musculoskeletal pain.

Herbal medicine use among hypertensive patients attending public and private health facilities in Freetown Sierra Leone

OBJECTIVE

This study aimed to determine the prevalence, determinants and pattern of herbal medicine use among hypertensive patients in Freetown.

METHODS AND MATERIALS

We conducted a cross-sectional study among hypertensive patients attending public and private health facilities in Freetown, Sierra Leone between August and October 2016. We analyzed the data using SPSS version 24. We used Chi-square, Fisher exact two-tailed test and regression analysis for data analysis. A p-value less than 0.05 was considered statistically significant.

RESULTS

Out of 260 study participants, over half (n = 148, 56.9%) reported using herbal medicine for the treatment of hypertension alone or together with comorbid condition(s). The most commonly used herbal medicine among users were honey (n = 89, 33.3%), moringa (n = 80, 30.0%) and garlic (n = 73, 27.3%). No significant difference existed between users and non-users of herbal medicine with regards to socio-demographic and health-related factors. The majority (n = 241, 92.7%) of respondents considered herbal medicine beneficial if it was recommended by a healthcare provider yet 85.1% (n = 126) did not disclose their herbal medicine use to their health care provider.

CONCLUSION

There is a high use of herbal medicines among hypertensive patients in Freetown, Sierra Leone. It is essential for healthcare providers to take heed of the findings of this study and routinely ask their patients about their herbal medicine use status. Such practice will provide the opportunity to discuss the benefits and risks of herbal medicine use with the aim of maximizing patient desired therapeutic outcomes.

Drug-induced arterial hypertension - a frequently ignored cause of secondary hypertension: a review

The prevalence of hypertension is likely to grow during the future years, mainly due to aging of the population and increasing prevalence of obesity, as an important risk factor for hypertension. One of the main causes of secondary hypertension, frequently ignored, is represented by certain categories of drugs, that can induce hypertension, increase the blood pressure values in previously controlled hypertension, decrease the effects of antihypertensive medication or induce a hypertensive emergency. These drugs may be over-the-counter medications, illicit drugs or prescription drugs used for the treatment of acute or chronic conditions. The most frequently incriminated drugs are steroids, nonsteroidal anti-inflammatory drugs, sympathomimetic agents, central nervous system stimulants (alcohol, amphetamine), dietary supplements (ginseng, natural liquorice etc), other therapeutic agents (sibutramine, antiemetic agents, oral physostigmine, L-dopa, leflunomide, growth hormone, thyroid hormone, recombinant human erythropoietin), antidepressants, immunosuppressants, antiangiogenic drugs, anaesthetics, heavy metals and toxins. Adding other drugs to antihypertensive treatment should be carefully evaluated by physicians, in order to avoid iatrogenic blood pressure elevations.

Influence of Shenxiong Glucose Injection on the Activities of Six CYP Isozymes and Metabolism of Warfarin in Rats Assessed Using Probe Cocktail and Pharmacokinetic Approaches

Shenxiong glucose injection (SGI), a traditional Chinese medicine (TCM) preparation, has been widely used for the treatment of various cardiovascular and cerebrovascular diseases for many years. We assessed the potential influences of SGI on the activities of six CYP enzymes (CYP1A2, CYP2C11, CYP2C19, CYP2D4, CYP2E1, and CYP3A2) and on the pharmacokinetics of warfarin in rats. We compared plasma pharmacokinetics of six probe drugs (caffeine/CYP1A2, tolbutamide/CYP2C11, omeprazole/CYP2C19, metoprolol/CYP2D4, chlorzoxazone/CYP2E1, and midazolam/CYP3A2) and of warfarin between control and SGI-pretreated groups, to estimate the effect on the relative activities of the six isozymes and warfarin metabolism. There were no significant differences in the pharmacokinetic parameters of caffeine, omeprazole, metoprolol, chlorzoxazone, and midazolam between the SGI-pretreated and control groups. However, many pharmacokinetic parameters of tolbutamide in SGI-pretreated rats were affected significantly (p < 0.05), and indicated tolbutamide metabolism in the former group was markedly slower. Moreover, SGI reduced the clearance of warfarin. These results suggested SGI showed no effects on the enzyme activities of rat CYP1A2, CYP2C19, CYP2D4, CYP2E1, and CYP3A2, but inhibited the enzyme activity of CYP2C11, and improved the blood concentration of warfarin. This suggests that the dose of warfarin may need be adjusted when co-administrated with SGI.

Heart Toxicity Related to Herbs and Dietary Supplements: Online Table of Case Reports. Part 4 of 5

BACKGROUND

The purpose of this review was to create an online research summary table of heart toxicity case reports related to dietary supplements (DS; includes herbs).

METHODS

Documented PubMed case reports of DS appearing to contribute to heart-related problems were used to create a "Toxic Table" that summarized the research (1966 to April, 2016, and cross-referencing). Keywords included "herb," "dietary supplement," and cardiac terms. Case reports were excluded if they were herb combinations (some exceptions), Chinese herb mixtures, teas of mixed herb contents, mushrooms, poisonous plants, self-harm (e.g. suicide), excess dose (except vitamins/minerals), drugs or illegal drugs, drug-herbal interactions, and confounders of drugs or diseases. The spectrum of heart toxicities included hypertension, hypotension, hypokalemia, bradycardia, tachycardia, arrhythmia, ventricular fibrillation, heart attack, cardiac arrest, heart failure, and death.

RESULTS

Heart related problems were associated with approximately seven herbs: Four traditional Chinese medicine herbs - Don quai (Angelica sinensis), Jin bu huan (Lycopodium serratum), Thundergod vine or lei gong teng (Tripterygium wilfordii Hook F), and Ting kung teng (Erycibe henryi prain); one an Ayruvedic herb - Aswagandha, (Withania somnifera); and two North American herbs - blue cohosh (Caulophyllum thalictroides), and Yohimbe (Pausinystalia johimbe). Aconitum and Ephedra species are no longer sold in the United States. The DS included, but are not limited to five DS - bitter orange, caffeine, certain energy drinks, nitric oxide products, and a calming product. Six additional DS are no longer sold. Licorice was the food related to heart problems.

CONCLUSION

The online "Toxic Table" forewarns clinicians, consumers and the DS industry by listing DS with case reports related to heart toxicity. It may also contribute to Phase IV post marketing surveillance to diminish adverse events that Government officials use to regulate DS.

A systematic review of the pharmacokinetic and pharmacodynamic interactions of herbal medicine with warfarin

Objectives

The aim of this study was to systematically review data regarding pharmacokinetic (PK)-pharmacodynamic (PD) parameters from randomized controlled trials relating to interactions between herbal medicines and warfarin.

Methods

Three electronic databases were searched to identify relevant trials. Two reviewers independently performed the study selection and data extraction. The risk of bias and reporting quality were also assessed independently by two reviewers using the Cochrane risk of bias tool and the consolidated standards of reporting trials (CONSORT). Outcomes were measured for all reported PK-PD parameters and adverse events.

Results

Nine randomized controlled trials met our inclusion criteria. Most of the included studies were unclear regarding the risk of bias and had a low quality of methodology. Using CONSORT, the reporting percentages for the articles ranged from 36.5% to 61.5% and the mean percentage for all articles was 45.6%. St John’s wort and echinacea affected the PK parameters of warfarin. Ginseng, ginger, garlic, and cranberry had no significant effect on the PK parameters. American ginseng altered the PD parameters of warfarin. St John’s wort, ginseng, Korea red ginseng, ginkgo, ginger, garlic, aged garlic, and echincea did not significantly alter the PD parameters. Studies of ginkgo and cranberry showed conflicting results on the PK parameters and PD parameters, respectively. The incidence of adverse events in all trials was low and no major adverse events were reported.

Conclusions

It was difficult to determine whether ten herbal medicines had significant effects on the PK-PD parameters of warfarin. Low quality of evidence, different compounds within and different compositions of the herbs, and methodological limitations of the crossover study, which is a clinical study in which subjects receive a sequence of different interventions, made it difficult to form conclusions. Additional studies that remedy these vulnerabilities are necessary to verify these results.

Herbal approach in the treatment of pancytopenia

Pancytopenia is a health condition in which there is a reduction in the amount of leucocytes, erythrocytes and thrombocytes. If more than one of the blood cells is low then the condition is called as bicytopenia. The pancytopenic condition is observed in treatment of diseased conditions like thalassemia and hepatitis C. Iatrogenically pancytopenia is caused by some antibiotics and anti-HCV drugs. Medical conditions like aplastic anaemia, lymphoma, copper deficiency, and so forth can also cause pancytopenia. Pancytopenia can in turn decrease the immunity of the person and thereby can be fatal. Current therapies for pancytopenia include bone marrow stimulant drugs, blood transfusion and bone marrow transplant. The current therapies are very excruciating and have long-term side-effects. Therefore, treating these condition using herbal drugs is very important. Herbs like wheatgrass, papaya leaves and garlic are effective in treating single lineage cytopenias. The present review is focused on the potential effects of natural herbs for the treatment of pancytopenia.

Evaluation of Herb-Drug Interactions of Hovenia dulcis Fruit Extracts

Background:

Hovenia dulcis (Rhamnaceae) fruits are popularly used as herbal medicines or dietary supplements in Asian countries due to functions such as liver protection and detoxification from alcohol poisoning. Accordingly, it is very likely for dietary supplemental products, including H. dulcis fruit extracts, to be taken with prescription drugs.

Objective:

In this study, possible food–drug interactions involving H. dulcis fruit extracts were evaluated based on the inhibition of cytochrome P450 (CYP) enzyme activity.

Material and Methods:

The water extract of H. dulcis fruit extracts was incubated in human liver microsomes with CYP-specific substrates. The formation of the CYP-specific metabolites was measured using liquid chromatography-tandem mass spectrometry.

Results:

H. dulcis fruit extracts showed negligible effects on seven CYP isozyme activities at all concentrations tested.

Conclusion:

This result suggests that H. dulcis fruit extracts may have minimal pharmacokinetic interactions with coadministered drugs through the modulation of CYP enzymes.

SUMMARY

Food-drug interactions involving H. dulcis fruit extracts were evaluated.

The inhibition of CYPs by H. dulcis extracts was tested.

H. dulcis extracts showed negligible effects on CYP activities.

H. dulcis extracts may have minimal pharmacokinetic interactions with co-administered drugs.

Abbreviations Used: CYP: cytochrome P450 enzymes, HPLC: High performance liquid chromatography, LC-MS/MS : liquid chromatography-tandem mass spectrometry, MRM: multiple-reaction monitoring

Effects of propolis on warfarin efficacy

Introduction

Warfarin is commonly used to avoid thromboembolism, predominantly for cardiovascular pathologies. However, the consumption of several herbal products is not permitted during its use due to the associated interactions. Propolis is a popular phytotherapy product made by honey bees. The use of propolis has been dramatically increasing in recent times.

Aim

To evaluate the possible interactions between propolis and warfarin in a mouse model with determination of the international normalized ratio (INR) values.

Material and methods

CD-1 mice were employed in the experimental model. The mice were warfarinized, and propolis was administered simultaneously. The INR values were obtained. All animals were sacrificed at the end of the study.

Results

The baseline INR value was 0.8 ±0.1. After 72 h, the INR value increased as expected. The INR value was 7.28 ±1.08 in the control group and 5.8 ±2.88 in the propolis group. At the end of the study, the INR value was 1.3 ±0.37. Propolis interacted with warfarin and caused a decrease in the INR value.

Conclusions

Propolis interactions, especially with warfarin, should be kept in mind and further studied. Healthcare specialists should be aware of this possible interaction between warfarin and propolis and inform patients about it.

Old and new oral anticoagulants: Food, herbal medicines and drug interactions

The most commonly prescribed oral anticoagulants worldwide are the vitamin K antagonists (VKAs) such as warfarin. Factors affecting the pharmacokinetics of VKAs are important because deviations from their narrow therapeutic window can result in bleedings due to over-anticoagulation or thrombosis because of under-anticoagulation. In addition to pharmacodynamic interactions (e.g., augmented bleeding risk for concomitant use of NSAIDs), interactions with drugs, foods, herbs, and over-the-counter medications may affect the risk/benefit ratio of VKAs. Direct oral anticoagulants (DOACs) including Factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and thrombin inhibitor (dabigatran) are poised to replace warfarin. Phase-3 studies and real-world evaluations have established that the safety profile of DOACs is superior to those of VKAs. However, some pharmacokinetic and pharmacodynamic interactions are expected. Herein we present a critical review of VKAs and DOACs with focus on their potential for interactions with drugs, foods, herbs and over-the-counter medications.

Botanicals and Their Bioactive Phytochemicals for Women's Health

Botanical dietary supplements are increasingly popular for women's health, particularly for older women. The specific botanicals women take vary as a function of age. Younger women will use botanicals for urinary tract infections, especially Vaccinium macrocarpon (cranberry), where there is evidence for efficacy. Botanical dietary supplements for premenstrual syndrome (PMS) are less commonly used, and rigorous clinical trials have not been done. Some examples include Vitex agnus-castus (chasteberry), Angelica sinensis (dong quai), Viburnum opulus/prunifolium (cramp bark and black haw), and Zingiber officinale (ginger). Pregnant women have also used ginger for relief from nausea. Natural galactagogues for lactating women include Trigonella foenum-graecum (fenugreek) and Silybum marianum (milk thistle); however, rigorous safety and efficacy studies are lacking. Older women suffering menopausal symptoms are increasingly likely to use botanicals, especially since the Women's Health Initiative showed an increased risk for breast cancer associated with traditional hormone therapy. Serotonergic mechanisms similar to antidepressants have been proposed for Actaea/Cimicifuga racemosa (black cohosh) and Valeriana officinalis (valerian). Plant extracts with estrogenic activities for menopausal symptom relief include Glycine max (soy), Trifolium pratense (red clover), Pueraria lobata (kudzu), Humulus lupulus (hops), Glycyrrhiza species (licorice), Rheum rhaponticum (rhubarb), Vitex agnus-castus (chasteberry), Linum usitatissimum (flaxseed), Epimedium species (herba Epimedii, horny goat weed), and Medicago sativa (alfalfa). Some of the estrogenic botanicals have also been shown to have protective effects against osteoporosis. Several of these botanicals could have additional breast cancer preventive effects linked to hormonal, chemical, inflammatory, and/or epigenetic pathways. Finally, although botanicals are perceived as natural safe remedies, it is important for women and their healthcare providers to realize that they have not been rigorously tested for potential toxic effects and/or drug/botanical interactions. Understanding the mechanism of action of these supplements used for women's health will ultimately lead to standardized botanical products with higher efficacy, safety, and chemopreventive properties.

Complementary and alternative medicine use among cancer patients in Palestine with special reference to safety-related concerns

ETHNOPHARMACOLOGICAL RELEVANCE

The use of CAM including herbal medicine as the most preferred CAM modality, among cancer patients who are taking prescription medications has shown to be highly prevalent worldwide as well as in several Middle Eastern countries, with a high percentage of the patients do not disclose their CAM use to treating physician.

AIM OF THE STUDY

The current study aimed to evaluate the patterns of CAM use among two cohorts of cancer patients in Palestine over a three-year period, and to identify socio-demographic factors that are associated with CAM use.

MATERIALS AND METHODS

Across-sectional survey of patients attending outpatient cancer clinics. The method was based on a semi-structured questionnaire. In order to identify safety-related concerns associated with the products listed, a literature search was conducted using different databases (PubMed, Micromedex, AltMedDex, and the Natural Medicine Comprehensive Database).

RESULTS

In 472 cancer patients including 372 of the 2011 cohort; and 100 of the 2014 cohort, the overall prevalence of CAM use was 69.5%. CAM users were more likely to be ≤65 years old, village resident, being in the midst of chemotherapy, to have high interest spiritual quest, and to have no other chronic diseases. A significant number of CAM users reported using herbal preparations (98.3%, and 89.6% in the two study cohorts, respectively). In the current study, a total of 40 plant taxa belonging to 23 botanical families were reported by ≥3 cancer patients in the two cohort groups. The top most commonly used plant in the 2011 cohort group was Arum palaestinum (43.5%), while Ephedra foeminea emerged as the top most commonly utilized plant (from 0.0% in 2011 to 55.2% in the 2014 cohort), mainly due to a recent publicizing and portraying of the plant in the local media as an effective cancer herbal remedy. Safety-related concerns were associated with 33 (82.5%) herbs, including herb-drug interactions with altered pharmacokinetics (8, 20% herbs), direct toxic effects (16, 40% herbs), and increased in vitro response of cancer cells to chemotherapy (30, 75% herbs).

CONCLUSIONS

CAM use, especially herbal medicine in cancer is highly prevalent in Palestine. This study has demonstrated the role of the media on the emergence of new CAM herbal therapies among cancer patients in Palestine, and discussed its potential implications on patients and for oncologists who are treating them. Some of the most widely used herbal medicines by cancer patients in the present work are known to interact with conventional anticancer drugs. Hence, the disclosure of the use of herbal remedies by patients to health professionals with sufficient training in CAM use is important for the later in order to assess whether there are any possible herbal drug interactions and/or harmful drug reactions.