Toxicity and drug interactions associated with herbal products: ephedra and St. John's Wort

Community Pharmacists' Views and Practices Regarding Natural Health Products Sold in Community Pharmacies

BACKGROUND

Reports of regulatory and evidentiary gaps have raised concerns about the marketing and use of natural health products (NHPs). The majority of NHPs offered for sale are purchased at a community pharmacy and pharmacists are "front-line" health professionals involved in the marketing and provision of NHPs. To date, the involvement of pharmacists in pharmacy care involving NHPs and the degree to which concerns over the safety, efficacy, marketing and regulation of NHPs are addressed in pharmacy care in Canada have not been studied.

METHODS

Using Qualtrics, a web-based data collection and analysis software, and a study instrument made up of fifteen (15) open-ended, closed and rating scale questions, we surveyed the attitudes and practices of 403 community pharmacists in the Canadian province of Alberta regarding NHPs offered for sale in community pharmacies.

RESULTS

The majority of pharmacists surveyed (276; 68%) recommend NHPs to clients sometimes to very often. Vitamin D, calcium, multivitamins, prenatal vitamins, probiotics and fish oil and omega-3 fatty acids were the most frequently recommended NHPs. The most common indications for which NHPs are recommended include bone and musculoskeletal disorders, maintenance of general health, gastrointestinal disorders and pregnancy. Review articles published in the Pharmacist's Letter and Canadian Pharmacists Journal were the primary basis for recommending NHPs. The majority of pharmacists surveyed (339; 84%) recommend the use of NHPs concurrently with conventional drugs, while a significant number and proportion (125; 31%) recommend alternative use. Pharmacists in the study overwhelmingly reported providing counselling on NHPs to clients based on information obtained mainly from the Natural Medicines Comprehensive Database.

CONCLUSIONS

The study findings indicate a high prevalence of pharmacy care relating to NHPs among study participants. Although pharmacists' practices around NHPs are consistent with the existing licensing framework, we found some involvement in problematic practices that necessitate further research and potential policy scrutiny. The study also uncovered patterns of recommendations, including sources relied on in recommending NHPs and in providing counselling to patients, that raise concerns about the quality and credibility of NHP-related care provided to pharmacy patrons.

Utilization and Safety of Common Over-the-Counter Dietary/Nutritional Supplements, Herbal Agents, and Homeopathic Compounds for Disease Prevention

Dietary supplements are commonly used by patients as part of their medical care plan. Often clinicians may not be aware of their use, because patients do not always consider these to be medications. All clinicians need to continually ask patients about their use of dietary supplements when collecting a medication history. Dietary supplements and prescription medications often share similar enzymatic pathways for their metabolism. These interactions may lead to severe adverse reactions. This article reviews available evidence for a variety of dietary supplements in select disease categories.

Computational Optimization of Bioanalytical Parameters for the Evaluation of the Toxicity of the Phytomarker 1,4 Napthoquinone and its Metabolite 1,2,4-trihydroxynapththalene

Objectives:

Lawsone (1,4 naphthoquinone) is a non redox cycling compound that can be catalyzed by DT diaphorase (DTD) into 1,2,4-trihydroxynaphthalene (THN), which can generate reactive oxygen species by auto oxidation. The purpose of this study was to evaluate the toxicity of the phytomarker 1,4 naphthoquinone and its metabolite THN by using the molecular docking program AutoDock 4.

Methods:

The 3D structure of ligands such as hydrogen peroxide (H₂O₂), nitric oxide synthase (NOS), catalase (CAT), glutathione (GSH), glutathione reductase (GR), glucose 6-phosphate dehydrogenase (G6PDH) and nicotinamide adenine dinucleotide phosphate hydrogen (NADPH) were drawn using hyperchem drawing tools and minimizing the energy of all pdb files with the help of hyperchem by MM⁺ followed by a semi-empirical (PM3) method. The docking process was studied with ligand molecules to identify suitable dockings at protein binding sites through annealing and genetic simulation algorithms. The program auto dock tools (ADT) was released as an extension suite to the python molecular viewer used to prepare proteins and ligands. Grids centered on active sites were obtained with spacings of 54 × 55 × 56, and a grid spacing of 0.503 was calculated. Comparisons of Global and Local Search Methods in Drug Docking were adopted to determine parameters; a maximum number of 250,000 energy evaluations, a maximum number of generations of 27,000, and mutation and crossover rates of 0.02 and 0.8 were used. The number of docking runs was set to 10.

Results:

Lawsone and THN can be considered to efficiently bind with NOS, CAT, GSH, GR, G6PDH and NADPH, which has been confirmed through hydrogen bond affinity with the respective amino acids.

Conclusion:

Naphthoquinone derivatives of lawsone, which can be metabolized into THN by a catalyst DTD, were examined. Lawsone and THN were found to be identically potent molecules for their affinities for selected proteins.

Effects of herbal drugs in Mahuang decoction and their main components on intestinal transport characteristics of Ephedra alkaloids evaluated by a Caco-2 cell monolayer model

ETHNOPHARMACOLOGICAL RELEVANCE

Mahuang decoction, Ephedra combined with Cassia twig, Bitter apricot kernel and Prepared licorice, has been widely used as a multi-herb prescription in traditional Chinese medicine (TCM). Many modern pharmacological studies have shown that the compatibility application of these four herbs has promising therapeutic effects on respiratory infection, acute glomerulonephritis and chronic renal failure. However, the underlying principles for governing the formulation of Mahuang decoction remain unknown. In this study, we used a Caco-2 cell monolayer model to explicate the possible compatibility mechanism of Mahuang decoction from the perspective of intestinal absorption.

MATERIAL AND METHODS

Firstly, the apical-to-basolateral and basolarteral-to-apical transport of the main characteristic active alkaloids in Ephedra, l-ephedrine (LEP), d-pseudoephedrine (DPEP) and l-methylephedrine (LMEP), as a single compound, was investigated. Secondly, the influence of main components in Cassia twig, Bitter apricot kernel and Prepared licorice on the transport of LEP, DPEP and LMEP was investigated. Finally, the bidirectional transport of these three alkaloids in single Ephedra extract, in Mahuang decoction and in drug pair extracts, such as Ephedra-Cassia twig, Ephedra-Bitter apricot kernel, Ephedra-Prepared licorice, was assessed.

RESULTS

The investigated LEP, DPEP and LMEP could transport through the Caco-2 cell monolayer at a high level, with the efflux ratio (ER) of 1.41, 1.33 and 1.30, respectively, when the cells were treated with each single compound solution. In the presence of verapamil, the permeability from apical side to basolateral side (PAB) of the three alkaloids increased significantly (P<0.05), and their ERs decreased. The treatment of cells with Mahuang decoction and the drug pair extracts from Ephedra-Cassia twig, Ephedra-Bitter apricot kernel and Ephedra-Prepared licorice appreciably decreased PAB of LEP, DPEP and LMEP with increased ERs, compared to the treatment with single Ephedra extract. When concomitant administration with herbal drugs and their main ingredients (including cinnamaldehyde-cinnamyl alcohol-cinnamic acid group, volatile oil from Cassia twig, liquiritin-glycyrrhizic acid group from Prepared licorice, Cassia twig extract, Bitter apricot kernel extract and Prepared licorice extract), was adopted, PAB of LEP, DPEP and LMEP were reduced significantly and the ERs of the corresponding compounds were promoted appreciably. Only amygdalin (from Bitter apricot kernel) had little influence on the transport of Ephedra alkaloids.

CONCLUSION

The findings indicate that LEP, DPEP and LMEP in Ephedra extract have similar absorption as in the pure solution of each compound. The intestinal absorption of LEP, DPEP and LMEP is through passive diffusion and these compounds may be P-gp substrates. The compatibility application of Cassia twig, Bitter apricot kernel and Prepared licorice, and their main components except amygdalin can suppress the absorption of the three main Ephedra alkaloids across the Caco-2 cell monolayer. On the basis of our results, Cassia twig, Bitter apricot kernel and Prepared licorice in Mahuang decoction decrease the absorption of Ephedra alkaloids, which may alleviate the drastic diaphoretic function and toxicity of Ephedra.

East meets West: current issues relevant to integrating Chinese medicine

This article describes the challenges that integration of Chinese medicine (CM) and biomedicine are likely to bring for improving safety, research, education, and cross-disciplinary communication. Potential strategies to meet these challenges are suggested, including the use of accessible language for the Western biomedical community, and further development of whole-system randomized controlled trials that support individualized treatment approaches.

Evaluation of subchronic toxicity of the hydroethanolic extract of Tropaeolum majus in Wistar rats

ETHNOPHARMACOLOGICAL RELEVANCE

The use of medicinal plants for the treatment of diseases usually comes from the belief that they present low toxicity due their natural origin. However, it is necessary a toxicological and pharmacological evaluation for these plants. Tropaeolum majus is a medicinal plant used in popular medicine to treat several diseases, including cardiovascular disorders, urinary tract infections and asthma. Even though several studies proved its therapeutic effects, there are few toxicological studies with this species.

AIM OF THE STUDY

The present study was carried out to evaluate the subchronic toxicity of the hydroethanolic extract obtained from leaves of T. majus (HETM) in Wistar rats.

MATERIAL AND METHODS

Male and female Wistar rats received three doses of HETM (75, 375 and 750 mg/kg) for 28 days. After the treatments biochemical, hematological and histopathological parameters were analyzed.

RESULTS

No significant alterations in the animal's body weight gain, relative organs weight, serum biochemical analysis, hematological or histopathological analyses of liver, kidneys and spleen were observed.

CONCLUSIONS

These results demonstrate the absence of subchronic toxicity due to oral treatment with HETM for 28 days in Wistar rats. However, other toxicological studies are necessary to evaluate the total safety of this plant.

Effects of ephedra on autonomic nervous modulation in healthy young adults

AIM OF THE STUDY

Given the popularity of the use of ephedra in traditional Chinese medicine around the world, a greater understanding of its actions is required. This study aims to assess the effects of ephedra on autonomic nervous modulation using power spectral analysis of heart rate variability (HRV).

METHODS

This was a randomized, double-blind, placebo-controlled, crossover study. Twenty healthy subjects were given 1g of ephedra dry extract or placebo once per day for 14 days in a crossover fashion with a 7-day washout period between treatments. Sequential HRV measures at baseline and at 30, 60, 120, and 180 min after taking ephedra or the placebo on days 1 and 14 were obtained and compared. In addition, the baseline HRV measurements on days 1, 3, 7, 10, and 14 were also obtained and compared.

RESULTS

The normalized low-frequency component (LF%) and the low/high-frequency component ratio (LF/HF) of the HRV were significantly increased, whereas the high-frequency component (HF) and normalized HF (HF%) were significantly decreased at 120 and 180 min after taking ephedra on days 1 and 14. In addition, the baseline LF% and LF/HF were significantly increased, whereas the baseline HF% was significantly decreased on days 10 and 14, as compared to day 1.

CONCLUSIONS

By power spectral analysis of the HRV of healthy young adults, it is suggested that ingestion of ephedra dry extract acutely and chronically affects autonomic nervous activity by tilting the sympathovagal balance toward increased sympathetic activity, whereas parasympathetic activity was impaired.

Acute effects of ephedra on autonomic nervous modulation in healthy young adults

The aim of this study was to assess the acute effects of ephedra on autonomic nervous modulation by means of heart rate variability (HRV) analysis, using a randomized, double-blind, placebo-controlled, crossover design. On three separate days, 20 healthy subjects took capsules containing either 1 or 2 g of ephedra dry extract or a placebo, and the sequential percentage changes in HRV measures were compared. After the subjects took ephedra, the normalized low-frequency component (LF) and the ratio of LF to high-frequency component (HF) increased significantly in a dose-dependent manner, whereas the normalized HF (HF%) decreased significantly. We conclude that ingestion of ephedra tilts the sympathovagal balance dose-dependently toward increased sympathetic activity and impairs parasympathetic activity.

Herbal supplements and therapeutic drug monitoring: focus on digoxin immunoassays and interactions with St. John's wort

Herbal supplements can affect concentrations of therapeutic drugs measured in biological fluids by different mechanisms. Herbal products can either directly interfere with the methodology used in the measurement of drugs or indirectly interfere by altering the pharmacokinetics of coadministered drugs. The active components of Chan Su, Lu-Shen-Wan, Dan Shen, Asian and Siberian ginseng, oleander containing supplements, and Ashwagandha interfere with digoxin measurements by immunoassays, especially the polyclonal antibody-based immunoassays. Herbal supplements are sometimes contaminated with Western drugs causing drug toxicity. A therapeutic drug monitoring (TDM) service is very helpful for diagnosis of drug toxicity in such patients. Herbal products such as St. John's wort, a popular herbal antidepressant, increase the clearance of certain drugs either by increasing the activity of liver or intestinal cytochrome P-450 mixed-function oxidase or through modulation of the P-glycoprotein efflux pump. Significantly reduced concentrations of various therapeutic drugs such as digoxin, theophylline, cyclosporine, tacrolimus, tricyclic antidepressants, warfarin, and protease inhibitors can be observed due to interaction of these drugs with St. John's wort, causing treatment failure. On the other hand, a few drugs such as carbamazepine, mycophenolic acid, and procainamide do not show any interaction with St. John's wort. Understanding the effect of herbal products on TDM methodologies and identification of interactions between herbal products and drugs by TDM are very important clinically.