Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: a systematic literature review

Changes in Reported Dietary Supplement Use in Cognitively Normal National Alzheimer's Coordinating Center Participants Aged 55 and Older From 2015 to 2019

BACKGROUND

Although reported dietary supplement use is common in older adults, evaluations of dietary supplement use over the past 10 y are lacking.

OBJECTIVE

This analysis determined changes in reported dietary supplement use in cognitively normal older adults (aged ≥ 55 y) using the National Alzheimer's Coordinating Center data from 2015 to 2019 using a serial cross-sectional study design.

METHODS

The first available visit for cognitively normal participants aged ≥ 55 y from 2015 to 2019 with a complete medication form was used, resulting in 9357 participants. Associations between visit year categories and reported use of dietary supplement categories/individual supplements were tested using categorical statistics. To determine whether the probabilities of reported supplement use changed in 2019 compared with those of 2015, z-scores and two-sided P values were used. Weighted analyses were used to confirm analytical findings.

RESULTS

When comparing 2015 and 2019, the reported use of any dietary supplement decreased from 77.7% in 2015 to 71.0% in 2019 (P < 0.0001); any vitamin from 72.5% to 65.5% (P < 0.0001); any mineral from 39.2% to 30.4% (P < 0.0001); "other" nonvitamin/nonmineral supplements from 34.4% to 26.9% (P < 0.0001), calcium from 31.2% to 21.7% (P < 0.0001), multivitamins from 48.4% to 38.4% (P < 0.0001), potassium from 5.6% to 3.5% (P = 0.001), vitamin C from 13.0% to 9.2% (P = 0.0002), chondroitin from 6.0% to 4.1% (P = 0.006), glucosamine from 11.1% to 6.5% (P < 0.0001), and all omega fatty acids from 25.2% to 17.0% (P < 0.0001). Reported use increased for vitamin B7/biotin from 3.1% in 2015 to 5.8% in 2019 (P = 0.0003), melatonin from 3.1% to 5.8% (P = 0.0002), and turmeric from 1.2% to 4.7% (P < 0.0001).

CONCLUSION

Although the reported use of many major dietary supplement categories and individual supplements significantly decreased in older adults from 2015 to 2019, biotin, turmeric, and melatonin significantly increased. Because biotin may interfere with some laboratory tests, this may have important public health implications.

Knowledge and Beliefs about Herb/Supplement Consumption and Herb/Supplement-Drug Interactions among the General Population, including Healthcare Professionals and Pharmacists: A Systematic Review and Guidelines for a Smart Decision System

The increased consumption of a variety of herbs/supplements has been raising serious health concerns. Owing to an inadequate understanding of herb/supplement-drug interactions, the simultaneous consumption of these products may result in deleterious effects and, in extreme cases, even fatal outcomes. This systematic review is aimed at understanding the knowledge and beliefs about the consumption of herbs/supplements and herb/drug-supplement interactions (HDIs). The study follows the PRISMA guidelines. Four online databases (Web of Science; PubMed; Cochrane; and EBSCOhost) were searched, and a total of 44 studies were included, encompassing 16,929 participants. Herb and supplement consumption is explained mostly by the reported benefits across multiple conditions and ease of use. Regarding HDIs, most people take both herbs/supplements and prescription drugs simultaneously. Only a small percentage of participants have knowledge about their interaction effects, and many reported adverse interactions or side effects. Nevertheless, the main reason for stopping the prescribed drug intake is the perceived lack of its effect, and not due to interactions. Therefore, it is important to increase the knowledge about supplement use so that further strategies can be elaborated to better detect or be alert for whenever a potentially dangerous reaction and/or interaction may occur. This paper raises awareness regarding the need for developing a decision support system and ends with some considerations about the development of a technological solution capable of detecting HDIs and, thereby, aiding in the improvement of pharmacy services.

Lysiphyllum strychnifolium (Craib) A. Schmitz Extracts Moderate the Expression of Drug-Metabolizing Enzymes: In Vivo Study to Clinical Propose

Lysiphyllum strychnifolium (Craib) A. Schmitz (LS) has been traditionally used as a medicinal herb by folk healers in Thailand with rare evidence-based support. Hepatic cytochrome P450s (CYPs450) are well known as the drug-metabolizing enzymes that catalyze all drugs and toxicants. In this study, we investigated the mRNA levels of six clinically important CYPs450, i.e., CYP1A2, 3A2, 2C11, 2D1, 2D2, and 2E1, in rats given LS extracts. Seventy Wistar rats were randomized into seven groups (n = 10). Each group was given LS stem ethanol (SE) and leaf water (LW) extracts orally at doses of 300, 2000, and 5000 mg/kg body weight (mg/kg.bw) for twenty-eight consecutive days. After treatment, the expression of CYPs450 genes was measured using quantitative real-time PCR. The results revealed that SE and LW, which contained quercetin and gallic acid, promoted the upregulation of all CYPs450. Almost all CYPs450 genes were downregulated in all male LW-treated rats but upregulated in female-treated groups, suggesting that CYP gene expressions in LS-treated rats were influenced by gender. Moderate and high doses of the LS extracts had a tendency to induce six CYP450s’ transcription levels in both rat genders. CYP2E1 gene showed a unique expression level in male rats receiving SE at a dose of 2000 mg/kg.bw, whereas a low dose of 300 mg/kg.bw was found in the LW-treated female group. As a result, our findings suggest that different doses of LS extracts can moderate the varying mRNA expression of clinically relevant CYP genes. In this study, we provide information about CYP induction and inhibition in vivo, which could be a desirable condition for furthering the practical use of LS extracts in humans.

The Prevalence of Dietary Supplements That Claim Estrogen-like Effects in Japanese Women

Recently, adverse events, such as irregular vaginal bleeding and menstrual disorders, associated with the use of dietary supplements containing Pueraria mirifica, have been reported in Japan. P. mirifica contains phytoestrogens, such as deoxymiroestrol and miroestrol. Therefore, we investigated the use of supplements that claim to have estrogen-like effects (i.e., estrogen-like supplements) in Japanese women aged from 15 to 69 years old in an online survey. The prevalence of estrogen-like supplement use was 5%, accounting for approximately 15% of the sample, including ex-users. The majority of the users were in their 40s and 50s, mainly using these supplements for the treatment of menopausal symptoms. In contrast, the younger generation mainly used them for beauty purposes, such as weight loss, mastogenic effects, and skin care. Many of them visited a clinic or took medicines for menstrual-related troubles. In all age groups, soybeans/isoflavones were the most commonly used, followed by equol and placenta. Participants in their teens and 20s also used P. mirifica. Among them, 16.2% had experienced adverse events, including irregular vaginal bleeding, breast swelling and pain, and heavy menstruation. In conclusion, estrogen-like supplement use is associated with adverse events; thus, it is necessary to pay attention to the use of these supplement. Furthermore, because the purpose of use differs depending on generation, caution according to each generation is necessary.

Differences in the Perception of Dietary Supplements between Dietary Supplement/Medicine Users and Non-Users

Some patients use dietary supplements and medicines concomitantly, with an inappropriate perception of their safety and efficacy. To clarify the perception between dietary supplement and medicine users and non-users, we conducted an internet survey. In this survey, 38.9% of participants used dietary supplements, 32.6% used prescription medicines, and 14.7% used dietary supplements and prescription medicines concomitantly. Then, we conducted a further survey on four groups, dietary supplement and prescription medicine users, dietary supplement only users, prescription medicine only users, and non-users (500 each). Dietary supplement users had favorable outcomes in terms of both the safety and efficacy of dietary supplements compared to dietary supplement non-users. This perception of dietary supplements was independent from medicine use. The awareness of the Health Food Network consumer navigation site, which provides information about dietary supplements for consumers, was the highest among dietary supplement and prescription medicine users, but it was still low (2.2%). In conclusion, consumers who use dietary supplement and prescription medicine concomitantly have favorable outcomes for their safety and efficacy and a low awareness of their interaction. There is a need to provide information, especially regarding the risk of interaction, that takes into account the consumer's situation.

Why Did I Consult My Pharmacist about Herbal and Dietary Supplements? An Online Survey Amid the COVID-19 Pandemic in Malaysia

Herbal and dietary supplements (HDSs) are frequently obtained from community pharmacies, but community pharmacists (CPs) have been underutilized for information regarding them. This study aimed to determine the prevalence of, factors behind, and reasons for consultation with CPs among HDS consumers in Malaysia. A cross-sectional study using an online survey was conducted among conveniently sampled individuals in Malaysia. Reasons for consultation or non-consultation with CPs about HDSs were sought from the respondents. A logistic regression analysis was conducted to determine the predictors of consultation with CPs. Overall, 40.3% (239/593) of participants consulted CPs about the HDSs that they purchased. The participants were predominantly unmarried (362/588, 61.6%) and belonged to the 18-29 age group (332/593, 56%). The multivariate analysis showed that a suburban residential setting was the only significant predictor for consultation with CPs (adjusted odds ratio = 0.390, 95% CI = 0.260-0.583). Respondents who consulted CPs generally agreed that the CPs were the right people to consult on HDSs (mean = 4.37, SD = 0.73). However, their discussion with CPs regarding HDSs mostly revolved around the benefits and directions for use, but little on the potential risks. Meanwhile, most respondents who did not consult CPs agreed that they had never thought of consulting CPs about their HDS use (mean = 3.45, SD = 1.02). The majority of them referred to the Internet (61.3%, 217/354) and social media (59.9%, 212/354) for information about HDSs. The findings from this study show that more efforts are warranted in encouraging consumers to consult CPs about their HDS use and to enhance their awareness of the roles of CPs in ensuring the safe use of HDSs.

Effect of turmeric supplementation on the pharmacokinetics of paclitaxel in breast cancer patients: A study with population pharmacokinetics approach

Turmeric is one of the most used herbal supplements among cancer patients. It reportedly modulates the function of CYP450 enzymes and drug transporters. This study investigates the effect of turmeric on the pharmacokinetics of paclitaxel in breast cancer patients. This is a prospective longitudinal study with 60 breast cancer patients on treatment with single-agent paclitaxel and turmeric. The patients were followed up for two consecutive chemotherapy cycles, and their blood samples were collected, first without turmeric (first cycle) and the next after a 21-day concomitant administration of 2 g/day turmeric (second cycle). Plasma samples were quantified for paclitaxel concentration using High Performance Liquid Chromatograph with UV detector (HPLC-UV) method. The sparse concentration-time data of paclitaxel were subjected to population pharmacokinetic modeling, and then noncompartmental analysis (NCA) was performed on the simulated data to estimate the pharmacokinetic parameters of paclitaxel, before and after turmeric supplementation, for comparisons. The population pharmacokinetic parameters of paclitaxel differed from before to after turmeric supplementation. NCA of simulated concentration-time profiles showed a statistically significant reduction of 7.7% and 12.1% in AUC_inf and Cmax, respectively. Given the small magnitude of the changes in pharmacokinetic parameters, the observed changes are not clinically relevant. Thereby, turmeric at the recommended dose can be combined safely with paclitaxel.

Effect of Phosphate Binders and a Dietary Iron Supplement on the Pharmacokinetics of a Single Dose of Vadadustat in Healthy Adults

Vadadustat is a hypoxia-inducible factor prolyl-hydroxylase inhibitor being developed for the treatment of anemia in patients with chronic kidney disease. Sequelae of chronic kidney disease include hyperphosphatemia and anemia, which are frequently treated with phosphate binders and iron supplements, respectively. Two studies evaluating the pharmacokinetics, safety, and tolerability of a single oral dose of vadadustat coadministered with a phosphate binder or iron supplement were conducted in healthy adult participants. In study 1, 54 healthy women and men were administered vadadustat (300 mg) alone and 1 hour before, concurrently with, or 2 hours after a phosphate binder (sevelamer carbonate 1600 mg, calcium acetate 1334 mg, or ferric citrate 2000 mg). In study 2, 10 healthy men were administered vadadustat (450 mg) alone and concomitantly with the oral iron supplement ferrous sulfate (325 mg [equivalent to 65 mg of elemental iron]). Vadadustat exposure was reduced by coadministration with sevelamer carbonate, calcium acetate, ferric citrate, or ferrous sulfate. Geometric least squares mean ratios for area under the concentration-time curve from time 0 to infinity were reduced 37% to 55% by phosphate binders and 46% by ferrous sulfate. However, when vadadustat was administered 1 hour before phosphate binders, 90% confidence intervals for vadadustat exposure were within the no-effect boundaries of +50% to -33%, indicating that drug-drug interactions can be reduced by administering vadadustat 1 hour before phosphate binders. Vadadustat was well tolerated when administered in conjunction with phosphate binders or an iron supplement.

OUP accepted manuscript

Background

Complementary medicines (CM) are frequently used by patients with cancer. Controversy exists over the effectiveness and risk that CM may add to conventional cancer therapy. The incidence of CM use among patients enrolled in phase III clinical trials is unknown.

Methods

Medication lists from 6 international phase III clinical trials were retrospectively reviewed to identify patients using CM. Patients had metastatic breast, colorectal, or lung cancers. Quality of life, adverse events, overall survival, and progression-free survival were compared between CM users and non-users. Baseline differences between groups were adjusted with propensity score matching groups.

Results

Seven hundred and six of 3446 patients (20.5%) used at least one CM. CM use was highest among patients with breast cancer (35.6%). CM users had more favorable baseline prognostic factors (ECOG 0-1, non-smoking status, younger age, and fewer metastases). CM use was associated with lower rates of adverse events (50% vs. 62%, P = .002) and quality of life was similar between both groups. After adjustment with propensity score matching, CM use was also associated with longer overall survival in patients with lung cancer (adjusted hazard ratio 0.80, 95%CI, 0.68-0.94, P =.0054). However, several key control variables like EGFR status were not available.

Conclusion

One in 5 patients in phase III clinical trials report using CM. CM was not associated with worse cancer-specific outcomes. However, CM users had more favorable baseline prognostic factors, and likely other confounders that may have contributed to improved outcomes observed in the lung cohort. Physicians should monitor for CM use and potential interactions with clinical trial drugs.

Determination of the Awareness about and Need for Health Support Pharmacies as the Provider of Consultation Service about Nutrition Education and Diet-Related Health Promotion by Health Professionals in Japan

Health support pharmacies (HSPs) have been established as a new category of pharmacies in Japan. In addition to prescriptions, HSPs provide several health services, including consultations on diet/nutrition, health foods, and nursing care. Therefore, not only individuals receiving medications but also community residents should have access to HSPs. However, it is unclear whether people are aware of HSPs. Thus, the purpose of this study was to assess the awareness about HSPs and determine the need for their services. To this end, we conducted an online cross-sectional questionnaire survey in 10,000 Japanese adults. Approximately 60.2% of the participants were aware of family pharmacies/pharmacists, and 21.8% of these participants had a family pharmacy/pharmacist. Meanwhile, 2.6% of the participants were aware of HSPs, while 9.2% of the participants had only heard of HSPs. Awareness of HSPs was higher among men and younger individuals than among women and older generations. In addition, only 7.2% of the participants were aware of the location of the HSP in their area of residence. At the time at which this survey was conducted, only 3.5% of the participants were using HSP services, and half of them did not perceive the merits of using these services. However, 44.4% of the participants wished to avail themselves of HSP services in the future, and this desire increased with age. Half of the participants wished to use services that were associated with drugs, and the need for other services, such as consultations on diet/nutrition or health foods, was low. In conclusion, there was low awareness about HSPs among the survey participants. However, from our findings, we gathered that if individuals are aware of HSPs, they will wish to use HSP services. To improve healthy life expectancy, it is important to increase awareness about HSPs and their number.

Current perspectives in herbal and conventional drug interactions based on clinical manifestations

Background

Herbs are an important source of pharmaceuticals. Herbs are traditionally used by millions of peoples for medicine, food and drink in developed and developing nations considering that they are safe. But, interaction of herbs with other medicines may cause serious adverse effects or reduces their efficacy. The demand for “alternative” medicines has been increased significantly, which include medicine derived from plant or herbal origin. The objective of this review article mainly focuses on drug interactions of commonly used herbs along with possible mechanisms. The method adopted for this review is searching of herb-drug interactions in online database.

Main text

Herb-drug interaction leads to pharmacological modification. The drug use along with herbs may show pharmacodynamic and pharmacokinetic interactions. Pharmacokinetic interaction causes alteration in absorption, distribution, metabolism and elimination. Similarly, pharmacodynamic interaction causes additive or synergistic or antagonist effect on the drugs or vice versa. Researchers had demonstrated that herbs show the toxicities and drug interactions like other pharmacologically active compounds. There is lack of knowledge amongst physician, pharmacist and consumers related to pharmacological action and mechanism of herb-drug interaction. This review article focuses on the herb-drug interaction of danshen (Salvia miltiorrhiza), Echinacea (Echinacea purpurea), garlic (Allium sativum), ginkgo (Ginkgo biloba), goldenseal (Hydrastis canadensis), green tea (Camellia sinensis), kava (Piper methysticum), liquorice (Glycyrrhiza glabra), milk thistle (Silybum marianum) and St. John’s wort (Hypericum perforatum) along with probable mechanisms and clinical manifestation based on case studies reported in literature.

Conclusion

Herb-drug interactions may lead to serious side effects. Physician, pharmacist and patients must be more cautious while prescribing and or consuming these herbs.

Japanese newspaper advertisements for dietary supplements before and after COVID-19: a content analysis

OBJECTIVES

Public health institutions have alerted consumers about advertising for dietary supplements with false claims of preventing or treating COVID-19. We quantitatively and qualitatively examined newspaper advertisements for dietary supplements before and after the COVID-19 spread.

DESIGN

Content analysis.

PARTICIPANTS

We analysed advertisements for dietary supplements in two major Japanese newspapers in February-July 2019 and February-July 2020. Our analysis covered 2167 advertisements.

RESULTS

The number of advertisements for dietary supplements that claimed to be effective in infection prevention (p=0.009) and improving joint (p=0.002) and digestive functions (p=0.002) significantly increased after the spread of COVID-19 compared with before. Dietary supplements that claimed to be effective in preventing infection were advertised in combination with recommendations for gargling and handwashing. Such terms as 'defence' and 'prevent' were used to promote the preventive effect.

CONCLUSIONS

False and misleading claims in advertising for dietary supplements may result in consumer harm, such as overdosing and failure to take preventive behaviour. While the pandemic continues, there will be an increasing need for disseminating accessible information about the appropriate use of dietary supplements, consumer education and warnings to manufacturers.

Suplementy diety – specyficzna żywność

Rynek suplementów diety rozwija się bardzo dynamicznie, co ma związek z rozpowszechnieniem tej kategorii produktów w środkach masowego przekazu, stosunkowo bezproblemową procedurą wprowadzenia na polski rynek oraz powszechną dostępnością (można je nabyć w aptece, sklepach zielarskich, spożywczych oraz w Internecie). Z definicji suplementy mają być uzupełnieniem diety, zaliczają się do żywności oraz nie mogą wykazywać działania leczniczego. Ich postać, która została ustawowo określona, może być wizualnie identyczna z postacią farmaceutyczną produktów leczniczych, co może wprowadzać konsumentów w błąd, jeżeli nie wiedzą, jak rozróżniać te dwie grupy. Polska legislacja nie uwzględnia żadnych wymogów dotyczących parametrów technologicznych czy właściwości fizycznych gotowych produktów. Na bezpieczeństwo stosowania suplementów diety, oprócz ich jakości i rzeczywistej zawartości deklarowanych składników, składa się również ewentualna obecność zanieczyszczeń i niedozwolonych substancji dodatkowych. Wybiórcza kontrola rynku oraz brak szczegółowych wytycznych dotyczących parametrów postaci suplementów daje znaczną dowolność producentom, jednocześnie umożliwia wprowadzenie na rynek produktów o wątpliwej jakości, które mogą zagrażać konsumentom, będąc całkowicie pozbawionymi działania prozdrowotnego. Ze względu na rosnące zainteresowanie tą grupą produktów przez konsumentów, przedstawiono w pracy sytuację prawną suplementów diety na polskim rynku, odnosząc się także do legislacji europejskiej i amerykańskiej. Omówiono procedurę wprowadzania na rynek, podstawowe wytyczne stawiane tej grupie produktów, wskazania do stosowania oraz aspekty związane z bezpieczeństwem i zagrożeniami wynikającymi ze stosowania suplementów diety.

A Content Analysis of Video Advertisements for Dietary Supplements in Japan

Dietary supplements are widely advertised and the market is expanding worldwide. Research suggests that dietary supplement advertising may lead consumers to make inappropriate health-related decisions, to express behaviors such as overdosing, and to neglect healthy lifestyle behaviors. We conducted a content analysis of video advertisements for dietary supplements and described the content of advertisements with high numbers and frequent views. We analyzed 82 video advertisements on YouTube that promoted fat-reduction effects. We extracted 22 themes and classified them into 10 categories. The categories with the highest numbers of advertisements were “Exemption” (i.e., consuming the product frees the audience from refraining from binge eating) (20 ads, 24.4%) and “Health Concerns” (i.e., the product intake solves the health concerns of the audience) (19 ads, 23.2%). These advertisements may stimulate negative audience attitudes toward appropriate health behaviors. The category with the most frequent views was “Lifestyle” (i.e., adding product intake to a healthy lifestyle) (3,035,298 views). “Lifestyle” advertisements portray physical activity in a positive light and may promote appropriate health behaviors in the audience. We discuss the possible effects of the advertisements on audiences and consider issues for future research and practice.

Ethical considerations and challenges in herbal drug trials with the focus on scientific validity and risk assessment

Scientific validity and risk assessment are two main ethical issues which raise specific challenges and are unique to clinical trials investigating crude extracts/fractions from herbal materials. There are considerable challenges for both clinical investigators and ethics committee members in dealing with such issues, many of them remain unresolved, resulting in a large variation in ethical requirements, justification, and decisions. Despite a remarkable surge in herbal medicine research globally, a number of clinical investigators or even ethics committee members have limited confidence in dealing with related ethical issues. In this article, we extensively review and discuss the two main ethical issues (i.e., scientific validity and risk assessment) and highlight key considerations that are important for ethical review and justification for the conduct of herbal drug trials.

Polish students’ knowledge of dietary supplements

Background

The increasing intake of dietary supplements (DS) can be observed worldwide. These preparations are classified as a special category of foods and are subject to food law, not pharmaceutical regulations. As a result, the requirements for DS are much less restrictive than for medications.

Methodology

This research was conducted in a group of young Polish students of pharmacy at the Medical University of Silesia in Katowice (SUM) and of finance and accounting at the University of Economics in Katowice (UE). The survey contained questions concerning DS, such as difference to drugs, scope of use, and safety.

Results

The respondents answered questions about taking DS and the effects of their use. DS were used either currently or in the past by about 70% of the respondents, while about 30% of the surveyed population declared that they did not use these preparations. Women and UE students predominated among those not taking DS.

Conclusion

Multi-component products taken for a period of less than 3 months to supplement a deficit for a given component were used the most often. One product was taken at a time. The respondents read product information and followed the recommended doses. Over 50% of the studied population was aware of the negative effects of DS. Adverse symptoms of DS use were observed by 5% of the respondents.

Deficiency of vitamins C and E in women of childbearing age in Brazil: a systematic review and meta-analysis

BACKGROUND

Despite the several options available for supplements containing vitamins C and E, evidence regarding the prevalence of deficiency or insufficiency of these vitamins is weak.

OBJECTIVES

To estimate the prevalence of deficiency or insufficiency of vitamins C and E and associated factors among women of childbearing age, in Brazil.

DESIGN AND SETTING

Systematic review and meta-analysis conducted at a Brazilian public university.

METHODS

A search from index inception until May 2020 was conducted. Meta-analyses were performed using inverse variance for fixed models, with summary proportions calculation using Freeman-Tukey double arcsine (base case). Reporting and methodological quality were assessed using the Joanna Briggs Institute tool for prevalence studies.

RESULTS

Our review identified 12 studies, comprising 1,316 participants, especially breastfeeding women. There was at least one quality weakness in all studies, mainly regarding sampling method (i.e. convenience sampling) and small sample size. The prevalence of vitamin C deficiency ranged from 0% to 40%. Only vitamin E deficiency was synthetized in meta-analyses, with mean prevalences of 6% regardless of the alpha-tocopherol cutoff in plasma, and 5% and 16% for cutoffs of < 1.6-12.0 mmol/l and < 16.2 mmol/l, respectively. The cumulative meta-analysis suggested that a trend to lower prevalence of vitamin E deficiency occurred in recent studies.

CONCLUSIONS

Although the studies identified in this systematic review had poor methodological and reporting quality, mild-moderate vitamin C and E deficiencies were identified, especially in breastfeeding women. Thus, designing and implementing policies does not seem to be a priority, because the need has not been properly dimensioned among women of childbearing age in Brazil.

REGISTRATION NUMBER IN PROSPERO

CRD42020221605.

Multifaceted Factors Causing Conflicting Outcomes in Herb-Drug Interactions

Metabolic enzyme and/or transporter-mediated pharmacokinetic (PK) changes in a drug caused by concomitant herbal products have been a primary issue of herb and drug interactions (HDIs), because PK changes of a drug may result in the alternation of efficacy and toxicity. Studies on HDIs have been carried out by predictive in vitro and in vivo preclinical studies, and clinical trials. Nevertheless, the discrepancies between predictive data and the clinical significance on HDIs still exist, and different reports of HDIs add to rather than clarify the confusion regarding the use of herbal products and drug combinations. Here, we briefly review the underlying mechanisms causing PK-based HDIs, and more importantly summarize challenging issues, such as dose and treatment period effects, to be considered in study designs and interpretations of HDI evaluations.

Guidelines for Cancer-Related Pain: A Systematic Review of Complementary and Alternative Medicine Recommendations

BACKGROUND AND OBJECTIVE

Although up to 85% of patients with cancer use complementary and alternative medicine (CAM), they commonly do not disclose this information to their healthcare providers. Cancer-related pain (CRP) is one of the most common symptoms among those who may seek CAM. This study was conducted to identify the quantity and assess the quality of CAM recommendations across clinical practice guidelines (CPGs) for the treatment and/or management of CRP, as this has not been explored in the literature.

METHODS

A systematic review was conducted to identify cancer pain CPGs. MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from 2009 to 2020. The Guideline International Network and the National Centre for Complementary and Integrative Health websites were also searched. Eligible CPGs on CRP in adults were assessed using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

RESULTS

Of 771 unique search results, 13 mentioned CAM and 11 made CAM recommendations. Eligible CPGs were published in 2009 or later and focused on the treatment/management of CRP. Scaled domain percentages from highest to lowest ranged from (overall, CAM): 88.1%, 88.1% (for scope and purpose) to 21.0%, 8.5% (for applicability). Quality varied within and across CPGs. One CPG was recommended by both appraisers; 6 were recommended as "Yes" or "Yes with modifications."

CONCLUSIONS

The present study has identified and summarized a number of CPGs that clinicians may consult to understand what CAMs are recommended in the context of the treatment and/or management of CRP.

Toxicity and gas chromatography-mass spectrometry analyses of a polyherbal formulation commonly used in Ibadan metropolis, Nigeria

A polyherbal formulation mainly composed of Hibiscus sabdariffa and Aloe barbadensis commonly patronized by some staff and students of a College Hospital in Ibadan, Nigeria was evaluated for its toxicity status and bioactive constituents. Its safety was assessed using acute and sub-chronic toxicity models in Wistar rats while Gas Chromatography-Mass Spectrometry (GC-MS) was used to identify the bioactive constituents. Findings showed that oral administration of the polyherbal formulation did not cause any notable behavioral changes or mortality in the animals during the acute toxicity testing. Similarly, statistical analysis of the data obtained showed that sub-chronic administration of the polyherbal formulation did not cause any significant changes in the serum activities of liver-function enzymes, hematological markers, serum electrolytes and other evaluated blood-chemistry indices in the experimental animals compared to those of their control counterparts. These observations were substantiated by the liver photomicrographs which showed that treatment of animals with the polyherbal mixture did not induce any visible lesions or derangements in the examined organ. Besides, GC-MS screening of the polyherbal formulation revealed compounds with known biological effects which are associable with the locally acclaimed therapeutic applications of the formulation. The outcome of this study therefore suggests high safety for the investigated polyherbal mixture and thus supports its usage in folklore medicine.

Assessing the enrichment of dietary supplement coverage in the Unified Medical Language System

OBJECTIVE

We sought to assess the need for additional coverage of dietary supplements (DS) in the Unified Medical Language System (UMLS) by investigating (1) the overlap between the integrated DIetary Supplements Knowledge base (iDISK) DS ingredient terminology and the UMLS and (2) the coverage of iDISK and the UMLS over DS mentions in the biomedical literature.

MATERIALS AND METHODS

We estimated the overlap between iDISK and the UMLS by mapping iDISK to the UMLS using exact and normalized strings. The coverage of iDISK and the UMLS over DS mentions in the biomedical literature was evaluated via a DS named-entity recognition (NER) task within PubMed abstracts.

RESULTS

The coverage analysis revealed that only 30% of iDISK terms can be matched to the UMLS, although these cover over 99% of iDISK concepts. A manual review revealed that a majority of the unmatched terms represented new synonyms, rather than lexical variants. For NER, iDISK nearly doubles the precision and achieves a higher F1 score than the UMLS, while maintaining a competitive recall.

DISCUSSION

While iDISK has significant concept overlap with the UMLS, it contains many novel synonyms. Furthermore, almost 3000 of these overlapping UMLS concepts are missing a DS designation, which could be provided by iDISK. The NER experiments show that the specialization of iDISK is useful for identifying DS mentions.

CONCLUSIONS

Our results show that the DS representation in the UMLS could be enriched by adding DS designations to many concepts and by adding new synonyms.

Turkish inappropriate medication use in the elderly (TIME) criteria to improve prescribing in older adults: TIME-to-STOP/TIME-to-START

Aim

To meet the current need in different European countries for improving prescribing in older adults, we aimed to create an update screening tool getting origin from the two user friendly criterion sets: the STOPP/STARTv2 criteria and CRIME criteria.

Findings

Based on thorough literature review, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified. As a result, 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced.

Message

TIME criterion set is an update screening tool reported from Eastern Europe that included experts from geriatrics and other specialties frequently giving care to older adults and some additional practical explanations for clinical use.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users.

Purpose

To improve prescribing in older adults, criterion sets have been introduced from different countries. While current criterion sets are useful to some extent, they do not meet the need in some European countries. Turkish inappropriate medication use in the elderly (TIME) criteria was planned to meet this need.

Methods

In phase 1, the user friendly sets: STOPP/START version2 and CRIME criteria were combined. National experts composed of geriatricians and non-geriatricians were invited to review and comment. In phase 2, thorough literature review was performed and reference-based revisions, omissions, and additions were made. Explanatory additions were added to some criteria to improve application in practice. In phase 3, all working group members reviewed the criteria/explanations and agreed on the final content.

Results

Phase 1 was performed by 49 expert academicians between May and October 2016. Phase 2 was performed by 23 working group academicians between October 2016 and November 2018 and included face-to-face interviews between at least two geriatrician members and one criterion-related specialist. Phase 3 was completed between November 2018–March 2019 with review and approval of all criteria by working group academicians. As a result, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified from the first draft. A total of 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced.

Conclusion

TIME criteria is an update screening tool that differs from the current useful tools by the interactive study of experts from geriatrics and non-geriatrics, inclusion of practical explanations for some criteria and by its eastern European origin. TIME study respectfully acknowledges its roots from STOPP/START and CRIME criteria. Studies are needed whether it would lead improvements in older adults’ health.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users.

Outcome Expectancies, Health Information Seeking, and Cancer Beliefs Associated with Multivitamin/Mineral Use in a National Sample, HINTS-FDA 2015

BACKGROUND

Dietary supplements, including multivitamins/minerals, are commonly reported by adults, yet little is known about multivitamin/mineral use in relation to information seeking, cancer-specific outcome expectancies, and cancer beliefs.

OBJECTIVE

To examine the relationship of heath information seeking, beliefs about cancer, and outcome expectancies with multivitamin/mineral use within a national sample.

DESIGN

A secondary analysis of data collected by The Health Information National Trends Survey (HINTS) and the US Food and Drug Administration (FDA) (HINTS-FDA 2015) was conducted. HINTS-FDA 2015 evaluated information seeking, beliefs about cancer, and health behaviors and was a self-administered, two-stage mail survey sent to a random sample of US postal addresses stratified by county smoking rates.

PARTICIPANTS

Adult household residents were invited to participate, resulting in a 33% response rate (n=3,738).

MAIN OUTCOME MEASURES

Participants self-reported use of multivitamin/mineral products.

STATISTICAL ANALYSES

Adjusting for covariates (demographics, single-ingredient and herbal supplement use) weighted stepwise binary logistic regression was used to examine correlates of self-reported multivitamin/mineral use.

RESULTS

Intake was associated with less than a high school education, having health insurance, and single-ingredient and herbal supplement use. Trust in health organizations (odds ratio [OR]=1.67, P<0.001) and the expectancy that cancer could be avoided with dietary supplements (OR=1.76, P<0.001) correlated with use. Agreement that supplements labeled as "anticarcinogenic" could treat (OR=3.07, P<0.001) or prevent cancer (OR=6.06, P<0.001) correlated with multivitamin/mineral use. Fatalistic beliefs (P<0.001) and negative information-seeking experiences (P<0.001) were associated with slightly lower odds of use.

CONCLUSIONS

Despite leading health organizations' discouragement of dietary supplements for cancer prevention, this study found that trust in health organizations and outcome expectancies were associated with multivitamin/mineral use. This divergence presents a need to explore how dietary supplement evidence based recommendations can be translated and disseminated for the public.

Current trends in drug metabolism and pharmacokinetics

Pharmacokinetics (PK) is the study of the absorption, distribution, metabolism, and excretion (ADME) processes of a drug. Understanding PK properties is essential for drug development and precision medication. In this review we provided an overview of recent research on PK with focus on the following aspects: (1) an update on drug-metabolizing enzymes and transporters in the determination of PK, as well as advances in xenobiotic receptors and noncoding RNAs (ncRNAs) in the modulation of PK, providing new understanding of the transcriptional and posttranscriptional regulatory mechanisms that result in inter-individual variations in pharmacotherapy; (2) current status and trends in assessing drug-drug interactions, especially interactions between drugs and herbs, between drugs and therapeutic biologics, and microbiota-mediated interactions; (3) advances in understanding the effects of diseases on PK, particularly changes in metabolizing enzymes and transporters with disease progression; (4) trends in mathematical modeling including physiologically-based PK modeling and novel animal models such as CRISPR/Cas9-based animal models for DMPK studies; (5) emerging non-classical xenobiotic metabolic pathways and the involvement of novel metabolic enzymes, especially non-P450s. Existing challenges and perspectives on future directions are discussed, and may stimulate the development of new research models, technologies, and strategies towards the development of better drugs and improved clinical practice.

General public knowledge and use of dietary supplements in Riyadh, Saudi Arabia

Context:

Dietary supplements is a growing industry, pharmaceuticals are having several types of similar supplements and multivitamins as over-the-counter products, a complete diet is necessary for a healthy body which leads to the usage of supplements or multivitamins complementing diets as needed, therefore leading to its encouraged usage among the population worldwide.

Aims:

The study was aimed to determine the public's knowledge and their use of dietary supplements.

Settings and Design:

A cross-sectional study was conducted among the general public of Riyadh, Saudi Arabia.

Methods and Materials:

The sample consisted of 679 participants including 41% males and 59% females. The ethnicity of the participants is 100% Arabs.

Statistical Analysis Used:

SPSS.

Results:

The sociodemographic data showed there were more female participants than males (59.1% vs. 40.9%), most of our participants had at least bachelor degree (64.4%), most of our participants had normal BMI (62.3%). 88.5% had knowledge on supplements and only 11.5% stated they were not aware at all.

Conclusions:

Dietary supplements and multivitamins consumption is prevalent among Saudi Arabian population. Our study suggests the majority of consumers understand the supportive role of dietary supplements and are aware of risks and side effects.

Pharmacokinetic Interactions between Cardiovascular Medicines and Plant Products

The growing use of plant products among patients with cardiovascular pharmacotherapy raises the concerns about their potential interactions with conventional cardiovascular medicines. Plant products can influence pharmacokinetics or/and pharmacological activity of coadministered drugs and some of these interactions may lead to unexpected clinical outcomes. Numerous studies and case reports showed various pharmacokinetic interactions that are characterized by a high degree of unpredictability. This review highlights the pharmacokinetic clinically relevant interactions between major conventional cardiovascular medicines and plant products with an emphasis on their putative mechanisms, drawbacks of herbal products use, and the perspectives for further well-designed studies.

Immunomodulatory effects of dietary IMUNO-2865 in mice, pre-and post-vaccine challenge with parainfluenza virus 5

Herbal remedies and nutraceuticals continue to be used as treatments for a variety of maladies ranging from joint disease to obesity. IMUNO-2865 is a natural nutraceutical supplement that has been advertised to modulate inflammation, boost cytokine activity promoting a robust immunity, but has yet to be evaluated as an adjuvant. In the present study, 4-week-old C57BL/6 female mice (n = 45) were fed 0, 5 or 50 mg/5 g tablet IMUNO-2865 (I-2865) in a tablet formulated feed. One group of mice (n = 15, 5 mice/diet) were placed on a feed diet for 14 days, while the other group of 30 mice (10 mice/diet) were placed on the diet for 28 days. Five mice from each diet group in the 28-day feeding trial were vaccinated on day 7 with a mouse recombinant parainfluenza virus to mimic viral challenge. On days 0, 14 and 28 blood samples were collected. Mice were humanely euthanized on days 14 and 28. Spleens were collected to analyze organ weight/body weight ratios, cell recovery, T cell and B cell phenotype, cell proliferation, antibody titers and cytokine production. Administration of dietary I-2865 for 14 days had no effect on murine immunity. In the 28-day dietary vaccine trial, I-2865 supplementation did not enhance vaccine response, based on vaccine antigen-specific IgG titers, nor did it alter T cell and B cell phenotype, function or cytokine response, but it did decrease splenocyte numbers in the vaccinated mice.

Potential drug-drug interactions and associated factors among hospitalized cardiac patients at Jimma University Medical Center, Southwest Ethiopia

Background

Concomitant use of several drugs for a patient is often imposing increased risk of drug-drug interactions. Drug-drug interactions are a major cause for concern in patients with cardiovascular disorders due to multiple co-existing conditions and the wide class of drugs they receive. This study is aimed to assess the prevalence of potential drug-drug interactions and associated factors among hospitalized cardiac patients at medical wards of Jimma University Medical Center, Southwest Ethiopia.

Methods

A hospital-based prospective observational study was conducted among hospitalized cardiac adult patients based on the inclusion criteria. Patient-specific data were collected using structured data collection tool. Potential drug-drug interaction was analyzed using Micromedex 3.0 DRUG-REAX^® System. Data were analyzed using statistical software package, version 20.0. To identify the independent predictors of potential drug-drug interaction, multiple stepwise backward logistic regression analysis was done. Statistical significance was considered at a p-value < 0.05. Written informed consent from patients was obtained and the patients were informed about confidentiality of the information obtained.

Results

Of the total 200 patients, majority were male (52.50%) and with a mean(±standard deviation) age of 42.54(±7.89) years. Out of 673 patients' prescriptions analyzed, 521 prescriptions comprised potential drug interactions and it was found that 967 drug interactions were present. The prevalence rate of potential drug-drug interactions among the study unit was 4.83 per patient and 1.44 per prescription regardless of the severity during their hospital stay. Overall the prevalence rate of potential drug interactions was 74.41%. Older age (adjusted odds ratio (95% confidence interval): 1.067 (2.33-27.12), p = 0.049), long hospital stay (⩾7 days) (adjusted odds ratio (95% confidence interval): 2.80 (1.71-4.61), p = 0.024), and polypharmacy (adjusted odds ratio (95% confidence interval): 1.64 (0.66-4.11), p = 0.041) were independent predictors for the occurrence of potential drug-drug interactions.

Conclusion

This study demonstrated a high prevalence of potential DIs among hospitalized cardiac patients in medical wards due to the complexity of pharmacotherapy. The prevalence rate is directly related to age, number of prescribed drugs, and length of hospital stay. Pharmacodynamic drug-drug interaction was the common mechanism of drug-drug interactions. Therefore, close monitoring of hospitalized patients is highly recommended.

Dietary quercetin supplements: Assessment of online product informations and quantitation of quercetin in the products by high-performance liquid chromatography

Administration of the increasingly popular dietary supplements containing quercetin may interfere with drug therapy. We intended to evaluate the online availability and quercetin content of the high-dose mono-component quercetin products and to review the potential use of quercetin products and their interactions with drugs. We monitored the online access to quercetin-containing dietary supplements, collected the relevant information from the websites, procured selected products from the vendors, and subjected them to substance analysis. The quercetin content was quantified by an HPLC-UV method. Twenty-five websites offered mono-component quercetin products, and nine products were procured. The quercetin content of eight products differed only ±10% from the nominal dose, whereas one product contained almost 30% more quercetin. Misleading indications such as antitumor and cardiovascular effects were often found on the sellers' websites. Quercetin-containing dietary supplements are available online with misleading indications. The recommended daily doses are often high (occasionally over 1,000 mg), which may induce clinically relevant interactions with medications. Because high-quercetin content of dietary supplements was confirmed, health care professionals should be aware of the unregulated internet market of dietary supplements and should consider the interactions of these substances with drugs.

Interaction between phytotherapy and oral anticancer agents: prospective study and literature review

Cancer is becoming more prevalent in elderly patient. Due to polypharmacy, older adults with cancer are predisposed to drug-drug interactions. There is also an increasing interest in the use of complementary and alternative medicine (CAM). Thirty to seventy percent of patients with cancer have used CAM. Through pharmaceutical counseling sessions, we can provide advices on herb-drug interactions (HDI). All the patients seen in pharmaceutical counseling sessions were prospectively included. Information was collected during these sessions: prescribed medication (oral anticancer agents (OAA) and other drugs), CAM (phytotherapy especially), and use of over-the-counter (OTC) drugs. If pharmacist considered an interaction or an intervention clinically relevant, the oncologist was notified. Then, a literature review was realized to identify the potential HDI (no interactions, precautions for use, contraindication). Among 201 pharmacist counseling sessions, it resulted in 104 interventions related to 46 HDI, 28 drug-drug interactions and 30 others (wrong dosage, omission…). To determine HDI, we review 73 medicinal plants which are used by our patients with cancer and 31 OAA. A total of 1829 recommendations were formulated about 59 (75%) medical plants and their interaction with an OAA. Herb-drug interactions should not be ignored by healthcare providers in their management of cancer patients in daily practice.

The mechanisms of pharmacokinetic food-drug interactions - A perspective from the UNGAP group

The simultaneous intake of food and drugs can have a strong impact on drug release, absorption, distribution, metabolism and/or elimination and consequently, on the efficacy and safety of pharmacotherapy. As such, food-drug interactions are one of the main challenges in oral drug administration. Whereas pharmacokinetic (PK) food-drug interactions can have a variety of causes, pharmacodynamic (PD) food-drug interactions occur due to specific pharmacological interactions between a drug and particular drinks or food. In recent years, extensive efforts were made to elucidate the mechanisms that drive pharmacokinetic food-drug interactions. Their occurrence depends mainly on the properties of the drug substance, the formulation and a multitude of physiological factors. Every intake of food or drink changes the physiological conditions in the human gastrointestinal tract. Therefore, a precise understanding of how different foods and drinks affect the processes of drug absorption, distribution, metabolism and/or elimination as well as formulation performance is important in order to be able to predict and avoid such interactions. Furthermore, it must be considered that beverages such as milk, grapefruit juice and alcohol can also lead to specific food-drug interactions. In this regard, the growing use of food supplements and functional food requires urgent attention in oral pharmacotherapy. Recently, a new consortium in Understanding Gastrointestinal Absorption-related Processes (UNGAP) was established through COST, a funding organisation of the European Union supporting translational research across Europe. In this review of the UNGAP Working group "Food-Drug Interface", the different mechanisms that can lead to pharmacokinetic food-drug interactions are discussed and summarised from different expert perspectives.

Herbal medicine use during breastfeeding: a cross-sectional study among mothers visiting public health facilities in the Western area of Sierra Leone

BACKGROUND

The use of medications, including herbal medicines during breastfeeding is always a concern among women. Currently, there is no published evidence on whether Sierra Leonean women use herbal medicine during breastfeeding. This study investigates the prevalence, correlates and pattern of herbal medicine use during breastfeeding.

METHODOLOGY

We conducted a cross-sectional study among 378 current breastfeeding mothers visiting public healthcare facilities within the Western area of Sierra Leone. Descriptive statistics and logistic regression analysis were used for data analysis.

RESULTS

Over a third of mothers (n = 140, 37.0%) used herbal medicine during breastfeeding. However, very few herbal medicine users (2.1%, n = 3) used herbal medicine to augment breastfeeding. Dietary changes were the most common method used to increase breast milk supply (93.9%, n = 355) with cassava leaves sauce and tubers being the most common dietary addition. Mothers with children more than six months old were more likely to use herbal medicine than mothers with younger children (OR:1.8; CI:1.13-2.85,p = 0.013). Among herbal medicine users, only 11.4% (n = 16) disclosed their herbal medicine use to their conventional healthcare providers.

CONCLUSION

The use of herbal medicine among breastfeeding mothers attending public health facilities in the Western area of Sierra Leone is common. Whilst this use is not usually specific to increasing breast milk supply, our study indicates that herbal medicines may be used to 'cleanse' initial breast milk.

PharmActa: Empowering Patients to Avoid Clinical Significant Drug⁻Herb Interactions

Herbal medicinal products (HMPs) are the subject of increasing interest regarding their benefits for health. However, a serious concern is the potential appearance of clinically significant drug⁻herb interactions in patients. This work provides an overview of drug⁻herb interactions and an evaluation of their clinical significance. We discuss how personalized health services and mobile health applications can utilize tools that provide essential information to patients to avoid drug⁻HMP interactions. There is a specific mention to PharmActa, a dedicated mobile app for personalized pharmaceutical care with information regarding drug⁻HMPs interactions. Several studies over the years have shown that for some HMPs, the potential to present clinically significant interactions is evident, especially for many of the top selling HMPs. Towards that, PharmActa presents how we can improve the way that information regarding potential drug⁻herb interactions can be disseminated to the public. The utilization of technologies focusing on medical information and context awareness introduce a new era in healthcare. The exploitation of eHealth tools and pervasive mobile monitoring technologies in the case of HMPs will allow the citizens to be informed and avoid potential drug⁻HMPs interactions enhancing the effectiveness and ensuring safety for HMPs.

Investigation and Comparison of Nutritional Supplement Use, Knowledge, and Attitudes in Medical and Non-Medical Students in China

The objective of this study is to investigate and compare the prevalence, knowledge, and attitudes of Chinese university students with respect to nutritional supplements. We conducted a cross-sectional study in several universities around China from January to December 2017, and enrolled a total of 8752 students. Of these, 4252 were medical students and 4500 were non-medical students. The use of nutritional supplements was reported by 58.9% in universities students, with a higher rate for medical students as compared to non-medical students. It was found 24.2% of participants had taken supplements in the past year. Medical students had a higher level of knowledge on nutritional supplements than non-medical students (p < 0.001). The most commonly used nutritional supplements were vitamin C, calcium, and vitamin B. Gender (p < 0.001), household income (p < 0.001), and health status (p < 0.001) were related to the nutritional supplement use after adjustment for related factors. In conclusion, in China, nutritional supplement use was found to be more common in medical students than those studying other disciplines, and was associated with sex, income, and health status. The attitude towards nutritional supplements by medical students was positive. Students’ knowledge levels about nutritional supplements need to be improved

Current regulatory guidelines and resources to support research of dietary supplements in the United States

The U.S. Dietary Supplement Health and Education Act (DSHEA) established the regulatory framework for dietary supplements as foods through the Food and Drug Administration (FDA). DSHEA outlined the legal definition, labeling requirements, and process for adverse event reporting for dietary supplements. FDA also issued formal guidance on current Good Manufacturing Practice to ensure that processes for preparation, packaging, labeling, and storage of supplements and ingredients are documented and meet specifications to ensure purity, composition, and strength. However, efficacy of dietary supplements is not required under U.S. law. Despite regulations to improve the marketplace, many challenges remain; as a result, the quality and safety of products available can be highly variable, especially for botanical and herbal products. The ability of regulators to successfully carry out their mission is hampered by the sheer number of products and manufacturing facilities and a lack of analytical methods for all ingredients and products in the marketplace, this is especially difficult for herbal and botanical dietary supplements. Safety issues continue to exist such as adulteration and contamination, especially with specific product types (i.e. body building, sexual enhancement). Thus, a need remains for continued efforts and improved techniques to assess the quality of dietary supplements, especially with regard to purity, bioavailability, and safety. This review will highlight the existing American regulatory framework for dietary supplements and will describe the remaining regulatory barriers to ensuring that safe and high-quality dietary supplements are offered in the marketplace.

Follow that botanical: Challenges and recommendations for assessing absorption, distribution, metabolism and excretion of botanical dietary supplements

Botanical dietary supplements are complex mixtures containing one or more botanical ingredient(s), each containing numerous constituents potentially responsible for its purported biological activity. Absorption, distribution, metabolism, and excretion (ADME) data are critical to understand the safety of botanical dietary supplements, including their potential for pharmacokinetic botanical-drug or botanical-botanical interactions. However, ADME data for botanical dietary supplements are rarely available and frequently inadequate to characterize their fate in vivo. Based on an assessment of the current status of botanical dietary supplements ADME research, the following key areas are identified that require robust data for human safety assessment: 1) phytochemical characterization including contaminant analysis and botanical authentication; 2) in vitro and/or in vivo data for identifying potential botanical-botanical or botanical-drug interactions and active/marker constituents; 3) robust ADME study design to include systemic exposure data on active/marker constituents using traditional or novel analytical chemistry and statistical approaches such as poly-pharmacokinetics; and 4) investigation of human relevance. A case study with Ginkgo biloba extract is used to highlight the challenges and proposed approaches in using ADME data for human safety assessment of botanical dietary supplements.

Filled prescriptions of age-related contraindicated drugs in children: a one-year nationwide cohort study in the Netherlands

Background Children are still prescribed age contraindicated drugs, but information about the number and type of these drugs dispensed for children in the Netherlands is limited. Objective To determine the incidence and prevalence of contraindicated drugs that were dispensed for the use by children. Setting The study was conducted in the Netherlands with routinely collected data from 95% of all community pharmacies. Method We performed a one-year nationwide observational study where all patients aged 17 years or younger who have received at least one prescription in 2016 were included. Contraindicated drugs were selected, according to the 5th level of ATC code, using different information sources. Main outcome measure The proportion of (newly) contraindicated drugs that were dispensed to children. Results In total, 3.9% of all children received at least one drug that was contraindicated for their age. The highest percentage of contraindicated drugs that was dispensed, was observed in patients aged 1–2 years and 13–17 years (7.0 and 5.7%, respectively) and the percentage of contraindicated drugs that were dispensed was higher in female than in male patients (4.3 and 3.6%, respectively; p value < 0.001). Conclusion The results of this study show that a substantial percentage of children received a drug that was conta-indicated for their age, and it happes more in female than in male patients. Furthermore, the information about this type of contraindications is limited and inconsistent.

Warfarin Safety: A Cross-Sectional Study of the Factors Associated with the Consumption of Medicinal Plants in a Brazilian Anticoagulation Clinic

OBJECTIVE

The aim of this study was to analyze factors associated with the consumption of medicinal plants by patients being treated with warfarin in a Brazilian anticoagulation clinic and to study the safety of medicinal plant use in patients on warfarin therapy.

METHODS

The study was performed as an observational cross-sectional analysis. Study participants were outpatients on long-term warfarin therapy for at least 2 months for atrial fibrillation or prosthetic cardiac valves. Interviews were carried out concerning information about the habits of medicinal herb consumption, and logistic regression analysis was performed to identify factors associated with the consumption of herbs. The scientific names of the medicinal plants were identified to search for information on the effects on the hemostasis of the interactions between the medicinal herbs reported and warfarin.

RESULTS

The mean age of the 273 patients included was 60.8 years; 58.7% were women. Medicinal plants were used by 67% of the participants. No association between demographic and clinical data and the use of medicinal plants was identified. Patients reported a total of 64 different plants, primarily consumed in the form of tea. The plants were mainly used to treat respiratory tract and central nervous system disorders. About 40% of the plants cited have been reported to potentially interfere with the anticoagulation therapy, principally by potentiating the effects of warfarin, which could, increase the risk of bleeding.

CONCLUSION

The use of medicinal plants was highly common and widespread in patients receiving warfarin as an anticoagulation therapy. Univariate analysis of variables associated with the consumption of herbs showed no statistically significant difference in the consumption of medicinal plants for any of the sociodemographic and clinical data. The medicinal plants that were reportedly consumed by the patients could affect hemostasis. This study reinforces the need for further studies evaluating the habits of patients consuming medicinal plants and their clinical implications, and will help to design strategies to manage the risks associated with warfarin-herbal interactions.

Prevalence, Knowledge and Attitudes Concerning Dietary Supplements among a Student Population in Croatia

The aim of this study was to determine the prevalence of usage and the knowledge and attitudes towards dietary supplements among medical sciences and nonmedical sciences students from Croatia. The study was conducted based on a questionnaire about dietary supplement usage, knowledge and attitudes. The prevalence of dietary supplement use, among 910 university students was 30.5%. The most-used dietary supplements were vitamins (18.0% in medical sciences students and 9.8% in non-medical sciences students). For all students, the internet (66.1%) was the most common source of information, followed by healthcare professionals (33.2%). The most common reason for taking dietary supplements was to maintain good health (26.4%). Use of the internet rather than health professionals as a trusted information source should be revised among this young population. Supplement intake was significantly associated with body mass index (BMI) (p = 0.016) and physical activity (p = 0.050). Students with normal BMI (61.5%) and the most physically active students (37.7%) took significantly more dietary supplements. Results of this study could help medicine faculties to improve their curriculum and support the development of public health messages aimed at wise and safe use of dietary supplements.

Evaluation of Point-of-Care Resources for Dietary Supplement Information

Objective.

To evaluate 6 tertiary, point-of-care drug information resources’ dietary supplement content.

Methods.

This was a cross-sectional evaluation of Lexicomp Natural Products Database, Micromedex Alternative Medicine, Clinical Pharmacology, Natural Medicines, The Review of Natural Products, and Handbook of Nonprescription Drugs. Each resource was evaluated for scope, completeness, consistency, and ease of use.

Results.

For a sample of 66 supplements, scope scores ranged from 69.7% (Micromedex) to 100% (Natural Medicines). Completeness scores were high considering uses, dose, adverse effects, and mechanism (85.7% to 100%). Overall completeness scores ranged from 82.5% (Handbook of Nonprescription Drugs) to 100% (Clinical Pharmacology, Natural Medicines, The Review of Natural Products). Consistency scores ranged from 0% (Handbook of Nonprescription Drugs) to 100% (Natural Medicines, The Review of Natural Products). Mean time to locate and gather information was similar among groups.

Conclusions.

Resources were similar for completeness and ease of use. Scope and consistency varied depending on the resource.

Interindividual Differences in Caffeine Metabolism and Factors Driving Caffeine Consumption

Most individuals adjust their caffeine intake according to the objective and subjective effects induced by the methylxanthine. However, to reach the desired effects, the quantity of caffeine consumed varies largely among individuals. It has been known for decades that the metabolism, clearance, and pharmacokinetics of caffeine is affected by many factors such as age, sex and hormones, liver disease, obesity, smoking, and diet. Caffeine also interacts with many medications. All these factors will be reviewed in the present document and discussed in light of the most recent data concerning the genetic variability affecting caffeine levels and effects at the pharmacokinetic and pharmacodynamic levels that both critically drive the level of caffeine consumption. The pharmacokinetics of caffeine are highly variable among individuals due to a polymorphism at the level of the CYP1A2 isoform of cytochrome P450, which metabolizes 95% of the caffeine ingested. Moreover there is a polymorphism at the level of another critical enzyme, N-acetyltransferase 2. At the pharmacodynamic level, there are several polymorphisms at the main brain target of caffeine, the adenosine A2A receptor or ADORA2. Genetic studies, including genome-wide association studies, identified several loci critically involved in caffeine consumption and its consequences on sleep, anxiety, and potentially in neurodegenerative and psychiatric diseases. We start reaching a better picture on how a multiplicity of biologic mechanisms seems to drive the levels of caffeine consumption, although much more knowledge is still required to understand caffeine consumption and effects on body functions.