A review of potential harmful interactions between anticoagulant/antiplatelet agents and Chinese herbal medicines

Impact of Banhabaekchulcheonmatang (Banxia Baizhu Tianma Tang) and Hwangryeonhaedoktang (Huang Lian Jie Du Tang) on edoxaban: Herb-drug interaction study in healthy subjects

ETHNOPHARMACOLOGICAL RELEVANCE

Concurrent use of traditional herbal medicines and conventional drugs, particularly for stroke treatment, is widespread, raising concerns about potential drug interactions.

AIM OF THE STUDY

This clinical study aimed to investigate interactions between edoxaban, a direct oral anticoagulant, and two traditional herbal medicines commonly used for stroke: Banhabaekchulcheonmatang (BBCT) and Hwangryeonhaedoktang (HRHDT).

MATERIALS AND METHODS

Korean healthy volunteers participated in a randomized, open-label, three-period, three-treatment, two-sequence clinical study. Treatments consisted of a single oral dose of edoxaban tablet (60 mg) in the presence or absence of multiple doses of BBCT or HRHDT three times daily for six days. Pharmacokinetic and pharmacodynamic parameters of edoxaban and its active metabolite M4 were assessed following administration of edoxaban alone or in co-administration with BBCT or HRHDT.

RESULTS

When edoxaban was co-administered with BBCT or HRHDT, the area under the curve (AUC) of edoxaban remained unaffected. However, its peak concentrations (Cmax) were decreased by 18.5%-28.1%. Similarly, co-administration of edoxaban with BBCT or HRHDT slightly decreased the AUC of M4 and reduced its Cmax by 16.8%-27.1%. Results revealed that BBCT and HRHDT had a minor impact on pharmacokinetics of edoxaban and M4. Despite alterations in systemic exposures, all pharmacodynamic parameters of edoxaban derived from activated partial thromboplastin time and prothrombin time were equivalent irrespective of herbal medicine co-administration.

CONCLUSIONS

These findings contribute to our understanding of potential interactions between conventional anticoagulants and traditional herbal medicines, highlighting the need for comprehensive evaluation in clinical practice.

Increased risk of major adverse cardiovascular events in young and middle-aged adults with obesity receiving Chinese herbal medicine: A nationwide cohort study

BACKGROUND

Many patients with obesity in Taiwan seek Chinese herbal medicines (CHM) from traditional Chinese medicine (TCM) clinics. This study aimed to estimate the risk of major adverse cardiovascular events (MACEs) in adults diagnosed with obesity, with or without CHM.

METHODS

Patients with obesity aged 18 to 50 years were identified using diagnostic codes from Taiwan's National Health Insurance Research Database between 2008 and 2018. We randomized 67 655 patients with or without CHM using propensity score matching. All patients were followed up from the start of the study until MACEs, death, or the end of 2018. A Cox proportional regression model was used to evaluate the hazard ratios of MACEs in the CHM and non-CHM cohorts.

RESULTS

During a median follow-up of 4.2 years, the CHM group had a higher incidence of MACEs than the non-CHM control cohort (9.35 vs 8.27 per 1000 person-years). The CHM group had a 1.13-fold higher risk of MACEs compared with the non-CHM control (adjusted hazard ratio [aHR] = 1.13; 95% CI], 1.07-1.19; p < 0.001), especially in ischemic stroke (aHR = 1.18; 95% CI, 1.07-1.31; p < 0.01), arrhythmia (aHR = 1.26; 95% CI, 1.14-1.38; p < 0.001), and young adults aged 18 to 29 years (aHR = 1.22; 95% CI, 1.05-1.43; p < 0.001).

CONCLUSION

Although certain CHMs offer cardiovascular benefits, young and middle-aged obese adults receiving CHM exhibit a higher risk of MACEs than those not receiving CHM. Therefore, TCM practitioners should be cautious when prescribing medications to young patients with obesity, considering their potential cardiovascular risks.

Ginger for Pain Management in Primary Dysmenorrhea: A Systematic Review and Meta-Analysis

Background: Primary dysmenorrhea is a common gynecological disorder that affects many women of reproductive age. Ginger, a widely used spice with anti-inflammatory properties, has been suggested as a potential treatment for the painful cramps associated with this condition. Objective: The aim of this systematic review and meta-analysis was to evaluate the efficacy of ginger for pain management in primary dysmenorrhea. Methods: Our systematic review was registered in Prospero (CRD42023418001). Six English (PubMed, Scopus, Web of Science, PsycINFO, CINAHL complete, and Cochrane) and one Persian electric database (SID) was searched up to May 2023 for English or Persian studies that measure the effect of ginger on pain in dysmenorrhea. The Cochrane tool was used to assess the risk of bias of the included studies. Random effects meta-analyses were performed to obtain standardized mean differences (SMD) and 95% confidence intervals (CI). Results: Out of the 804 articles initially identified from the search, 24 were included for qualitative analysis and 12 for quantitative analysis after a full-text evaluation. The combined results of the studies indicate that ginger is notably more effective than placebo in reducing both the intensity (SMD = -1.13; 95% CI = -1.59 to -0.68, I2 = 81.05%) and duration of pain (SMD = -0.29; 95% CI = -0.46 to -0.12). There were no differences between ginger and nonsteroidal anti-inflammatory drugs (NSAIDs) (SMD = 0.01; 95% CI = -0.24 to 0.25), or exercise (SMD = 0.06; 95% CI = -0.66 to 0.78) for pain intensity. Safety-related data were infrequently reported. Conclusions: The results of this meta-analysis suggest that ginger can effectively reduce pain associated with dysmenorrhea. The findings are limited due to risk of bias in the included studies and the unclear risk-benefit ratio.

Quantitative determination of the antibacterial activity of licorice (Glycyrrhiza glabra) and tetracycline gel against Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg) and Prevotella intermedia (Pi) - a microbiological in vitro study

OBJECTIVES

The aim of this study was to evaluate and compare the antibacterial efficacy of licorice gel and tetracycline gel against Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia.

METHODS

An indigenously prepared 50 μL licorice and tetracycline gel was subjected to antibacterial sensitivity test (thrice) against Aa, Pg, Pi by agar well diffusion method using Brain Heart Infusion media. Colonies of Aa, Pg, Pi was transferred into broth and incubated at 37 °C for 24 h and diameter of inhibition zone was measured.

RESULTS

The drug release profile of licorice gel at six regular intervals was higher when compared to tetracycline. MIC of licorice gel (50 μg/mL) against Aa (14 mg), Pg (7 mg), Pi (7 mg) respectively. The diameter of inhibition zone of licorice gel was significant against Aa when compared to tetracycline gel. However, tetracycline gel exhibited significant diameter of inhibition zone against Pg and Pi when compared to licorice gel. There was a statistical significance difference between licorice and tetracycline gel against Aa (p=0.043*), Pg (p=0.037*), Pi (p=0.046*) while assessing antibacterial sensitivity test.

CONCLUSIONS

Licorice gel has anti-inflammatory and anti-microbial properties which can act against periodontal pathogens and can be considered in treating periodontal disease at low concentrations. Therefore, it can be used as an adjunctive local drug delivery agent to non-surgical periodontal therapy (NSPT) in treating periodontal disease.

Chinese herbal compound preparation Qing-Xin-Jie-Yu granules for intermediate coronary lesions in patients with stable coronary artery disease: Study protocol for a multicenter, randomized, double-blind, placebo-controlled trial

INTRODUCTION

Despite the available secondary preventive treatments, the management of stable coronary artery disease (SCAD) remains challenging. Intermediate coronary lesion (ICL), defined as luminal stenosis between 50% and 70%, is a key stage of SCAD. However, existing therapeutic strategies are limitated in delaying plaque progression and associated with various adverse effects and economic burdens. Qing-Xin-Jie-Yu Granules (QXJYG) with proven anti-platelet, anti-inflammatory, and lipid-lowering effects may compensate for the drawbacks of current treatments and can be tested as a complementary therapy. Therefore, this study aims to investigate the efficacy and safety of QXJYG in treating ICL, with a particular focus on its impact on myocardial ischemia and plaque progression.

MATERIALS AND METHODS

This is a multicenter, randomized, double-blind, placebo-controlled trial. A total of 120 participants with ICL will be randomly assigned to two groups in a 1:1 ratio. In addition to basic medications, the intervention group will receive QXJYG, while the control group will receive a placebo for over 6 months, followed by a 12-month follow-up. The primary efficacy outcome is computed tomography-derived fractional flow reserve. The secondary outcomes include the degree of coronary stenosis, coronary artery calcification score, Gensini score, Seattle Angina Questionnaire score, high-sensitivity C-reactive protein, matrix metalloproteinase-9, blood lipids, and carotid artery ultrasound parameters. Major adverse cardiovascular events are recorded as endpoints. The safety outcomes include composite events of bleeding, laboratory test results, and adverse events. Clinical visits are scheduled at baseline, every 2 months during the treatment, and after a 12-month follow-up.

DISCUSSION

This trial is anticipated to yield reliable results to verify the efficacy and safety of QXJYG in the treatment of ICL, which will provide novel insights to help address the prevailing therapeutic dilemma of ICL, thereby facilitating for the management of SCAD.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200059262. Registered on April 27, 2022.

Comparison of the effect of licorice and chlorhexidine mouthwash on the oral health of intubated patients in the intensive care unit

BACKGROUND

Chlorhexidine mouthwash is a common oral hygiene product used in intensive care units, but it may have some adverse effects. Licorice, a natural herb, could be a potential alternative to chlorhexidine. However, the effect of licorice mouthwash on the oral health of intubated patients has not been studied yet. Therefore, this study aimed to compare the effects of licorice and chlorhexidine mouthwash on the oral health of intubated patients.

METHODS

This was a triple-blind clinical trial. The sample included 130 intubated patients admitted to an intensive care unit in Iran. The samples were selected by convenience sampling and randomly assigned to two groups: A and B. In group A, the main researcher applied 15 ml of 0.2% chlorhexidine mouthwash after each brushing (twice a day for 5.5 days) and suctioned it after 30 s. In group B, 20% licorice mouthwash was used instead of chlorhexidine. The demographic information questionnaire and the Beck Oral Assessment Scale (BOAS) were completed by one of the nurses before and on the sixth day of the study.

RESULTS

Finally, 60 patients in each group completed the study. There was no significant difference between the groups in terms of demographic variables or oral health before the intervention (P > 0.05). The oral health of patients in both the chlorhexidine and liquorice mouthwash groups improved significantly after the intervention (P < 0.05). However, there was no significant difference in oral health between the two groups at postintervention (P = 0.06).

CONCLUSION

The results demonstrated that both mouthwashes exerted a comparable effect on dental and oral health. However, the chlorhexidine mouthwash showed a greater impact on the reduction of dental plaque and the thinning of saliva compared to licorice mouthwash. In essential cases, licorice mouthwash can be employed as an alternative to chlorhexidine.

Complications of toxins and fillers in facial aesthetics

Dermal filler and botulinum toxin injections are among the most performed non-invasive procedures for rejuvenation and contouring, internationally. Although most dermal fillers and approved botulinum toxins are well tolerated with a high safety profile, adverse events and/or complications can happen. Injection-related sequelae and side effects are usually rare, mild, transient, and self-limiting in nature. However, devastating and life-changing complications, such as intravascular occlusion, skin necrosis, permanent visual impairment, and stroke, have been reported. Risk reduction measures include an in-depth knowledge of anatomy, physiology, and pharmacology, correct patient selection, correct identification of clinical indications, and, fundamentally, the importance of appropriate skill and training. In this paper, some of the complications are discussed and advice on how to minimise adverse events and complications from these injectables is provided.

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.

Toxicities of herbal abortifacients

BACKGROUND

In the post-Roe era, barriers to facility-based abortions may lead to an increased incidence of self-managed abortions. While misoprostol-based medication abortions have significant literature supporting its safety profile, there is a knowledge deficit within the medical community regarding the toxicities of commonly used herbal abortifacients.

METHODS

This is a narrative review, based on a MEDLINE and HOLLIS database search, of self-managed abortion methods with herbal abortifacients and their associated toxicities.

RESULTS

Common herbal abortifacients with significant morbidity and mortality implications include pennyroyal, blue cohosh, rue, and quinine. Other commonly reported abortifacients considered to be less toxic also are discussed in brief. Special considerations for hepatic, cardiac, renal, and hematologic toxicities are important in patients with significant exposures to these herbal substances.

CONCLUSION

There is an anticipated increase in the utility of herbal xenobiotics for self-managed abortions with post-Roe restrictions to standard mifepristone-misoprostol protocols. Frontline providers should be aware of the associated toxicities and have special considerations when treating a poisoned patient in this population.

Preoperative Use and Discontinuation of Traditional Chinese Herbal Medicine and Dietary Supplements in Taiwan: A Cross-Sectional Questionnaire Survey

Traditional Chinese herbal medicine has widespread use in Taiwan. This cross-sectional questionnaire survey investigates the preoperative use and discontinuation of Chinese herbal medicine and dietary supplements among Taiwanese patients. We obtained the types, frequency, and sources of Chinese herbal remedies and supplements used. Among 1428 presurgical patients, 727 (50.9%) and 977 (68.4%) reported the use of traditional Chinese herbal medicine and supplements in the past one month, respectively. Only 17.5% of the 727 patients stated discontinuation of herbal remedies 4.7 ± 5.1 (1-24) days before the surgery, and 36.2% took traditional Chinese herbal medicine with concomitant physician-prescribed Western medicine for their underlying diseases. The most commonly used Chinese herbs are goji berry (Lycium barbarum) (62.9%) and Si-Shen-Tang (48.1%) in single and compound forms, respectively. The presurgical use of traditional Chinese herbal medicine was common in patients undergoing gynecologic (68.6%) surgery or diagnosed with asthma (60.8%). Women and those with a high household income had a greater tendency to use herbal remedies. This study demonstrates the high proportion of the presurgical use of Chinese herbal remedies and supplements along with physician-prescribed Western medicine in Taiwan. Surgeons and anesthesiologists should be aware of the potential adverse effects of drug-herb interaction for Chinese patients.

Potential anticoagulant of traditional chinese medicine and novel targets for anticoagulant drugs

BACKGROUND

Anticoagulants are the main drugs used for the prevention and treatment of thrombosis. Currently, anticoagulant drugs are primarily multitarget heparin drugs, single-target FXa inhibitors and FIIa inhibitors. In addition, some traditional Chinese drugs also have anticoagulant effects, but they are not the main direction of treatment at present. But the anticoagulant drugs mentioned above, all have a common side effect is bleeding. Many other anticoagulation targets are under investigation. With further exploration of coagulation mechanism, how to further determine new anticoagulant targets and how to make traditional Chinese medicine play anticoagulant role have become a new field of exploration.

PURPOSE

The purpose of the study was to summarize the recent research progress on coagulation mechanisms, new anticoagulant targets and traditional Chinese medicine.

METHODS

A comprehensive literature search was conducted using four electronic databases, including PubMed, Embase, CNKI, Wanfang database and ClinicalTrials.gov, from the inception of the study to 28 Feb 2023. Key words used in the literature search were "anticoagulation", "anticoagulant targets", "new targets", "coagulation mechanisms", "potential anticoagulant", "herb medicine", "botanical medicine", "Chinese medicine", "traditional Chinese medicine", "blood coagulation factor", keywords are linked with AND/OR. Recent findings on coagulation mechanisms, potential anticoagulant targets and traditional Chinese medicine were studied.

RESULTS

The active components extracted from the Chinese medicinal herbs, Salvia miltiorrhiza, Chuanxiong rhizoma, safflower and Panax notoginseng have obvious anticoagulant effects and can be used as potential anticoagulant drugs, but the risk of bleeding is unclear. TF/FVIIa, FVIII, FIX, FXI, FXII, and FXIII have all been evaluated as targets in animal studies or clinical trials. FIX and FXI are the most studied anticoagulant targets, but FXI inhibitors have shown stronger advantages.

CONCLUSION

This review of potential anticoagulants provides a comprehensive resource. Literature analysis suggests that FXI inhibitors can be used as potential anticoagulant candidates. In addition, we should not ignore the anticoagulant effect of traditional Chinese medicine, and look forward to more research and the emergence of new drugs.

Licorice as a herbal extract in periodontal therapy

Periodontal disease is caused by specific pathogens which results in inflammation of the tooth-supporting structures and subsequently causes the continued breakdown of alveolar bone and periodontal ligament. Licorice (Glycyrrhiza glabra) is a perennial herb with substantial medicinal value. Licorice extract is derived from dried, unpeeled stolons and roots of Glycyrrhiza uralensis and G. glabra. The bioactive ingredients in licorice extract such as glycyrrhizin, licoricidin, glabridin, licochalcone A, and licorisoflavan A have anti-inflammatory, antimicrobial, and anti-adherence effects that are beneficial against periodontal disease. Since periodontal disease has a complex etiology that includes the host response and microorganisms, licorice phytochemicals offer a therapeutic advantage due to their dual functionality. The aim of this review was to enumerate the bioactive compounds present in herbal licorice extract and to elucidate the beneficial effects of licorice and its derivatives in periodontal therapy. Literature review and clinical trials evaluating the effect of licorice on periodontopathogens and periodontal disease are included in this article.

Licorice as a herbal extract in periodontal therapy

Periodontal disease is caused by specific pathogens which results in inflammation of the tooth-supporting structures and subsequently causes the continued breakdown of alveolar bone and periodontal ligament. Licorice (Glycyrrhiza glabra) is a perennial herb with substantial medicinal value. Licorice extract is derived from dried, unpeeled stolons and roots of Glycyrrhiza uralensis and G. glabra. The bioactive ingredients in licorice extract such as glycyrrhizin, licoricidin, glabridin, licochalcone A, and licorisoflavan A have anti-inflammatory, antimicrobial, and anti-adherence effects that are beneficial against periodontal disease. Since periodontal disease has a complex etiology that includes the host response and microorganisms, licorice phytochemicals offer a therapeutic advantage due to their dual functionality. The aim of this review was to enumerate the bioactive compounds present in herbal licorice extract and to elucidate the beneficial effects of licorice and its derivatives in periodontal therapy. Literature review and clinical trials evaluating the effect of licorice on periodontopathogens and periodontal disease are included in this article.

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.

Multimorbidity, polypharmacy and inappropriate prescribing in elderly patients with atrial fibrillation: A report from the China Atrial Fibrillation Registry Study

Background

Multimorbidity, polypharmacy and inappropriate prescribing is common in elderly patients worldwide. We aimed to explore the current status of multimorbidity, polypharmacy and the appropriateness of pharmacological therapy among elderly patients with atrial fibrillation (AF) in China.

Materials and methods

We randomly selected 500 patients aged 65 years or older from the China AF Registry study. Multimorbidity was defined as ≥2 comorbidities and polypharmacy was defined as ≥5 long-term prescribed drugs. Appropriateness of prescribing was evaluated using the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 2. Patients’ attitudes toward polypharmacy were evaluated by the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire.

Results

Among the 500 patients included (mean age 75.2 ± 6.7 years, 49.0% male), 98.0% had multimorbidity and 49.4% had polypharmacy. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was 43.6% (n = 218) and 71.6% (n = 358), respectively. Traditional Chinese medicine attributed largely to PIMs. Anticoagulants were the most common PPOs. Many clinical factors increased the risk of PIMs and PPOs. However, polypharmacy increased the risk of PIMs (OR 2.70, 95%CI 1.78–4.11; p &lt; 0.0001), but not PPOs. In addition, 73.7% patients with polypharmacy were willing to have one or more of their medications prescribed if advised by their doctor.

Conclusion

Multimorbidity and polypharmacy were highly prevalent in elderly patients with AF in China. A high prevalence of inappropriate prescribing was also observed. Therefore, much more attention should be paid to the serious health problem in the elderly population.

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.

Vegan nutrition: a preliminary guide for health professionals

Since the beginning of the 21st century, interest in vegan diets has been rapidly increasing in most countries. Misconceptions about vegan diets are widespread among the general population and health professionals. Vegan diets can be health-promoting and may offer certain important advantages compared to typical Western (and other mainstream) eating patterns. However, adequate dietary sources/supplements of nutrients of focus specific to vegan diets should be identified and communicated. Without supplements/fortified foods, severe vitamin B12 deficiency may occur. Other potential nutrients of focus are calcium, vitamin D, iodine, omega-3 fatty acids, iron, zinc, selenium, vitamin A, and protein. Ensuring adequate nutrient status is particularly important during pregnancy, lactation, infancy, and childhood. Health professionals are often expected to be able to provide advice on the topic of vegan nutrition, but a precise and practical vegan nutrition guide for health professionals is lacking. Consequently, it is important and urgent to provide such a set of dietary recommendations. It is the aim of this article to provide vegan nutrition guidelines, based on current evidence, which can easily be communicated to vegan patients/clients, with the goal of ensuring adequate nutrient status in vegans.

A comprehensive evaluation of potentially significant drug-drug, drug-herb, and drug-food interactions among cancer patients receiving anticancer drugs

INTRODUCTION

During the cancer treatment path, cancer patients use numerous drugs, including anticancer, supportive, and other prescribed medications, along with herbs and certain products. This puts them at risk of significant drug interactions (DIs). This study describes DIs in cancer patients and their prevalence and predictors.

METHODS

A cross-sectional study design was used to achieve the study objectives. The study was carried out in two centers in the northern West Bank, Palestine. The Lexicomp® Drug Interactions tool (Lexi-Comp, Hudson OH, USA) was applied to check the potential DIs. In addition, the Statistical Package for the Social Sciences (SPSS) was used to show the results and find the associations.

RESULTS

The final analysis included 327 patients. Most of the participants were older than 50 years (61.2%), female (68.5%), and had a solid tumor (74.6%). The total number of potential DIs was 1753, including 1510 drug-drug interactions (DDIs), 24 drug-herb interactions, and 219 drug-food interactions. Importantly, the prevalence of DDIs was 88.1%. In multivariate analysis, the number of potential DDIs significantly decreased with the duration of treatment (p = 0.007), while it increased with the number of comorbidities (p < 0.001) and the number of drugs used (p < 0.001).

CONCLUSIONS

We found a high prevalence of DIs among cancer patients. This required health care providers to develop a comprehensive protocol to monitor and evaluate DIs by improving doctor-pharmacist communication and supporting the role of clinical pharmacists.

Current update on herbal sources of antithrombotic activity—a comprehensive review

Background

Herbs are commonly used to treat cardiovascular diseases in various traditional medicine. On the other hand, herb-drug interactions are most commonly encountered with conventional antiplatelet and anticoagulant drug prescriptions. This review presents a compilation of plants investigated for antiplatelet and anticoagulation recently and enumerates their possible lead compounds responsible for its action for paving further drug discovery and knowledge update.

Main body of the abstract

Information about the herbs was withdrawn from the PubMed database of the previous 5 years. We also hand-searched the bibliography of relevant articles for the acquisition of additional information. About 72 herbal sources were identified with the effect of antiplatelet activity, antithrombotic activity, and anticoagulant activity. Bioactive compounds and various secondary metabolites responsible for it, such as alkaloids, saponins, flavonoids, coumarins, polyphenols, furan derivatives, iridoid glycosides, sesquiterpenes, aporphine compounds, were reported.

Conclusion

Newer pharmacological moieties are needed to prevent or reduce the adverse effects of current anti-thrombotic agents and to improve the safety of patients and cost-effectiveness.

Potential clinical applications of phytopharmaceuticals for the in-patient management of coagulopathies in COVID-19

Thrombotic complications occur in many cardiovascular pathologies and have been demonstrated in COVID‐19. The currently used antithrombotic drugs are not free of adverse reactions, and COVID‐19 patients in particular, when treated with a therapeutic dose of an anticoagulant do not receive mortality benefits. The clinical management of COVID‐19 is one of the most difficult tasks for clinicians, and the search for safe, potent, and effective antithrombotic drugs may benefit from exploring naturally bioactive molecules from plant sources. This review describes recent advances in understanding the antithrombotic potential of herbal drug prototypes and points to their future clinical use as potent antithrombotic drugs. Although natural products are perceived to be safe, their clinical and therapeutic applications are not always apparent or accepted. More in‐depth studies are necessary to demonstrate the clinical usefulness of plant‐derived, bioactive compounds. In addition, holistic approaches in systematic investigations and the identification of antithrombotic mechanisms of the herbal bioactive molecule(s) need to be conducted in pre‐clinical studies. Moreover, rigorous studies are needed to compare the potency of herbal drugs to that of competitor chemical antithrombotic drugs, and to examine their interactions with Western antithrombotic medicines. We have also proposed a road map to improve the commercialization of phytopharmaceuticals.

Non-vitamin K Antagonist Oral Anticoagulants and Drug-Food Interactions: Implications for Clinical Practice and Potential Role of Probiotics and Prebiotics

Non-vitamin K antagonist oral anticoagulants (NOACs) are a therapeutic option to prevent stroke in patients with atrial fibrillation (AF). In fact, NOACs have become the recommended choice by international clinical practice guidelines over vitamin K antagonists (VKA), because of their efficacy and safety profile, especially in newly initiated patients. The more predictable pharmacokinetic and pharmacodynamic profile of this family of drugs allows preventing anticoagulation drug monitoring. Furthermore, NOACs have significantly fewer drug and food interactions in comparison with VKAs. Despite this, there are no studies that compare the effects on the quality of anticoagulation of NOACs with the intake of potential interactions drugs of P-glycoprotein and cytochrome P450 (CYP). This review brings an overview of NOACs pharmacokinetics profile and their potential drug-food interactions. We also briefly discuss the potential role of prebiotics and probiotics in patients under therapy with NOACs.

Case Report: Fatigue and Bleeding in a Polymedicated Patient Using Several Herbal Supplementations, Detected with g-Nomic® Software

This was a case report of severe fatigue and bleeding in a 65-year-old man with ischemic heart disease who was wearing a stent and taking multiple medications for hypertension and diabetes. The use of a drug interaction and personalized prescription software (g-Nomic^®) revealed potential interactions, involving acetylsalicylic acid and several non-pharmaceutical products including ginger, blueberry extracts, pineapple juice, docosahexaenoic acid and liquorice. Correction of these interactions resulted in complete remission of the reported side effects. This supports the idea that non-pharmaceuticals potentiated the effects of acetylsalicylic acid on haemostasis, producing the bleeding that would have caused fatigue. It is important to use appropriate tools to detect drug interactions that also take into account commonly used non-pharmaceutical products. Drug interactions can be considered illnesses by themselves.

Left atrial appendage occlusion for ischemic stroke prevention in patients with non-valvular atrial fibrillation: clinical expert opinion and consensus statement for the Asian-Pacific region

PURPOSE

To develop a consensus statement for left atrial appendage occlusion (LAAO) in Asian-Pacific patients with non-valvular atrial fibrillation (NVAF) at risk of ischemic stroke. The need for such a region-specific consensus was indicated by the relative paucity of clinical evidence for LAAO and oral anticoagulation therapy obtained in Asian-Pacific populations and the specific stroke and bleeding characteristics of this population.

METHODS

Consensus was developed by discussion and evaluation of available evidence and expert opinions during a 2-day meeting attended by clinical experts from the Asian-Pacific regions.

RESULTS

The consensus statement arrived at provides recommendations based on available evidence and expert opinions regarding LAAO in Asian-Pacific patients. Gaps in the evidence and other areas requiring further research were identified.

CONCLUSION

LAAO is an alternative device-based therapy in carefully selected patients with NVAF at risk of ischemic stroke. However, evidence for LAAO is primarily obtained from Caucasian populations, and data on LAAO in Asian-Pacific patients are scarce. While the present consensus statement addresses several therapy-related aspects based on careful interpretation of available evidence and expert opinions, other areas require additional evidence derived from Asian-Pacific populations.

Herb-drug interactions and toxicity: Underscoring potential mechanisms and forecasting clinically relevant interactions induced by common phytoconstituents via data mining and computational approaches

Herbals in the form of medicine are employed extensively around the world. Herbal and conventional medicine combination is a potentially dangerous practice mainly in comorbid, hepato insufficient and frail patients leading to perilous herb-drug interactions (HDI) and toxicity. This study features potential HDI of 15 globally famous plant species through data mining and computational methods. Several plant species were found to mimic warfarin. Phytochemicals from M. charantia induced hypoglycemica. M. chamomila and G. biloba possessed anticoagulant activities. S. hispanica reduces postprandial glycemia. R. officinalis has been reported to inhibit the efflux of anticancer substrates while A. sativum can boost the clearance of anticancer agents. P. ginseng can alter blood coagulation. A cross link of the biological and in silico data revealed that a plethora of herbal metabolites such as ursolic and rosmarinic acid among others are possible/probable inhibitors of specific CYP450 enzymes. Consequently, plant species/metabolites with a given pharmacological property/metabolizing enzyme should not be mixed with drugs having the same pharmacological property/metabolizing enzyme. Even if combined with drugs, herbal medicines must be used at low doses for a short period of time and under the supervision of a healthcare professional to avoid potential adverse and toxic effects.

Suboptimal Health, Dietary Supplementation, and Public Health Approaches to Regulatory Challenges in Dubai

Objectives: Presently, limited data are available on dietary supplements (DSs) and their associated effects on health status although the consumption of DS continues to expand. This study is aimed to explore the possible relationship between DSs consumption and suboptimal health status (SHS) in Dubai, United Arab Emirates (UAE). Methods: This study was a cross-sectional research held among a sample of citizens and residents in the Emirate of Dubai in the UAE using a well-structured, self-administered, anonymous survey. Frequency tables, odds ratios, and confidence intervals were generated during the data analysis using SPSS version 23. Results: A total of 618 participants were enrolled in this study and fully completed the questionnaire. In this study, 317 participants (51.3%) (95% CI: 47.3%-55.3%) reported the use of DS products. A significant association between DS consumption and suboptimal health status was detected (P < .001). DS consumers had a 1.5-fold increased odds of suboptimal health status when compared with non-DS consumers (95% CI 1.4-1.7). Conclusion: The findings of this study suggest a need to develop policies and programs that will help minimize the risk of possible adverse events that are associated with the utilization of DSs.

Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: Consensus Recommendations by the Asian Pacific Society of Cardiology on Strategies for Thrombotic and Bleeding Risk Management

The disease burden of AF is greater in Asia-Pacific than other areas of the world. Direct oral anticoagulants (DOACs) have emerged as effective alternatives to vitamin K antagonists (VKA) for preventing thromboembolic events in patients with AF. The Asian Pacific Society of Cardiology developed this consensus statement to guide physicians in the management of AF in Asian populations. Statements were developed by an expert consensus panel who reviewed the available data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting 17 statements provide guidance on the assessment of stroke risk of AF patients in the region, the appropriate use of DOACs in these patients, as well as the concomitant use of DOACs and antiplatelets, and the transition to DOACs from VKAs and vice versa. The periprocedural management of patients on DOAC therapy and the management of patients with bleeding while on DOACs are also discussed.

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.

Predictors for the use of traditional Chinese medicine among inpatients with first-time stroke: a population-based study

BACKGROUND

Stroke is one of the major causes of death and disability. The treatments that are provided to patients during hospitalization after an acute stroke are very important in stabilizing their medical condition and enabling the recovery of their motor functions. However, limited information is available regarding the use of traditional Chinese medicine (TCM) during hospitalization for first-time stroke patients. The researchers aimed to investigate the factors affecting TCM use and to provide clinicians with comprehensive information on TCM use among first-time stroke inpatients in Taiwan.

METHODS

The researchers collected and analyzed data, including patient characteristics, TCM use, and TCM prescription patterns, from the National Health Insurance Research Database in Taiwan for first-time stroke inpatients between 2006 and 2012.

RESULTS

Among the 89,162 first-time stroke patients, 7455 were TCM users, and 81,707 were TCM nonusers. The predictors for TCM use were as follows: age, 45-64 or < 45 years; men; living in a level 2, 4, or 7 urbanized area; insured amount ≥ 576 USD per month; ischemic stroke; hospitalized for first-time stroke for 8-14 days, 15-28 days, or ≥ 29 days; stroke severity index score 0-9 or 10-19; Charlson-Deyo comorbidity index score 0 or 1-2; hospitalization in a regional or community hospital; receiving rehabilitation; and previous experience with outpatient TCM use. An increase in the number of TCM users was observed from 2006 to 2012. Furthermore, 68.8-79.7% of TCM users used acupuncture only, while 17.8-26.1% used both acupuncture and Chinese herbal medicine.

CONCLUSIONS

An increasing number of first-time stroke patients have been choosing TCM as a complementary treatment during hospitalization. Moreover, TCM use is associated with demographic, clinical, and socioeconomic characteristics. These findings may help clinicians comprehensively understand the trend and the important factors affecting TCM utilization among patients who are hospitalized due to first-time stroke.

Antiplatelet Activity of Tussilagone via Inhibition of the GPVI Downstream Signaling Pathway in Platelets

Tussilagone is a sesquiterpenoid extracted from Tussilago farfara and is used as an oriental medicine for asthma and bronchitis. Although previous studies have shown that tussilagone has an inhibitory effect on platelet aggregation, no studies have been performed to investigate its precise effect on platelets, and the underlying mechanism remains unclear. In the present study, we showed that tussilagone inhibited platelet aggregation induced by collagen, thrombin and ADP, as well as platelet release induced by collagen and thrombin, in mice. Tussilagone decreased P-selectin expression and αIIbβ3 activation (JON/A binding) in activated platelets, which indicated that tussilagone inhibited platelet activation. Moreover, tussilagone suppressed platelet spreading on fibrinogen and clot retraction. The levels of phosphorylated Syk, PLCγ2, Akt, GSK3β, and MAPK (ERK1/2 and P38) and molecules associated with GPVI downstream signaling were downregulated in the presence of tussilagone. In addition, tussilagone prolonged the occlusion time in a mouse model of FeCl₃-induced carotid artery thrombosis and had no effect on mouse tail bleeding time. These results indicate that tussilagone inhibits platelet function in vitro and in vivo and that the underlying mechanism involves the Syk/PLCγ2-PKC/MAPK and PI3K-Akt-GSK3β signaling pathways downstream of GPVI. This research suggests that tussilagone is a potential candidate antiplatelet drug for the prevention of thrombosis.

Shaoyao Gancao Tang (SG-Tang), a formulated Chinese medicine, reduces aggregation and exerts neuroprotection in spinocerebellar ataxia type 17 (SCA17) cell and mouse models

Spinocerebellar ataxia (SCA) type 17 is an autosomal dominant ataxia caused by expanded polyglutamine (polyQ) tract in the TATA-box binding protein (TBP). Substantial studies have shown involvement of compromised mitochondria biogenesis regulator peroxisome proliferator-activated receptor gamma-coactivator 1 alpha (PGC-1α), nuclear factor erythroid 2-related factor 2 (NRF2), nuclear factor-Y subunit A (NFYA), and their downstream target genes in the pathogenesis of polyQ-expansion diseases. The extracts of Paeonia lactiflora (P. lactiflora) and Glycyrrhiza uralensis (G. uralensis) have long been used as a Chinese herbal medicine (CHM). Shaoyao Gancao Tang (SG-Tang) is a formulated CHM made of P. lactiflora and G. uralensis at a 1:1 ratio. In the present study, we demonstrated the aggregate-inhibitory and anti-oxidative effect of SG-Tang in 293 TBP/Q₇₉ cells. We then showed that SG-Tang reduced the aggregates and ameliorated the neurite outgrowth deficits in TBP/Q₇₉ SH-SY5Y cells. SG-Tang upregulated expression levels of NFYA, PGC-1α, NRF2, and their downstream target genes in TBP/Q₇₉ SH-SY5Y cells. Knock down of NFYA, PGC-1α, and NRF2 attenuated the neurite outgrowth promoting effect of SG-Tang on TBP/Q₇₉ SH-SY5Y cells. Furthermore, SG-Tang inhibited aggregation and rescued motor-deficits in SCA17 mouse model. The study results suggest the potential of SG-Tang in treating SCA17 and probable other polyQ diseases.

A review on plants and herbal components with antiarrhythmic activities and their interaction with current cardiac drugs

This paper aimed to compile information on plants or their compounds which have experimentally shown antiarrhythmic effect and to scrutinize the efficacy and potency of them and their potential interaction with conventional cardiac drugs. Literature searches were accomplished by using numerous electronic databases, and the available knowledge on different parts of herbs and their ingredients with antiarrhythmic effects up to 2019 were identified and collected. The results indicate that 36 herbs or their derivatives can be effective in the treatment of arrhythmias, especially in animal and cellular models. They affect various ionic channels in different action potential phases. The alterations in ionic currents lead to changing in the amplitude and duration of the action potential, effective refractory period, maximum velocity, resting membrane potential, channel trafficking, or intracellular calcium concentration. The agents that prolong action potential duration and effective refractory period such as dauricine and sophocarpine seem to be more beneficial if more comprehensive studies confirm their efficacy and safety. It is noteworthy that the consumption of some herbal agents for cardiovascular (e.g. Hawthorn and Ginseng) or other (e.g. Ginseng and Licorice) therapeutic purposes may boost the pro-arrhythmogenic effect of current cardiovascular drugs such as cardiac glycosides. This study accentuates known plants or their derivatives with anti-arrhythmic effects, potential interaction with other cardiac drugs, and the possible mechanisms involved. It can assist clinicians and scientists in research and therapeutic approaches to the management of cardiac arrhythmias.

Integrating traditional Chinese medicines into professional community pharmacy practice in China - Key stakeholder perspectives

Introduction

In China, Traditional Chinese Medicine (TCM) is an integral part of the health system in parallel with Western medicine (WM). However, pharmacists’ duty of care at this interface has not been fully explored. This qualitative study aimed to explore key stakeholders’ perceptions about the challenges and enablers to pharmacists’ adopting a professional role in patient care associated with the concurrent use of herbal medicines (HMs).

Methods

Participants were recruited from the expert pool of the National Research Center for Licensed Pharmacist Development using purposive sampling and snowballing. Participants targeted included government, academics and practicing pharmacists. An interview guide was developed following a literature review and face-to-face, audiotaped interviews conducted with key stakeholders.

Results

Fourteen semi-structured interviews with both practicing pharmacists and key stakeholder representatives were conducted in China in 2017. Thematic analysis identified 6 main themes which focused on how TCM was integrated with WM in China. Participants agreed that pharmacists should at least assume a role in drug safety associated with concurrent use of TCM and WM. However, barriers were identified within the government, education, pharmacy, pharmacist and research sectors, indicating a lack of coordinated strategies to improve this area of healthcare. A lack of clarity in defining the pharmacists’ role in this area and a disconnect between current regulatory standards and education/training system were the prominent themes. Participants looked towards the government to facilitate actions in the development of policies that support pharmacy practice and practice guidelines, and the review of competency standards, and registration criteria as being the most important enablers.

Conclusion

Guiding principles that outline standards for pharmacy practice regarding HMs in an integrated healthcare system are considered a priority, requiring a joint effort from the government, professional organizations and universities.

Inhibition of human thrombin by the constituents of licorice: inhibition kinetics and mechanistic insights through in vitro and in silico studies

Thrombin inhibition therapy is a practical strategy to reduce thrombotic and cardiovascular risks via blocking the formation of blood clots. This study aimed to identify naturally occurring thrombin inhibitors from licorice (one of the most popular edible herbs), as well as to investigate their inhibitory mechanisms. Among all tested licorice constituents, licochalcone A was found as the most efficacious agent against human thrombin (IC₅₀ = 7.96 μM). Inhibition kinetic analyses demonstrated that licochalcone A was a mixed inhibitor against thrombin-mediated Z-Gly-Gly-Arg-AMC acetate hydrolysis, with a K_i value of 12.23 μM. Furthermore, mass spectrometry-based chemoproteomic assays and molecular docking simulations revealed that licochalcone A could bind to human thrombin at both exosite I and the catalytic site. In summary, our findings demonstrated that the chalcones isolated from licorice were a new class of direct thrombin inhibitors, also suggesting that licochalcone A was a promising lead compound for developing novel anti-thrombotic agents.

Licochalcone A, a bioactive compound from licorice, displayed strong inhibition of thrombin.

Qing-Xin-Jie-Yu Granule for patients with stable coronary artery disease (QUEST Trial): A multicenter, double-blinded, randomized trial

BACKGROUND AND AIM

Despite optimal secondary preventive treatment, patients with stable coronary artery disease (SCAD) remain at high risk of cardiovascular events. This multicenter, double-blinded, randomized trial sought to determine whether the addition of Qing-Xin-Jie-Yu Granule (QXJYG), a traditional Chinese medicine prescription, to standard therapy would further reduce risk of cardiovascular events in patients with SCAD.

METHODS

A total of 1500 patients with documented SCAD were randomly assigned in a 1:1 ratio to QXJYG or placebo for 6 months, and followed up for another 6 months. The primary outcome was a composite of cardiovascular death, nonfatal myocardial infarction (MI) and coronary revascularization. Near the end of the trial, but before unblinding, a commonly used composite 'hard' endpoint composed of cardiovascular death, nonfatal myocardial infarction and ischemic stroke was additionally analyzed.

RESULTS

During a median follow-up of 12 months, no significant difference of the primary outcome between the two groups was observed (1.59% vs. 1.62%; hazard ratio, 0.41; 95% CI, 0.13-1.28). However, absolute risk of the composite 'hard' endpoint was reduced by 0.99% (0.31% vs. 1.30%; hazard ratio, 0.06; 95%CI, 0.01 to 0.53). No difference of adverse events between the two groups was observed.

CONCLUSION

In patients with SCAD, the addition of QXJYG to standard therapy was associated with reduced risk of nonfatal MI and the composite 'hard' endpoint of cardiovascular death, nonfatal MI and stroke. (http://www.chictr.org.cn/showproj.aspx?proj=5200, ChiCTR-TRC-13004370).

Prevalence of, and factors associated with health supplement use in Dubai, United Arab Emirates: a population-based cross-sectional study

BACKGROUND

Health supplement (HS) products that are available in the Emirate of Dubai (United Arab Emirates; UAE) contain chemicals that may adversely affect human health. This study aimed to investigate the prevalence of, and factors associated with HS consumption, knowledge, related adverse events, and reporting practices of adverse events amongst the general population in Dubai, UAE.

METHODS

A cross-sectional household telephone survey using a computer-assisted questionnaire was conducted amongst a random representative sample (n = 1203) of the Dubai population that assessed HS use and knowledge. Dependent variables were supplement use and reports of adverse events while independent variables included socio-demographic factors, knowledge, attitudes, and practice. Logistic regression analysis was performed to identify factors independently associated with HS use.

RESULTS

Among the 1203 participants in this study, 455 (37.8%) reported ever using HS. Amongst ever-users, reasons for use were to improve health (66.1%), for bodybuilding (9.9%), disease prevention (6.8%), and weight management (5.3%). The majority of users purchased their HS from pharmacies (88.4%) or were prescribed HS (46.6%). Vitamins were the most commonly used HS (87.9%) followed by minerals (10.5%) and sports nutrition products (10.5%). Only 2.9% of users experienced an adverse event associated with HS use which all resolved when the HS was discontinued. Only three of those affected reported the incident. Multivariate logistic regression analysis revealed that HS use was independently associated with female gender (adjusted odds ratio [AOR]; 3.26, 95% confidence interval [CI]: 2.26-4.70), higher income (AOR 2.41, 95% CI: 1.20-4.83), being a past-smoker (AOR 2.39, 95% CI: 1.27-4.48), having an allergy (AOR 1.75, 95% CI: 1.14-2.66), more frequent doctor visits (AOR 1.86, 95% CI: 1.02-3.39), taking prescribed medications (AOR 1.47, 95% CI: 1.04-2.06), and knowledge about HS (AOR 3.91, 95% CI: 2.26-6.76).

CONCLUSIONS

Our study provides the first population-based estimates of HS use and HS-related adverse events in the Gulf region. Adverse events associated with HS are infrequent and this may be due to the well-developed regulatory framework in Dubai and the high level of knowledge amongst consumers who mainly consume vitamins and minerals on the advice of pharmacists or healthcare professionals.

A Novel Integrative Processing Technology for the Preparation of Rehmanniae Radix Slices

The traditional processing method for the slices preparation of Rehmanniae roots is time- and energy-consuming and is prone to result in loss of active components during twice water-treatment (once for wash and the other for softening) and drying steps. In this study, we firstly explored an integrative processing technique for Rehmanniae Radix by 2x3 factorial experiment based on the contents of catalpol and verbascoside as measured by HPLC. The potential differences between the traditional stepwise processing technique and the integrative processing technique for catalpol and verbascoside in the prepared slices were investigated. To further confirm the effectiveness of drugs using the integrative processing technique, some pharmacological variables, such as rectal temperature, hematologic parameters (RBC, HGB, HCT, and blood viscosity), and coagulation parameters (TT, APTT, PT and FIB), were detected in a blood-heat and hemorrhage syndrome rat model. Two-way ANOVA analysis showed that drying for 18 h at 50°C was considered as the best combination of process conditions. The mean catalpol and verbascoside contents in the integrative method-processed samples (4.30% and 0.33%, respectively) were higher than those in the traditional method-processed samples (2.61% and 0.21%, respectively). Significant increases in rectal temperature, and hematologic parameters, TT, APTT, and FIB, were observed in the model group rats, compared to the blank group animals (P<0.01). Both in the integrative groups and traditional groups, the extracts caused significant decreases in rectal temperature, RBC, HGB, and HCT with increased concentration compared to the model group animals. All coagulation parameters tested were shortened in model rats received two kind prepared slices. There were no significant therapeutic differences between the integrative and the traditional method-processed slices on the hemostasis and hemorheological parameters in this blood-heat and hemorrhage syndrome rat model, indicating that our integrative method may be a feasible technique for processing Rehmanniae Radix slices.

Targeting Ubiquitin Proteasome Pathway with Traditional Chinese Medicine for Treatment of Spinocerebellar Ataxia Type 3

Nine autosomal dominant spinocerebellar ataxias (SCAs) are caused by an abnormal expansion of CAG trinucleotide repeats that encodes a polyglutamine (polyQ) tract within different genes. Accumulation of aggregated mutant proteins is a common feature of polyQ diseases, leading to progressive neuronal dysfunction and degeneration. SCA type 3 (SCA3), the most common form of SCA worldwide, is characterized by a CAG triplet expansion in chromosome 14q32.1 ATXN3 gene. As accumulation of the mutated polyQ protein is a possible initial event in the pathogenic cascade, clearance of aggregated protein by ubiquitin proteasome system (UPS) has been proposed to inhibit downstream detrimental events and suppress neuronal cell death. In this study, Chinese herbal medicine (CHM) extracts were studied for their proteasome-activating, polyQ aggregation-inhibitory and neuroprotective effects in GFP^u and ATXN3/Q 75 -GFP 293/SH-SY5Y cells. Among the 14 tested extracts, 8 displayed increased proteasome activity, which was confirmed by 20S proteasome activity assay and analysis of ubiquitinated and fused GFP proteins in GFP^u cells. All the eight extracts displayed good aggregation-inhibitory potential when tested in ATXN3/Q 75 -GFP 293 cells. Among them, neuroprotective effects of five selected extracts were shown by analyses of polyQ aggregation, neurite outgrowth, caspase 3 and proteasome activities, and ATXN3-GFP, ubiquitin, BCL2 and BAX protein levels in neuronal differentiated ATXN3/Q 75 -GFP SH-SY5Y cells. Finally, enhanced proteasome function, anti-oxidative activity and neuroprotection of catalpol, puerarin and daidzein (active constituents of Rehmannia glutinosa and Pueraria lobata) were demonstrated in GFP^u and/or ATXN3/Q 75 -GFP 293/SH-SY5Y cells. This study may have therapeutic implication in polyQ-mediated disorders.

Therapeutic benefits of liquorice in dentistry

Oral health influences general well-being and quality of life. Oral diseases can be debilitating and are a major heath concern worldwide. Medicinal plants have been used for thousands of years for treating human diseases. Considering the emergence of multi-drug resistant pathogens and financial difficulties in developing countries, there is an urgent need for developing new antimicrobial compounds which are safe, efficient and cost effective. Liquorice also known as yashtimadhu, sweetwood or mulhatti is one such herbal remedy which has shown to have immense potential in treatment of orofacial diseases. Liquorice is rich in secondary metabolites which are used in cosmetics, foods, traditional and modern medicine. It has well known properties such as antiviral, glucocorticoid, anti-inflammatory, antioxidant, anti-ulcerative, anti-carcinogenic and many more. Liquorice extracts and liquorice bioactive ingredients such as glabridin, licoricidin, licorisoflavan A, licochalcone A, and glycyrrhizin have shown beneficial effects in preventing and treating oral diseases. This paper reviews the effects of liquorice and its constituents on oral diseases such as dental caries, periodontitis, gingivitis, candidiasis, recurrent aphthous ulcer and oral cancer and its use as a root canal medicament and summarizes the results of clinical trials that investigated the potential beneficial effects of liquorice and its constituents as a prevention and treatment modality in oral diseases. Clinical trials, case reports and review of literature evaluating the effect of liquorice on oral microorganisms and oral diseases are included. Literature pertaining to the effects of liquorice on systemic diseases have been excluded from this review of literature.

Spontaneous spinal epidural hematoma of the thoracic spine after herbal medicine: a case report

Background

Spontaneous spinal epidural hematoma (SSEH) is an uncommon disease, but it can lead to acute cord compression with disabling consequences. Identifiable reasons for spontaneous hemorrhage are vascular malformations and bleeding disorders. However, SSEH after taking herbal medicines has not been described yet.

Case presentation

A 60-year-old female experienced sudden back pain combined with numbness and weakness in the lower limbs for several hours with no trauma, drug use, family history or any disease history. Her deep tendon reflexes were normoactive, and Babinski was negative. An emergent MRI showed a spinal epidural hematoma extending from T3 to T5. She was taken to surgery after immediate clinical and laboratory evaluations had been completed. Emergency decompression with laminectomy was performed and the patient recovered immediately after the surgery. Additional history taken from the patient at outpatient clinic after discharge revealed that she had been continuously taking herbal medicine containing black garlic for 8 weeks.

Conclusion

To our knowledge, no report has been previously issued on SSEH after taking herbal medicines. Although contradictory evidence is present on bleeding risks with herbal uses, we believe that it’s reasonable to ascertain if patients with SSEP are taking herbal medication before or during spinal surgery.

Guanxinning tablet for patients who switch from dual antiplatelet therapy to aspirin alone after percutaneous coronary intervention: study protocol for a cluster randomized controlled trial

Background

One-year dual antiplatelet therapy (DAPT), generally aspirin in combination with a P2Y12 receptor inhibitor, has been a standard treatment for patients undergoing percutaneous coronary intervention (PCI). Prolonged DAPT has proven itself effective in further reducing cardiovascular events, yet with increased risk of bleeding. Thus, it is of great necessity to find an alternative drug that is as effective but safer and more economic than the P2Y12 inhibitors after termination of one-year DAPT.

Methods

We will conduct a cluster randomized controlled trial in 3600 eligible post-PCI patients from 36 tertiary hospitals (100 patients per hospital) across mainland China. The hospitals served as clusters are randomized in a 2:1 ratio to Guanxinning tablet (GXNT) plus aspirin or aspirin alone for 12 months, with other conventional treatment applied in both groups. After the treatment period, all patients will be followed up for another 12 months. The primary outcome measure is composite cardiovascular events including cardiovascular death, non-fatal myocardial infarction, stent thrombosis, revascularization, ischemic stroke, and re-admission due to unstable angina. Secondary outcome measures are all-cause mortality, each individual component of the primary outcome measure, and stopping or reducing the rate of nitroglycerin administration. Adverse events, including bleeding, will be closely monitored during the whole trial period. In addition, a cost-effectiveness study of GXNT for the study population will be conducted along with this trial.

Discussion

This trial aims to determine whether the addition of GXNT will further improve prognosis without increasing bleeding risk for patients with coronary artery disease who have switched from DAPT to aspirin alone after PCI. Completion of this clinical trial might provide a novel, promising, and safer alternative to P2Y12 inhibitors for prolonged antiplatelet therapy in post-PCI patients.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IIR-17010688. Registered on 20 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-017-2373-x) contains supplementary material, which is available to authorized users.

Identification of the cytochrome P450 enzymes involved in the oxidative metabolism of trantinterol using ultra high-performance liquid chromatography coupled with tandem mass spectrometry

Trantinterol is a novel β₂-adrenoceptor agonist used for the treatment of asthma. This study aimed to identify the cytochrome P450 enzymes responsible for the metabolism of trantinterol to form 4-hydroxylamine trantinterol (M1) and tert-butyl hydroxylated trantinterol (M2), which was achieved using the chemical inhibition study, followed by the metabolism study of trantinterol in a panel of recombinant CYPs, as well as the kinetic study with the appropriate cDNA-expressed P450 enzymes. A highly selective and sensitive ultra high-performance liquid chromatography tandem mass spectrometry method was developed and validated for the simultaneous determination of M1 and M2. The inhibition study suggested that CYP2C19 and CYP3A4/5 were involved in the formation of M1 and M2, and CYP2D6 only contributed to the formation of M1. Assays with cDNA-expressed CYP enzymes further showed that the relative contributions of P450 isoforms were 2C19 > 3A4 > 2D6 > 2E1 for the formation of M1, and 3A4 > 2C19 > 2D6 for the formation of M2. The enzyme kinetic analysis was then performed in CYP2C19, CYP2D6 and CYP3A4. The kinetic parameters were determined and normalized with respect to the human hepatic microsomal P450 isoform concentrations. All the results support the conclusion that CYP3A4 and CYP2C19 are the major enzymes responsible for formation of M1 and M2, while CYP2D6 and CYP2E1 also engaged to a lesser degree. The results imply that potential drug–drug interactions may be noticed when trantinterol is used with CYP2C19 and CYP3A4 inducers or inhibitors, and we should pay attention to this phenomenon in clinical study.

The first report on the characterization of the main CYP450 enzymes and the kinetic study involved in trantinterol metabolism.

Uncertain Associations of Major Bleeding and Concurrent Use of Antiplatelet Agents and Chinese Medications: A Nested Case-Crossover Study

Despite the evidence that some commonly used Chinese medications (CMs) have antiplatelet/anticoagulant effects, many patients still used antiplatelets combined with CMs. We conducted a nested case-crossover study to examine the associations between the concomitant use of antiplatelets and CMs and major bleeding using population-based health database in Taiwan. Among the cohort of 79,463 outpatients prescribed antiplatelets (e.g., aspirin and clopidogrel) continuously, 1,209 patients hospitalized with new occurring bleeding in 2012 and 2013 were included. Those recruited patients served as their own controls to compare different times of exposure to prespecified CMs (e.g., Asian ginseng and dong quai) and antiplatelet agents. The periods of case, control 1, and control 2 were defined as 1–4 weeks, 6–9 weeks, and 13–16 weeks before hospitalization, respectively. Conditional logistic regression analyses found that concurrent use of antiplatelet drugs with any of the prespecified CMs in the case period might not significantly increase the risks of bleeding over that in the control periods (OR = 1.00, 95% CI 0.51 to 1.95 and OR = 1.13, 95% CI 0.65 to 1.97). The study showed no strong relationships between hospitalization for major bleeding events and concurrent use of antiplatelet drugs with the prespecified CMs.

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.

Herb-Drug Interactions of Commonly Used Chinese Medicinal Herbs

With more and more popular use of traditional herbal medicines, in particular Chinese herbal medicines, herb-drug interactions have become a more and more important safety issue in the clinical applications of the conventional drugs. Researches in this area are increasing very rapidly. Herb-drug interactions are complicated due to the fact that multiple chemical components are involved, and these compounds may possess diverse pharmacological activities. Interactions can be in both pharmacokinetics and pharmacodynamics. Abundant studies focused on pharmacokinetic interactions of herbs and drugs. Herbs may affect the behavior of the concomitantly used drugs by changing their absorption, distribution, metabolism, and excretion. Studies on pharmacodynamics interactions of herbs and drugs are still very limited. Herb-drug interactions are potentially causing changes in drug levels and drug activities and leading to either therapeutic failure or toxicities. Sometime it can be fatal. The exposures to drugs, lacking of knowledge in the potential adverse herb-drug interactions, will put big risk to patients' safety in medical services. On the contrary, some interactions may be therapeutically beneficial. It may be used to help develop new therapeutic strategies in the future. This chapter is trying to review the development in the area of herb-drug interactions based on the recently published research findings. Information on the potential interactions among the commonly used Chinese medicinal herbs and conventional drugs is summarized in this chapter.