Drug Interactions Between Herbal and Prescription Medicines

Effect of holographic Guasha on sleep quality of older adults with hypertension in the community: A prospective study

To explore the effect of holographic Guasha therapy on the Pittsburg Sleep Quality Index (PSQI) and Hamilton Anxiety Rating Scale (HAMA) in older adults with hypertension living in the community. This prospective study was conducted from July 2019 to December 2020. Older adults with hypertension (systolic pressure ≥ 140 mm Hg, diastolic pressure ≥ 90 mm Hg) were divided into the control and Guasha groups. The PSQI and HAMA were assessed before and after 4 weeks of intervention. 62 patients were enrolled, with 31/group (Guasha: 72.4 ± 6.9 years, 23.0 ± 3.1 kg/m2; control: 71.4 ± 6.3 years; 22.9 ± 2.9 kg/m2). The total PSQI score did not decrease in the control group after 4 weeks (from 14.8 ± 1.2 to 14.8 ± 1.8, P = .498) but decreased in the Guasha group (from 14.9 ± 1.1 to 6.8 ± 3.5, P < .001). All PSQI subscores decreased in the Guasha group after 4 weeks of Guasha intervention (all P < .05), except for the use of sleep medication, since the use of such drugs was an exclusion criterion. The HAMA index scores did not change in the control or Guasha group (both P > .05). Holographic Guasha appears to achieve better sleep outcomes than conventional treatment in improving the sleep quality of older adults with hypertension living in the community. The participants were not randomly assigned to the treatments, and the results should be confirmed in a formal trial.

Prevalence of acquired and transmitted HIV drug resistance in Iran: a systematic review and meta-analysis

BACKGROUND

There is no systematic review on the prevalence of HIV drug resistance (HIVDR) in Iran. We aimed to estimate the prevalence of HIVDR among people living with HIV (PLHIV) in Iran. We assessed HIVDR prevalence in antiretroviral therapy (ART) naïve PLHIV (i.e., those without a history of ART) and PLHIV receiving ART.

METHOD

We systematically searched Scopus, PubMed, Web of Science, Embase, Iranian databases (Iranian Medical Research Information System, Magiran, and Scientific Information Database), the references of studies, and Google Scholar until March 2023. A random-effects model was used to calculate a point estimate and 95% confidence interval (95% CI) for the prevalence of HIVDR in PLHIV.

RESULTS

Among 461 potential publications, 22 studies were included in the meta-analysis. The pooled prevalence of acquired HIVDR in PLHIV receiving ART was 34% (95% CI: 19, 50) for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), 27% (95% CI: 15, 41) for non-nucleoside reverse transcriptase inhibitors (NNRTIs), and 9% (95% CI: 3, 18) for protease inhibitors (PIs). The pooled prevalence of acquired HIVDR in treatment failure PLHIV was 50% (95% CI: 31, 69) for NRTIs, 49% (95% CI: 29, 69) for NNRTIs, 11% (95% CI: 2, 24) for PIs, and 1% (95% CI: 0, 4) for integrase inhibitors (INIs). The pooled prevalence of transmitted HIVDR in ART-naïve people was 3% (95% CI; 1, 6) for NRTIs, 5% (95% CI: 2, 9) for NNRTIs, and 0 for PIs and INIs.

CONCLUSION

The prevalence of HIVDR was relatively high in both ART-naïve PLHIV and those receiving ART. Without universal pretreatment HIVDR testing and more frequent routine HIV viral load testing among PLHIV who are on ART, the HIVDR prevalence might increase in PLHIV in Iran.

Sub-acute toxicity evaluation of aqueous leaf extract from Passiflora edulis Sims f. edulis (Gulupa) in Wistar rats

The genus Passiflora (Passifloraceae) comprises about 500 species. The Passiflora edulis stands out because of its economic and medicinal importance. It is widely planted in tropical and subtropical regions worldwide, especially in South America, the Caribbean, South Africa, and Asia. The aqueous extract of Passiflora edulis Sims f. edulis (Gulupa) leaves is used in traditional medicine for its soothing and tranquilizing effects on the central nervous system. Therefore, evaluating its safety for human use is a fundamental requirement to continue the development of new therapies within the framework of regulatory, preclinical, and clinical guidelines. Here, the sub-acute toxicity study was conducted following the Organization for Economic Cooperation and Development (OECD) guideline 407 for 28 days in Wistar albino rats. The study showed that 1000 mg/kg/day of the aqueous extract in 10 adult Wistar rats (five males and five females) was well tolerated. The hematological results are at normal levels. However, monocytopenia and eosinopenia were observed with a significant difference (P < 0,05) for both male and female rats treated with the aqueous extract of Passiflora edulis. The results show that liver and kidney function profiles were conserved. However, an increase in ALT is observed with significant differences between male and female rats treated with the extract compared to the controls. Study findings were limited to non-adverse histopathological results of a slightly increased incidence of focal periportal lymphocytic infiltrate in the liver and focal corticomedullary nephrocalcinosis in the kidney compared to control. Therefore, the aqueous extract of Passiflora edulis has a good safety profile in oral administration, was well tolerated, and did not cause any lethality or adverse effects in the sub-acute toxicity study in male and female rats. The NOAEL (no observed adverse effect level) for the 28-day subacute toxicity study was considered to be 1000 mg/kg.

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.

Herbal supplements in Jordan: a cross-sectional survey of pharmacists' perspectives and knowledge

OBJECTIVES

Pharmacists are ideal partners for engaging with the needs and expectations of patients. They can play a vital role by providing information and supplying herbal medicines. In some community settings, pharmacists are also the main first point of care. This study explored Jordanian community pharmacists' perspectives and knowledge of herbal medicines available in pharmacies.

DESIGN

A cross-sectional study using an online survey was developed, and it was distributed via social media platforms. The one-way analysis of variance (ANOVA) test was used to compare the mean knowledge scores between different demographic groups. Multiple linear regression analysis was used to identify predictors of herbal medicines knowledge.

SETTING

Jordanian community pharmacies.

PARTICIPANTS

401 Jordanian community pharmacists.

RESULTS

Herbal supplements are sold in practically all pharmacies (98.5%). Slimming aids (14.7%), followed by sexual and sports enhancements (14%) and maintaining general health (12.1%) were most requested by Jordanian customers. While supplements for maintaining general health (12%), followed by slimming aids (11.4%) and skin conditions (9.3%) were most recommended by Jordanian pharmacists. 63.1% were not aware of potential herb-drug interactions, 95.6% did not receive complaints from customers about herbal medicines and 41.2% would not report adverse reactions to the national pharmacovigilance services. The mean knowledge score for knowledge of use, regulation, adverse reactions, and drug interactions was 3.7 (SD: 0.7), 3.5 (SD: 0.8), 3.6 (SD: 0.8), and 3.6 (SD: 0.8) (out of 5), respectively. ANOVA test showed that total pharmacists' knowledge scores significantly differed based on the length of time practising pharmacy (p<0.05).

CONCLUSION

This study highlights some key concerns relating to recommendations, awareness and reporting of herbal medicines among Jordanian community pharmacists. Pharmacists need enhanced education to provide objective and evidence-based information on the benefits-risks of herbal medicines. Future studies need to be carried out to confirm whether our findings are transferable to other Middle Eastern countries.

Unpredictable adverse effects of herbal products

Herbal products are being increasingly used all over the world for preventive and therapeutic purposes because of the belief of their safety. They have become an important part of health care system in many countries since they can easily be purchased in the health food stores or online. However, the lack of sufficient study on their efficacy and toxicity, inadequate controls of their availability, reduce their safety. Unlike conventional drugs, herbal products are not regulated for purity and potency. Herbal products contain substances which can induce or inhibit enzymes that take part in drug metabolism. Therefore the concurrent use of drugs with some medicinal plants can cause serious adverse effects and can also decrease the efficacy of the therapy. Particularly, drugs with narrow therapeutic index and plants which can affect drug metabolizing enzymes when used together, may lead to unpredictable adverse reactions. Impurities, contaminants and adulterants found in the herbal products, are the most common malpractises in herbal raw-material trade. In this review the unpredictable adverse effects of herbal products due to their possible interactions with drugs and also due to the adulteration and contamination with prohibited chemicals will be discussed in detail.

Rooibos, a supportive role to play during the COVID-19 pandemic?

This article presents the potential health benefits of Rooibos to be considered a support during the COVID-19 pandemic. The recent pandemic of COVID-19 has led to severe morbidity and mortality. The highly infectious SARS-CoV-2 is known to prime a cytokine storm in patients and progression to acute lung injury/acute respiratory distress syndrome. Based on clinical features, the pathology of acute respiratory disorder induced by SARS-CoV-2 suggests that excessive inflammation, oxidative stress, and dysregulation of the renin angiotensin system are likely contributors to the COVID-19 disease. Rooibos, a well-known herbal tea, consumed for centuries, has displayed potent anti-inflammatory, antioxidant, redox modulating, anti-diabetic, anti-cancer, cardiometabolic support and organoprotective potential. This article describes how Rooibos can potentially play a supportive role by modulating the risk of some of the comorbidities associated with COVID-19 in order to promote general health during infections.

An educational intervention improved knowledge of dietary supplements in college students

BACKGROUND

We have previously reported on the prevalence of dietary supplements among college students; it was deduced that their intake of supplements increased according to their grade (i.e., 13.1% in the first grade to 20.5% in the sixth grade). We also reported that some students had experienced adverse events in Japan due to their intake of these supplements. However, awareness of dietary supplements among college students remains limited, even among pharmaceutical students. Being appropriately educated about them is important for pharmaceutical students, both for themselves as well as for their future careers as pharmacists.

METHODS

We conducted a lecture-based educational intervention about dietary supplements on 328 college students in Japan-184 from pharmaceutical science and 144 from environmental science or food and life science disciplines. The purpose of this study was to evaluate the effects of an educational intervention on college students' understanding of dietary supplements. The intervention involved a lecture that covered the quality of dietary supplements, how they differed from drugs, and a summary of their adverse events. The lecture was evaluated using a 14-question questionnaire. We then compared the pre- and post-intervention responses to the same questionnaire using a Wilcoxon signed-rank test. The questions were assessed using a Likert scale that ranged from "strongly agree" to "strongly disagree"; the latter being the preferred answer.

RESULTS

Before the intervention had taken place, the students' understanding of dietary supplements was shown to be deficient. Conversely, post-intervention, their knowledge levels had significantly improved, especially concerning agreement on whether "Dietary supplements are safe because they are just food items". Pre-intervention, 2.7% strongly agreed and 37.5% agreed; post-intervention, 1.2% strongly agreed and 15.6% agreed. On whether "Dietary supplements made from natural ingredients or herbs are safe", at the pre-intervention stage 2.8% strongly agreed and 44.0% agreed and post-intervention, 2.2% strongly agreed and 16.9% agreed. On whether "Dietary supplements made from food items are safe", 4.0% strongly agreed and 43.6% agreed pre-intervention and 0.9% strongly agreed and 16.6% agreed post-intervention. Despite there being a greater number of pharmaceutical students who had a correct understanding of dietary supplements before the intervention, these students still showed improvement after the lecture.

CONCLUSION

An intervention in the form of a single educational lecture has the capacity to improve college students' understanding of dietary supplements. It is important for pharmacists to be appropriately educated about dietary supplements when they consult with patients. We will evaluate the long-term effects of the intervention on the alumni (pharmacists) in a subsequent study.

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.

Intravenous lipid emulsion therapy for cardiac arrest and refractory ventricular tachycardia due to multiple herb intoxication

Herbal products have been used for therapeutic purposes for a long time. However, many herbs can be toxic and even life-threatening. If refractory ventricular tachycardia (VT) is caused by herbal products and shows no response to conventional therapy, intravenous lipid emulsion (ILE) therapy can be considered. We report a case of herbal intoxication leading to refractory VT, which was successfully treated with ILE therapy. A 36-year-old woman with aplastic anemia presented with mental changes. She had taken an unknown herbal decoction three days before visiting the hospital. Soon after coming to the hospital, she went into cardiac arrest. Cardiopulmonary resuscitation was performed, and return of spontaneous circulation with VT was achieved. Synchronized cardioversion was then performed and amiodarone was administered. However, VT with pulse continued, so ILE therapy was attempted, which led to the resolution of VT.

Prevalence of complementary and alternative medicine use among rheumatoid arthritis patients in Saudi Arabia

BACKGROUND AND AIM

The use of complementary and alternative medicine (CAM) is unexplored among Saudi rheumatoid arthritis (RA) patients. The aim of this study was to estimate the prevalence and types of CAM used among patients with RA and factors associated with their use.

EXPERIMENTAL PROCEDURE

A cross-sectional study was conducted at rheumatology clinics in two tertiary hospitals located in Riyadh, Saudi Arabia. The data was collected between May 2017 and February 2018. Unpaired Student's t-tests, Chi-square tests, and Pearson correlation tests were used to compare users vs nonusers.

RESULTS

A total of 438 patients (mean age = 49, SD ± 15 years; 89.7% females) were included in this study. Sixty seven percent of included patients had used CAM for their RA. The majority of CAM users were female (92.1%). The most frequently used CAM products were vitamin D (47%), calcium (37%), honey (15%), ginger (13%), turmeric (11%), black seeds (8%), and fenugreek (8%). One hundred ninety-six (45%) patients believe that CAM is safe, and 287 (96%) patients took it because they believed that CAM had "added benefits". Statistically significant differences were found for gender, RA duration, erythrocyte sedimentation rate (ESR) level, and seropositivity between CAM users and nonusers (P = 0.019, P = 0.011, P = 0.022, and P < 0.0001, respectively). A significant correlation was found between the Erythrocyte Sedimentation Rate (ESR) level, RA duration and CAM use (r = 0.110, P = 0.022 and r = 0.121, P = 0.012, respectively). These data indicated that patients who used CAM had higher ESR level and longer disease duration than patients didn't use CAM.

CONCLUSION

There is a high prevalence of CAM use among RA patients. CAM use was perceived to add benefit and patients using it had higher ESR. Larger studies are needed to assess the use of CAM and its impact on RA and its management.

Understanding the relevance of herb-drug interaction studies with special focus on interplays: a prerequisite for integrative medicine

Integrative medicine refers to the blending of conventional and evidence-based complementary medicines and therapies with the aim of using the most appropriate of either or both modalities for ultimate patient benefits. One of the major hurdles for the same is the chances of potential herb–drug interactions (HDIs). These HDIs could be beneficial or harmful, or even fatal; therefore, a thorough understanding of the eventualities of HDIs is essential so that a successful integration of the modern and complementary alternative systems of medicine could be achieved. Here, we summarize all the important points related to HDIs, including types, tools/methods for study, and prediction of the HDIs, along with a special focus on interplays between drug metabolizing enzymes and transporters. In addition, this article covers future perspective, with a focus on background endogenous players of interplays and approaches to predict the drug–disease–herb interactions so as to fetch the desired effects of these interactions.

Natural Health Product Interactions with Medication

Natural health products (or dietary supplements) refer to those products found in oral dosage forms, containing 1 or more active ingredients considered to be a nutrient, an herbal product, or any other nonnutrient/nonherbal substance. Their use continues to increase in the general population and in patients seen by nutrition support clinicians. Aside from an appraisal of product safety and effectiveness, attention should be paid to the potential for these product ingredients to interact with medication. Estimates are that at least 15 million adults in the United States are at risk for supplement-drug interactions. These can occur through both pharmacokinetic and pharmacodynamic mechanisms. This review describes the influence of dietary supplements on both the disposition and the effect of medication and provides numerous examples. Patients at greatest risk for interactions are those with chronic disease, who use multiple medications-particularly those with a narrow therapeutic range-have genetic variants in drug metabolism, impaired organ function, and are at either end of the age spectrum. Knowledge of the specific effects on drug absorption, metabolism, and effect is still incomplete. Relative to the large number of possible interactions between supplements and medication, only a small number of combinations have been examined or reported. The greatest limiting factor remains the quality or reliability of the existing evidence, as many widely accepted interactions are only theoretical based either on in vitro data or known pharmacology. A distinction needs to be clearly drawn between "documented" interactions and "potential" interactions. Although drug-drug interactions have been widely recognized, supplement-drug interactions may be as important to recognize, report, and manage.

Community pharmacists' perceptions about pharmaceutical service of over-the-counter traditional Chinese medicine: a survey study in Harbin of China

BACKGROUND

This study aims to investigate community pharmacist's perception on the provision of over-the-counter (OTC) traditional Chinese medicine (TCM) pharmaceutical services; focusing on the areas of their attitude, general practice, perceived barriers and suggested improvements.

METHODS

Questionnaire survey targeting community pharmacists in Harbin of China was applied in this study. Questionnaires were distributed and collected at community pharmacies. Data was analyzed by combining descriptive analysis and Chi-test.

RESULTS

280 valid questionnaires were collected, giving a response rate of 78%. Respondents generally showed positive attitude towards OTC TCM pharmaceutical services. However, they were uncertain about whether such pharmaceutical services should be considered as their primary responsibility. Respondents indicated that they acted proactively to find out all the medicines taken by their patients and to remind consumers of possible OTC TCM adverse reactions. However, they were less keen on recommending or re-directing consumers to suitable OTC TCM. The three main barriers hindering the provision of OTC TCM pharmaceutical service identified in this study were "insufficient professional knowledge" (54.6%), "ambiguity of the professional role of pharmacists" (54.6%) and "lack of scientific evidence of OTC TCM" (45.4%). The three main actions considered most relevant to improving pharmaceutical service of OTC TCM were "formulating or refining legislation to clarify the legal and professional role of pharmacists with respect to TCM" (60.7%), "strengthening training of pharmacists with respect to TCM" (57.9%), and "promoting public awareness of the pharmacist's role" (53.6%). According to the results of Chi-test, respondents' perceptions about the attitude, practice, perceived barriers, and improvement suggestions were significantly different depending on the education levels, certificate types and workloads of western medicine.

CONCLUSIONS

The community pharmacists in Harbin, China were positive about the provision of OTC TCM pharmaceutical services. However, they were less certain about taking this duty as their primary responsibility. Insufficient knowledge and lack of role definition in the area of OTC TCM were found to be the major factors discouraging the provision of pharmaceutical service on OTC TCM by community pharmacists.

Recent Advances in Anticancer Activities and Drug Delivery Systems of Tannins

Tannins, polyphenols in medicinal plants, have been divided into two groups of hydrolysable and condensed tannins, including gallotannins, ellagitannins, and (-)-epigallocatechin-3-gallate (EGCG). Potent anticancer activities have been observed in tannins (especially EGCG) with multiple mechanisms, such as apoptosis, cell cycle arrest, and inhibition of invasion and metastases. Furthermore, the combinational effects of tannins and anticancer drugs have been demonstrated in this review, including chemoprotective, chemosensitive, and antagonizing effects accompanying with anticancer effect. However, the applications of tannins have been hindered due to their poor liposolubility, low bioavailability, off-taste, and shorter half-life time in human body, such as EGCG, gallic acid, and ellagic acid. To tackle these obstacles, novel drug delivery systems have been employed to deliver tannins with the aim of improving their applications, such as gelatin nanoparticles, micelles, nanogold, liposomes, and so on. In this review, the chemical characteristics, anticancer properties, and drug delivery systems of tannins were discussed with an attempt to provide a systemic reference to promote the development of tannins as anticancer agents.

Herbal Product Use by African American Older Women

The purposes of this study were to identify patterns of herbal product use for health promotion and self-care management among older African American women, to explore their use of herbal products to manage disease-specific symptoms, and to compare users of herbal products to nonusers. The sample consisted of 57 community-residing African American women age 65 years and older. Of the sample, 33% used herbal product(s) within the past year. Those who used herbal products perceived their overall health to be better than those who did not use herbal products. However, differences in demographic characteristics and locus of control between herbal users and nonusers were not significant. More than 40% of the herbals used were not discussed with health care providers. Most participants using herbals were mixing herbal, prescription, and overthe-counter products. Indiscriminate use of herbal products in combination with or in place of conventional medicines can be problematic and costly.

Elicitation Based Enhancement of Secondary Metabolites in Rauwolfia serpentina and Solanum khasianum Hairy Root Cultures

BACKGROUND

Rauwolfia serpentina and Solanum khasianum are well-known medicinally important plants contained important alkaloids in their different parts. Elicitation of these alkaloids is important because of associated pharmaceutical properties. Targeted metabolites were ajmaline and ajmalicine in R. serpentina; solasodine and α-solanine in S. khasianum.

OBJECTIVE

Enhancement of secondary metabolites through biotic and abiotic elicitors in hairy root cultures of R. serpentina and S. khasianum.

MATERIALS AND METHODS

In this report, hairy root cultures of these two plants were established through Agrobacterium rhizogenes mediated transformation by optimizing various parameters as age of explants, duration of preculture, and co-cultivation period. NaCl was used as abiotic elicitors in these two plants. Cellulase from Aspergillus niger was used as biotic elicitor in S. khasianum and mannan from Saccharomyces cerevisiae was used in R. serpentina.

RESULTS

First time we have reported the effect of biotic and abiotic elicitors on the production of important metabolites in hairy root cultures of these two plants. Ajmalicine production was stimulated up to 14.8-fold at 100 mM concentration of NaCl after 1 week of treatment. Ajmaline concentration was also increased 2.9-fold at 100 mg/l dose of mannan after 1 week. Solasodine content was enhanced up to 4.0-fold and 3.6-fold at 100 mM and 200 mM NaCl, respectively, after 6 days of treatments.

CONCLUSION

This study explored the potential of the elicitation strategy in A. rhizogenes transformed cell cultures and this potential further used for commercial production of these pharmaceutically important secondary metabolites.

SUMMARY

Hairy roots of Rauwolfia serpentina were subjected to salt (abiotic stress) and mannan (biotic stress) treatment for 1 week. Ajmaline and ajmalicine secondary metabolites were quantified before and after stress treatmentAjmalicine yield was enhanced up to 14.8-fold at 100 mM concentration of NaCl. Ajmaline content was also stimulated 2.9-fold at 100 mg/l dose of mannan after 1 weekHairy roots of Solanum khasianum were treated with cellulase (biotic elicitor) and salt (abiotic stress)Solasodine content was improved up to 4.0-fold and 3.6-fold at 100 mM and 200 mM NaCl, respectively, after 6.days of treatmentsThe α-solanine content increased to 1.6-fold after 24 h of treatment at 100 μg/mL cellulase concentration. Abbreviations used: MS medium: Murashige and Skoog medium, B5 medium: Gamborg B5 medium, OD: Optical Density, NaCl: Sodium Chloride.

Pharmacokinetic interaction of Acacia catechu with CYP1A substrate theophylline in rabbits

OBJECTIVE

To investigate the effect of black catechu (BC) on the pharmacokinetics of theophylline (CYP1A2 substrate, with narrow therapeutic index) in rabbits.

METHODS

In the present investigation the effect of BC on the pharmacokinetics of theophylline, a CYP1A2 substrate was determined. In the study, BC (264 mg/kg, p. o.) or saline (control group) was given to rabbits for 7 consecutive days and on the 8th day theophylline (16 mg/kg) was administered orally one hour after BC or saline treatment. Blood samples were withdrawn at different time intervals (0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 24 and 36 h) from the marginal ear vein.

RESULTS

The pretreatment of rabbits with BC resulted in a significant increase in maximum blood concentration, time of peak concentration and area under the concentration time profile curve until last observation which was about 41.32%, 35.71% and 15.03%, respectively. While decreases in clearance, volume of distribution, and half-life were observed. It is suggested that BC pretreatment decreases the CYP1A metabolic activity leading to increase in bioavailability and decrease in oral clearance of theophylline, which may be due to inhibition of CYP1A.

CONCLUSION

BC can significantly alter theophylline pharmacokinetics in vivo possibly due to inhibition of CYP1A and P-glycoprotein activity. Based on these results, precaution should be exercised when administering BC with CYP1A substrate.

Adverse Psychiatric Effects Associated with Herbal Weight-Loss Products

Obesity and overeating are among the most prevalent health concerns worldwide and individuals are increasingly using performance and image-enhancing drugs (PIEDs) as an easy and fast way to control their weight. Among these, herbal weight-loss products (HWLPs) often attract users due to their health claims, assumed safety, easy availability, affordable price, extensive marketing, and the perceived lack of need for professional oversight. Reports suggest that certain HWLPs may lead to onset or exacerbation of psychiatric disturbances. Here we review the available evidence on psychiatric adverse effects of HWLPs due to their intrinsic toxicity and potential for interaction with psychiatric medications.

Medication Use in Adults with and without Hearing Impairment

The objective of this study was to determine whether hearing ability in adults is associated with medication use in general, the use of specific types of medication, or polypharmacy. In this exploratory study, data of the National Longitudinal Study on Hearing (NL-SH; n = 2,160) were used. In total, 62% of the participants reported using any medication in the past 28 days. Hearing ability in noise, as determined with an online digit-triplet speech-in-noise test, was significantly associated with (1) medication acting on the alimentary tract and metabolism (including diabetes and acid-related disorders), (2) use of calcium blockers, and (3) medication used for sensory organs.

Safety concerns in simultaneous use of prescription and 'over-the-counter' medicines- results of patient survey in Estonia

During the last decades, the share of population using prescription (Rx) medicines has considerably increased. With the wider introduction of self-medication and the use of over-the-counter (OTC) medicines, there is a real threat for drug-drug interactions between Rx and OTC medicines neither identified nor overseen by healthcare specialists.

The objectives of this survey were to ascertain how often, and for what conditions OTC and Rx medicines are used simultaneously, and to discuss possible health hazards connected with the concomitant use of these medicines.

This survey was designed as a descriptive, cross-sectional questionnaire-based interview which was conducted amongst pharmacy customers and patients in urban and rural areas of Estonia in between 2010–2012.

In total, 712 respondents participated in the survey. Of those, 50.4% reported concomitant use of Rx and OTC medicines during the survey. The simultaneous use of Rx and OTC medicines increased with age and the number of chronic diseases (both p < 0.001). Of chronic patients, 37.1% used Rx and OTC medicines on a daily basis over a four-week period before the survey, and considering reported chronic diseases and the most widespread OTC medicines, they could encounter drug-drug interactions between Rx medicines (e.g. antihypertensives, anti-inflammatory medicines) and OTC medicines (e.g. paracetamol, NSAID-s, herbal medicines and adsorbents).

The present survey revealed frequent concomitant use of Rx and OTC medicines. Especially vulnerable are chronic and elderly patients. In the future, both patients and healthcare specialists should pay more attention to possible drug-drug interactions of Rx and OTC medicines.

Euphorbia tirucalli aqueous extract induces cytotoxicity, genotoxicity and changes in antioxidant gene expression in human leukocytes

The medicinal use of Euphorbia tirucalli has to be made with caution, as our study indicates that the aqueous extract induces genotoxicity and cytotoxicity in human leukocytes

Evaluating medicinal plants for anticancer activity

Plants have been used for medical purposes since the beginning of human history and are the basis of modern medicine. Most chemotherapeutic drugs for cancer treatment are molecules identified and isolated from plants or their synthetic derivatives. Our hypothesis was that whole plant extracts selected according to ethnobotanical sources of historical use might contain multiple molecules with antitumor activities that could be very effective in killing human cancer cells. This study examined the effects of three whole plant extracts (ethanol extraction) on human tumor cells. The extracts were from Urtica membranacea (Urticaceae), Artemesia monosperma (Asteraceae), and Origanum dayi post (Labiatae). All three plant extracts exhibited dose- and time-dependent killing capabilities in various human derived tumor cell lines and primary cultures established from patients' biopsies. The killing activity was specific toward tumor cells, as the plant extracts had no effect on primary cultures of healthy human cells. Cell death caused by the whole plant extracts is via apoptosis. Plant extract 5 (Urtica membranacea) showed particularly strong anticancer capabilities since it inhibited actual tumor progression in a breast adenocarcinoma mouse model. Our results suggest that whole plant extracts are promising anticancer reagents.

Herbal products in pregnancy: experimental studies and clinical reports

The aim of this work is to provide an update from an overview of the literature of the most frequently consumed herbal remedies during pregnancy, both alone and concomitantly with prescribed medications and particularly on their side effects to the mother and fetus. We have also analyzed some of the adverse interactions that may occur due to concomitant use of herbal and pharmaceutical products during pregnancy. Herbal remedies are not evaluated according to the same standards as pharmaceuticals, and in the USA some of it are not licensed but sold as food supplements. There is a lack of basic knowledge on the part of both clinicians and patients as to the indications for use and safety of herbal medicines used in pregnancy and lactation. If 'traditional use' is the only available information, the pregnant woman should be made aware of this to enable her to make an informed decision concerning potential use.

Availability and needs of herbal medicinal information resources at community pharmacy, Riyadh region, Saudi Arabia

A cross-sectional survey of community pharmacists in Riyadh region, Saudi Arabia was conducted over a period of 6 months from July through December 2011. Data collection was carried out using a structured self-administered questionnaire. The survey questionnaire consisted of a brief introduction to the study and eleven questions. The questions consisted of close ended, multiple-choice, and fill-in short answers. A stratified random sample of one thousand and seven hundred registered pharmacy practitioners all over Saudi Arabia were randomly chosen to respond to the survey. The data from each of the returned questionnaire were coded and entered into Statistical Package for the Social Sciences (SPSS) version 19 software (SPSS Inc., Chicago, IL, USA) which was used for statistical analysis. Only one thousand four hundred one pharmacists responded to the survey (response rate is 82.4%) with a completely answered questionnaire. The study results show that 59.7% of the participants sometimes discuss herbal medicine use with their patients, while only 4.25% never discuss it. The study shows 48.5% of participated pharmacists record herbal medicine use sometimes where only 9.4% of them never did so. However, with regard to initiation of the discussion, the study shows that 44.3% of the respondents reported that patients initiate herbal issue discussion while 20.8% reported that pharmacists initiate the discussion. This discussion was reported to be a one time discussion or an ongoing discussion by 14.3% or 9.9% of the respondents respectively. According to the study results, respondents reported that the most common barriers that limit discussing herbal medicines' use with their patients were lack of time due to other obligations assigned to the community pharmacist (46%), lack of reliable resources (30.3%), lack of scientific evidence that support herbal medicine use (15.2%), or lack of knowledge of herbal medicines (13.4%). Yet, a small number of respondents was concerned about interest in herbal medicines (9.1%) and other reasons (2.4%). So it is urgent to ensure that pharmacists are appropriately educated and trained. Extra efforts are needed to increase the awareness of pharmacists to adverse drug reactions reporting system at Saudi Food and Drug Authority. Finally, more consideration to herbal issues should be addressed in both pharmacy colleges' curricula and continuous education program..

Complementary and integrative treatments: facial cosmetic enhancement

Complementary and integrative medicine is particularly popular among patients undergoing facial cosmetic enhancement. This article reviews the efficacy of the most commonly practiced integrative therapies among this surgical population, with a focus on the most current literature regarding the application or potential for application of these treatments to benefit patients undergoing facial aesthetic surgery. Adverse effects of the most popular herbal and dietary supplements are also reviewed. Finally, the potential for interaction among integrative treatments as well as with conventional pharmacologic therapy is discussed.

The prevalence of herb and dietary supplement use among children and adolescents in the United States: Results from the 2007 National Health Interview Survey

OBJECTIVE

The purpose of this study is to examine the national prevalence of herb and dietary supplement usage among children and adolescents age 4-17 in the United States, and to identify population factors associated with usage.

METHODS

Weighted population estimates are derived from the 2007 National Health Interview Child Complementary and Alternative Medicine Supplement (sample n=9417). Wald chi-square tests are used to compare factors associated with herb and dietary supplement use.

RESULTS

An estimated 2.9 million children and adolescents used herbs or dietary supplements in 2007. Pediatric herb and supplement use was more common among adolescents and non-Hispanic whites, and positively associated with parental education and household income. Children with activity limitations due to chronic health conditions, long-term prescription use, or relatively heavy use of physician services were also more likely to use herbal supplements. Echinacea and fish oil were most commonly used herbs and supplements.

CONCLUSIONS

Children in the US appear to use herbs or dietary supplements at a much lower rate than adults. This analysis shows a pattern of moderate and appropriate herb and supplement use in the pediatric population.

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

Background

The risks attributed to drug-herb interactions, even when known, are often ignored or underestimated, especially for those involving anti-clotting drugs and Chinese medicines. The aim of this study was to structurally search and evaluate the existing evidence-based data associated with potential drug interactions between anticoagulant/antiplatelet drugs and Chinese herbal medicines (CHMs) and evaluate the documented mechanisms, consequences, and/or severity of interactions.

Methodology and Findings

Information related to anticoagulant/antiplatelet drug-CHM interactions was retrieved from eight interaction-based textbooks, four web resources and available primary biomedical literature. The primary literature searches were conducted in English and/or Chinese from January 2000 through December 2011 using the secondary databases (e.g., PubMed, Airiti Library, China Journal full-text database). The search terms included the corresponding medical subject headings and key words. Herbs or natural products not used as a single entity CHM or in Chinese Medicinal Prescriptions were excluded from further review. The corresponding mechanisms and severity ratings of interactions were retrieved using MicroMedex®, Lexicomp® and Natural Medicines Comprehensive Database®. Finally, we found 90 single entity CHMs contributed to 306 documented drug-CHM interactions. A total of 194 (63.4%) interactions were verified for its evidence describing possible mechanisms and severity. Of them, 155 interactions (79.9%) were attributable to pharmacodynamic interactions, and almost all were rated as moderate to severe interactions. The major consequences of these interactions were increased bleeding risks due to the additive anticoagulant or antiplatelet effects of the CHMs, specifically danshen, dong quai, ginger, ginkgo, licorice, and turmeric.

Conclusions/Significance

Conventional anticoagulants and antiplatelet drugs were documented to have harmful interactions with some commonly used single entity CHMs. For those patients who are taking conventional anti-clotting medications with CHMs for cardiovascular or cerebrovascular diseases, the potential risks of increased bleeding due to drug-CHM interactions should not be ignored.

Ginkgo biloba: indications, mechanisms, and safety

Ginkgo biloba special extract (EGb761) is used in most randomized control trials. Indications include cognition and memory in Alzheimer disease, age-associated dementia, cerebral insufficiency, intermittent claudication, schizophrenia, and multi-infarct dementia. Dosages range from 80 to 720 mg/d for durations of 2 weeks to 2 years. Mechanisms of action include increasing cerebral blood flow, antioxidant and antiinflammatory effects, with antiplatelet effects attributed to flavone and terpene lactones. Possible interactions with monoamine oxidase inhibitors, alprazolam, haloperidol, warfarin, and nifedipine have been reported. Optimal dosage/duration, dose-response characteristics, drug interactions, bioavailability, long-term effects, and optimal intervention timing should be the focus of future work.

The Role of Complementary Medicine in a Pediatric Day Center in Germany

<b><i>Background:</i></b> The role of complementary alternative medicine (CAM) in pediatrics has considerably increased in the last years. The knowledge about potential side effects and possible interactions with conventional drugs is still limited, and often pediatricians do not know whether their patients use CAM. This can be critical, as in order to diagnose and treat illnesses properly physicians need to know about the full extent of the self-administered therapy of their patients. Many studies have been conducted in other countries in order to assess the extent of CAM use and the types of substances that are consumed, but in Germany data in regard to pediatric interventions are lacking. We therefore developed a questionnaire to evaluate the frequency of CAM use among German pediatric patients. <b><i>Patients and Methods:</i></b> 115 parents visiting the pediatric day center in Epe between September and November 2011 responded to the questionnaire. The survey contains questions concerning the prevalence of CAM use and data about socioeconomic factors. <b><i>Results:</i></b> A total of 75.7% of all children enrolled in the study had already been treated with CAM by their parents, while only 43.6% of the parents knew that there can be interactions with CAM and prescribed drugs. In only half of the cases (50.6%) the pediatrician knew about the CAM usage of the child. <b><i>Conclusion:</i></b> The frequency of CAM usage among children is higher than anticipated. It is essential that pediatricians know about possible interactions with conventional medicine, and it lies in their responsibility to include the question about CAM usage in their standard protocols.

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

BACKGROUND AND AIMS

The use of herbs and dietary supplements (HDS) alone or concomitantly with medications can potentially increase the risk of adverse events experienced by the patients. This review aims to evaluate the documented HDS-drug interactions and contraindications.

METHODS

A structured literature review was conducted on PubMed, EMBASE, Cochrane Library, tertiary literature and Internet.

RESULTS

While 85 primary literatures, six books and two web sites were reviewed for a total of 1,491 unique pairs of HDS-drug interactions, 213 HDS entities and 509 medications were involved. HDS products containing St. John's Wort, magnesium, calcium, iron, ginkgo had the greatest number of documented interactions with medications. Warfarin, insulin, aspirin, digoxin, and ticlopidine had the greatest number of reported interactions with HDS. Medications affecting the central nervous system or cardiovascular system had more documented interactions with HDS. Of the 882 HDS-drug interactions being described its mechanism and severity, 42.3% were due to altered pharmacokinetics and 240 were described as major interactions. Of the 152 identified HDS contraindications, the most frequent involved gastrointestinal (16.4%), neurological (14.5%), and renal/genitourinary diseases (12.5%). Flaxseed, echinacea, and yohimbe had the largest number of documented contraindications.

CONCLUSIONS

Although HDS-drug interactions and contraindications primarily concerned a relatively small subset of commonly used medications and HDS entities, this review provides the summary to identify patients, HDS products, and medications that are more susceptible to HDS-drug interactions and contraindications. The findings would facilitate the health-care professionals to communicate these documented interactions and contraindications to their patients and/or caregivers thereby preventing serious adverse events and improving desired therapeutic outcomes.

Concurrent use of antiplatelets, anticoagulants, or digoxin with Chinese medications: a population-based cohort study

PURPOSE

We examined the extent of concurrent use of antiplatelets, anticoagulants, or digoxin with Chinese medications (CMs) and identified its associated factors.

METHODS

A retrospective cohort study was conducted using one million random samples from the Longitudinal Health Insurance Database 2005 in Taiwan. High-risk Western medications (HRWMs) focused on in this study were antiplatelets (aspirin, clopidogrel, dipyridamole, ticlopidine), anticoagulants (heparin, warfarin), and digoxin. Concurrent use was described as having an overlapping use period of HRWM with CMs any time in 2005. Baseline demographics, comorbidities, and health service utilizations between patients with and without concurrent HRWM-CM use were compared. Logistic regression analyses were performed to identify factors associated with incident concurrent use.

RESULTS

Of the 70,698 eligible HRWM users, 13.2 % used CMs concurrently for an average duration of 26.7 ± 43 days. The incidence of concurrent HRWM-CM use, which excluded prior CM use within 6 months preceding the first CM use, was 6.3 %. Warfarin or ticlopidine users were more likely to be prescribed with CMs than were the other HRWM users. Factors associated with an increasing incidence of concurrent HRWM-CM use included female sex, age 45-54 years, middle monthly income, higher number of outpatient visits or distinct prescribed medications, and a previous diagnosis of heart diseases, stroke, or hypertension. In contrast, age ≥ 65 years and higher medical expenditure were associated with a lower incidence of concurrent use.

CONCLUSIONS

In the Taiwanese population, approximately one in eight HRWM users were concomitantly prescribed CMs. Whether such concurrent use is associated with adverse clinical outcomes warrants further investigations.

Herb-drug interaction of 50 Chinese herbal medicines on CYP3A4 activity in vitro and in vivo

The purpose of this study is to evaluate the effects of Chinese herbal medicines on the enzymatic activity of CYP3A4 and the possible metabolism-based herb-drug interactions in human liver microsomes and in rats. Fifty single-herbal preparations were screened for the activity of CYP3A4 using human liver microsomes for an in vitro probe reaction study. The enzymatic activity of CYP3A4 was estimated by determing the 6β-hydroxytestosterone metabolized from testosterone performed on a liquid chromatography-tandem mass spectrometry (LC-MS/MS). Huang Qin (Scutellaria baicalensis Geprgi), Mu Dan Pi (Paeonia suffruticosa Andr.), Ji Shiee Terng (Spatholobus suberectus Dunn.) and Huang Qi (Astragalus membranaceus [Fisch] Bge) have been demonstrated to have remarkable inhibiting effects on the metabolism of CYP3A4, whereas Xi Yi Hua (Magnolia biondii Pamp.) exhibited a moderate inhibition. These five single herbs were further investigated in an animal study using midazolam. Mu Dan Pi, Ji Shiee Terng and Huang Qi were observed to have greatly increased in the C(max) and AUC of midazolam. This study provides evidence of possible herb-drug interactions involved with certain single herbs.

Medical marijuana: clearing away the smoke

Recent advances in understanding of the mode of action of tetrahydrocannabinol and related cannabinoid in-gredients of marijuana, plus the accumulating anecdotal reports on potential medical benefits have spurred increasing re-search into possible medicinal uses of cannabis. Recent clinical trials with smoked and vaporized marijuana, as well as other botanical extracts indicate the likelihood that the cannabinoids can be useful in the management of neuropathic pain, spasticity due to multiple sclerosis, and possibly other indications. As with all medications, benefits and risks need to be weighed in recommending cannabis to patients. We present an algorithm that may be useful to physicians in determining whether cannabis might be recommended as a treatment in jurisdictions where such use is permitted.

Review of current and "omics" methods for assessing the toxicity (genotoxicity, teratogenicity and nephrotoxicity) of herbal medicines and mushrooms

ETHNOPHARMACOLOGICAL RELEVANCE

The increasing use of traditional herbal medicines around the world requires more scientific evidence for their putative harmlessness. To this end, a plethora of methods exist, more or less satisfying. In this post-genome era, recent reviews are however scarce, not only on the use of new "omics" methods (transcriptomics, proteomics, metabonomics) for genotoxicity, teratogenicity, and nephrotoxicity assessment, but also on conventional ones.

METHODS

The present work aims (i) to review conventional methods used to assess genotoxicity, teratogenicity and nephrotoxicity of medicinal plants and mushrooms; (ii) to report recent progress in the use of "omics" technologies in this field; (iii) to underline advantages and limitations of promising methods; and lastly (iv) to suggest ways whereby the genotoxicity, teratogenicity, and nephrotoxicity assessment of traditional herbal medicines could be more predictive.

RESULTS

Literature and safety reports show that structural alerts, in silico and classical in vitro and in vivo predictive methods are often used. The current trend to develop "omics" technologies to assess genotoxicity, teratogenicity and nephrotoxicity is promising but most often relies on methods that are still not standardized and validated.

CONCLUSION

Hence, it is critical that toxicologists in industry, regulatory agencies and academic institutions develop a consensus, based on rigorous methods, about the reliability and interpretation of endpoints. It will also be important to regulate the integration of conventional methods for toxicity assessments with new "omics" technologies.

The effect of garlic supplements and phytochemicals on the ADMET properties of drugs

INTRODUCTION

Garlic supplements have received wide public attention because of their health-beneficial effects. Although these products are considered as innocuous, several case reports and studies have shown the capacity of individual garlic phytochemicals/supplements to interfere with drug pharmacokinetics.

AREAS COVERED

This review covers recently published literature on garlic chemistry and composition, and provides a thorough review of published studies evaluating drug-garlic interactions. The authors illustrate the mechanisms underlying pharmacokinetic interactions, which could serve as important highlights in further research to explain results for drugs with narrow therapeutic indices or for drugs, utilizing multiple absorption, distribution and metabolism pathways.

EXPERT OPINION

To increase the relevance of further research on safety and efficacy of garlic supplements and phytochemicals, their composition should be addressed before conducting in vitro or in vivo research. It is also strongly recommended to characterize in vitro formulation performance to assess the rate and extent of garlic phytochemical release in order to anticipate the in vivo impact on the pharmacokinetics of concomitantly consumed drugs. The main conclusion of this review is that the impact of garlic on different stages of pharmacokinetics, especially on drug absorption and metabolism, is drug specific and dependent on the type/quality of utilized supplement.

Therapeutic potential of ginseng in the management of cardiovascular disorders

Although employed in Asian societies for thousands of years, the use of ginseng as an herbal medication for a variety of disorders has increased tremendously worldwide in recent years. Ginseng belongs to the genus Panax, of which there exists a variety, generally reflecting their geographic origin. North American ginseng (Panax quinquefolius) and Asian ginseng (Panax ginseng) are two such varieties possessing a plethora of pharmacological properties, which are attributed primarily to the presence of different ginsenosides that bestow these ginsengs with distinct pharmacodynamic profiles. The many cardiovascular benefits attributed to ginseng include cardioprotection, antihypertensive effects, and attenuation of myocardial hypertrophy and heart failure. Experimental studies have revealed a number of beneficial properties of ginseng, particularly in the area of cardiac protection, where ginseng and ginsenosides have been shown to protect the ischaemic and reperfused heart in a variety of experimental models. Emerging evidence also suggests that ginseng attenuates myocardial hypertrophy, thus blunting the remodelling and heart failure processes. However, clinical evidence of efficacy is not convincing, likely owing primarily to the paucity of well designed, randomized, controlled clinical trials. Adding to the complexity in understanding the cardiovascular effects of ginseng is the fact that each of the different ginseng varieties possesses distinct cardiovascular properties, as a result of their respective ginsenoside composition, rendering it difficult to assign a general, common cardiovascular effect to ginseng. Additional challenges include the identification of mechanisms (likely multifaceted) that account for the effects of ginseng and determining which ginsenoside(s) mediate these cardiovascular properties. These concerns notwithstanding, the potential cardiovascular benefit of ginseng is worthy of further studies in view of its possible development as a cardiovascular therapeutic agent, particularly as adjunctive therapy to existing medications.

Exploring knowledge and attitudes towards counselling about vitamin supplements in Jordanian community pharmacies

The use of multivitamins within a pharmaceutical setting has been the subject of considerable debate.

Objective

This research aimed to provide a platform for assessing and evaluating knowledge, attitudes and professional practices of Jordanian community pharmacists in counselling patients about the safe consumption of vitamins.

Methods

A cross-sectional study was conducted between October 2009 and May 2010. Data collection was carried out using a 44-item semi-structured self-administrated questionnaire. Setting: Community pharmacies in Amman with target sample of 400 pharmacists.

Results

A total of 388 pharmacists participated in this study. The majority (77.8%) of pharmacists believed that a balanced diet is more achievable by eating healthily than by vitamins supplements. 78.1% of participants believed that vitamins deficiency would not shorten life spans, while 80.7% agreed that vitamin supplements could be toxic or might contain unlabelled harmful ingredients. Less than half of pharmacists were aware that some antioxidant vitamins have been verified to be of unproven value, or may even cause cancer. While over 80% of pharmacists would recommend vitamins on a regular basis without prescription, the majority agreed that counselling on vitamin supplements is part of their role in pharmaceutical care (93.3%), in addition to providing relevant information to other healthcare professionals (78.4%). Moreover, responses to specific knowledge questions, such as the interactions of vitamins with drugs or the recommended dietary allowance of vitamins for infants, children, and pregnant women, were negative. Furthermore, only a minority of pharmacists would recheck the accuracy of dose regimens in prescriptions and symptoms of true vitamins deficiency or would follow up patients to record any consequences of vitamins consumption.

Conclusions

The questionnaire revealed satisfactory awareness of community pharmacists about their role in counselling; however, further programmes to update their knowledge are mandatory to emphasise the importance of vitamin supplements as part of complementary medicine, and their exclusion from being considered as merely over the counter (OTC) products.

Pharmacovigilance of herbal products in India

Herbal formulations being widely accepted therapeutic agents as antidiabetics, antiarthritics, hepatoprotectives, cough remedies, memory enhancers, and adaptogens. The commonest myth regarding herbal medicines is that these medicines are completely safe, and can therefore be safely consumed by the patient on his/her own, without a physician's prescription. This belief has led to large-scale self-medication by people all over the world, often leading to disappointing end-results, side-effects, or unwanted after-effects. There is an increasing awareness at several levels of the need to develop pharmacovigilance practices for herbal medicines. The current model of pharmacovigilance and its associated tools have been developed in relation to synthetic drugs, and applying these methods to monitoring the safety of herbal medicines presents unique challenges in addition to those described for conventional medicines. Several problems relate to the ways in which herbal medicines are named, perceived, sourced, and utilized. This may be because of differences in the use of nonorthodox drugs (e.g., herbal remedies) which may pose special toxicological problems, when used alone or in combination with other drugs. The purpose of pharmacovigilance is to detect, assess, and understand, and to prevent the adverse effects or any other possible drug-related problems, related to herbal, traditional, and complementary medicines.

Changes in herb and dietary supplement use in the U.S. adult population: a comparison of the 2002 and 2007 National Health Interview Surveys

BACKGROUND

Past national surveys indicate that use of herbs and dietary supplements rose rapidly in the United States during the 1990s and early 2000s. Additional research is needed to determine whether this growth rate and associated patterns of use have persisted over time.

OBJECTIVES

The objectives of this study were: (1) to assess population and subpopulation changes in rates of herb and supplement use; and (2) to assess changes in rates of disclosure of herb and supplement use to conventional medical providers.

METHODS

This study used data from the 2002 (n = 30,427) and 2007 (n = 22,657) Adult Complementary and Alternative Medicine File to the National Health Interview Survey (NHIS). Weighted group and subgroup comparisons used the Wald χ(2) tests to compare differences in herb and supplement use between 2002 and 2007.

RESULTS

The number of adults in the United States that ever used herbs or supplements grew slightly, from 50.6 million in 2002 to 55.1 million in 2007. However, the proportion of adults who reported use of herbs or supplements in the past 12 months dropped significantly: from 18.9% in 2002 to 17.9% in 2007 (P < 0.05). Subpopulation comparisons revealed that younger adults were less likely to use herbs and supplements in 2007 (17.6%) than in 2002 (20.0%), whereas older adults (ie, those aged ≥65 years) were more likely to do so (19.5% in 2007 vs. 13.2% in 2002). Racial and ethnic minorities also reported a significant decline in recent use. The proportion of respondents that disclosed herb or supplement use to their physician or another conventional medical professional rose, from 33.4% in 2002 to 45.4% in 2007. However, <1% of recent herb and supplement users disclosed this use to their pharmacist. Limitations of this research are that the 2 national data sets were not directly comparable and that questionnaires in the 2 surveys assessed were not identical.

CONCLUSIONS

Herbal preparations and dietary supplements remain popular in the United States, but the user population and patterns of use are changing. Ongoing surveillance of this health behavior is a public health priority.

The interaction potential of herbal medicinal products: a luminescence-based screening platform assessing effects on cytochrome P450 and its use with devil's claw (Harpagophyti radix) preparations

Objectives

Potential interactions between herbal medicinal products and the cytochrome (CYP) P450 system are an important safety concern. We set out to develop a screening panel for assessing such interactions and use it to evaluate the interaction potential of devil's claw.

Methods

The panel consisted of luminescence-based inhibition assays for CYP1A2, 2C9, 2C19, 2D6 and 3A4, and a reporter gene (luciferase) assay for pregnane X receptor (PXR) activation and CYP3A4 induction. Caftaric acid and chlorogenic acid, two compounds with strong fluorescence quenching properties, were used to demonstrate the assay's resistance to interference. We tested 10 commercial devil's claw preparations as well as harpagoside and harpagide, two important constituents of devil's claw.

Key findings

Five preparations were found to weakly inhibit CYP3A4 (IC50 124.2–327.6 µg/ml) and five were found to weakly activate PXR (EC50 10.21–169.3 µg/ml). Harpagoside and harpagide did not inhibit CYP3A4. In agreement with published data, bergamottin, a natural product known to interact with CYP3A4, was shown to inhibit CYP3A4 with an IC50 of 13.63 µm and activate PXR with an EC50 of 6.7 µm.

Conclusions

Devil's claw preparations are unlikely to have a clinically relevant effect on CYP function. The assay panel proved effective in screening devil's claw preparations, demonstrating its suitability for use with plant extracts. It showed superior sensitivity and resistance to interference.