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Hoerr R, Zimmermann A, Seitz F, Dienel A. Single and Repeated Doses of EGb 761 ® do not Affect Pharmacokinetics or Pharmacodynamics of Rivaroxaban in Healthy Subjects. Front Pharmacol 2022; 13:868843. [PMID: 35517810 PMCID: PMC9065292 DOI: 10.3389/fphar.2022.868843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/18/2022] [Indexed: 12/02/2022] Open
Abstract
The present drug-drug interaction study investigates whether single or repeated doses of 240 mg Ginkgo biloba extract EGb 761® alter the pharmacokinetics or pharmacodynamics of rivaroxaban in healthy subjects. This was a single-centre, two-period, fixed-sequence trial. In Period 1, rivaroxaban was taken alone. In Period 2, rivaroxaban was given on the first and last of 8 days of EGb 761® treatment. Plasma concentrations of rivaroxaban and anti-Factor Xa activity were determined until 48 h after each rivaroxaban intake. The data of forty-one healthy subjects (25 males, 16 females) aged 21–70 years were evaluable. Geometric mean ratios (90% confidence intervals) for rivaroxaban administered concomitantly with a single or multiple doses of EGb 761® vs. rivaroxaban administered alone were 97.97 (91.78, 104.58) and 96.78 (90.67, 103.31) for maximum concentration (Cmax), 98.55 (94.43, 102.84) and 97.82 (93.73, 102.08) for area under the concentration-time curve (AUC0-∞) of rivaroxaban in plasma (primary endpoints), 98.19 (92.00, 104.80) and 99.78 (93.43, 106.55) for maximum effect (Emax), 99.46 (93.63, 105.66) and 99.12 (93.25, 105.35) for area under the effect curve (AUEC0-48). All 90% confidence intervals were within the prespecified range of 80%–125%. Neither adverse events related to haemorrhages nor clinically significant findings in haematology or coagulation parameters were observed. The treatments were safe and well-tolerated. Single and repeated doses of EGb 761® neither affect plasma concentrations of rivaroxaban nor anti-Factor Xa activity in healthy subjects.
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Affiliation(s)
- Robert Hoerr
- Dr. Willmar Schwabe GmbH & Co. KG, Research and Development, Karlsruhe, Germany
| | - Andrea Zimmermann
- Dr. Willmar Schwabe GmbH & Co. KG, Biometry Department, Karlsruhe, Germany
| | | | - Angelika Dienel
- Dr. Willmar Schwabe GmbH & Co. KG, Clinical Research, Karlsruhe, Germany
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Kloft C, Hoerr R. EGb 761 ® Does Not Affect Blood Coagulation and Bleeding Time in Patients with Probable Alzheimer's Dementia-Secondary Analysis of a Randomized, Double-Blind Placebo-Controlled Trial. Healthcare (Basel) 2021; 9:healthcare9121678. [PMID: 34946404 PMCID: PMC8701823 DOI: 10.3390/healthcare9121678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
Following reports of bleeding upon Ginkgo intake, we assessed whether Ginkgo extract EGb 761® affects coagulation or platelet function or increases the risk of bleeding. In a double-blind, placebo-controlled trial, prothrombin time, activated partial thromboplastin time, international normalized ratio and bleeding time were measured in patients with Alzheimer’s dementia at baseline, weeks 6 and 26. A total of 513 patients were randomized to 120 mg (n = 169) or 240 mg EGb 761® (n = 170) or placebo (n = 174). No relevant changes were found for coagulation parameters and bleeding time. Numbers of bleeding-related adverse events were similar in all groups. Concomitant intake of acetylsalicylic acid was documented for 68 patients in the placebo group and 105 in the EGb 761® groups. Within these groups, the means at baseline and week 26 differed by less than 1 unit for prothrombin time and bleeding time and less than 0.1 unit for international normalized ratio. Data on warfarin treatment in nine patients each taking placebo or EGb 761® did not indicate enhancement of warfarin effects by EGb 761®. No evidence was found that EGb 761® affects hemostasis or increases the bleeding risk. No pharmacodynamic interactions with warfarin or acetylsalicylic acid were found.
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Affiliation(s)
- Charlotte Kloft
- Institute of Pharmacy, Freie Universität Berlin, 12169 Berlin, Germany;
| | - Robert Hoerr
- Research & Development, Dr. Willmar Schwabe GmbH & Co. KG, 76227 Karlsruhe, Germany
- Correspondence: ; Tel.: +49-721-4005-492
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Truong VL, Jun M, Jeong WS. Phytochemical and Over-The-Counter Drug Interactions: Involvement of Phase I and II Drug-Metabolizing Enzymes and Phase III Transporters. J Med Food 2021; 24:786-805. [PMID: 34382862 DOI: 10.1089/jmf.2021.k.0003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Consumption of plant-derived natural products and over-the-counter (OTC) drugs is increasing on a global scale, and studies of phytochemical-OTC drug interactions are becoming more significant. The intake of dietary plants and herbs rich in phytochemicals may affect drug-metabolizing enzymes (DMEs) and transporters. These effects may lead to alterations in pharmacokinetics and pharmacodynamics of OTC drugs when concomitantly administered. Some phytochemical-drug interactions benefit patients through enhanced efficacy, but many interactions cause adverse effects. This review discusses possible mechanisms of phytochemical-OTC drug interactions mediated by phase I and II DMEs and phase III transporters. In addition, current information is summarized for interactions between phytochemicals derived from fruits, vegetables, and herbs and OTC drugs, and counseling is provided on appropriate and safe use of OTC drugs.
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Affiliation(s)
- Van-Long Truong
- Food and Bio-Industry Research Institute, School of Food Science and Biotechnology, College of Agriculture and Life Sciences, Kyungpook National University, Daegu, Korea
| | - Mira Jun
- Brain Busan 21 Plus Program, Department of Food Science and Nutrition, Graduate School, Center for Silver-Targeted Biomaterials, Dong-A University, Busan, Korea
| | - Woo-Sik Jeong
- Food and Bio-Industry Research Institute, School of Food Science and Biotechnology, College of Agriculture and Life Sciences, Kyungpook National University, Daegu, Korea
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Tomino C, Ilari S, Solfrizzi V, Malafoglia V, Zilio G, Russo P, Proietti S, Marcolongo F, Scapagnini G, Muscoli C, Rossini PM. Mild Cognitive Impairment and Mild Dementia: The Role of Ginkgo biloba (EGb 761 ®). Pharmaceuticals (Basel) 2021; 14:ph14040305. [PMID: 33915701 PMCID: PMC8065464 DOI: 10.3390/ph14040305] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/15/2021] [Accepted: 03/26/2021] [Indexed: 12/17/2022] Open
Abstract
Mild cognitive impairment (MCI) and dementia are clinically prevalent in the elderly. There is a high risk of cognitive decline in patients diagnosed with MCI or dementia. This review describes the effectiveness of Ginkgo biloba leaf special extract EGb 761® for the treatment of dementia syndromes and EGb 761® combination therapy with other medications for symptomatic dementia. This drug has shown convincing results, improving cognitive function, neuropsychiatric symptoms and consequent reduction of caregiver stress and maintenance of autonomy in patients with age-related cognitive decline, MCI and mild to moderate dementia. Currently, there is little evidence to support the combination therapy with anti-dementia drugs and, therefore, more evidence is needed to evaluate the role of EGb 761® in mixed therapy.
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Affiliation(s)
- Carlo Tomino
- Scientific Direction, IRCCS San Raffaele Roma, 00166 Rome, Italy; (C.T.); (S.P.)
| | - Sara Ilari
- Department of Health Science, Institute of Research for Food Safety & Health (IRC-FSH), University “Magna Graecia” of Catanzaro, 88201 Catanzaro, Italy; (S.I.); (C.M.)
| | - Vincenzo Solfrizzi
- Clinica Medica “Frugoni” and Geriatric Medicine-Memory Unit, University of Bari Aldo Moro, 70122 Bari, Italy;
| | - Valentina Malafoglia
- Institute for Research on Pain, ISAL Foundation, Torre Pedrera, 47922 Rimini, Italy;
| | - Guglielmo Zilio
- Scientific Department, Schwabe Pharma Italia S.r.l., 39044 Egna, Italy;
| | - Patrizia Russo
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Roma, 00166 Rome, Italy;
- Department of Human Sciences and Quality of Life Promotion, San Raffaele University, Via di Val Cannuta, 247, 00166 Rome, Italy
- Correspondence: or
| | - Stefania Proietti
- Scientific Direction, IRCCS San Raffaele Roma, 00166 Rome, Italy; (C.T.); (S.P.)
| | - Federica Marcolongo
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Roma, 00166 Rome, Italy;
| | - Giovanni Scapagnini
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy;
| | - Carolina Muscoli
- Department of Health Science, Institute of Research for Food Safety & Health (IRC-FSH), University “Magna Graecia” of Catanzaro, 88201 Catanzaro, Italy; (S.I.); (C.M.)
| | - Paolo Maria Rossini
- Department of Neuroscience & Neurorehabilitation, IRCCS San Raffaele Roma, 00163 Rome, Italy;
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Petersen MJ, Bergien SO, Staerk D. A systematic review of possible interactions for herbal medicines and dietary supplements used concomitantly with disease-modifying or symptom-alleviating multiple sclerosis drugs. Phytother Res 2021; 35:3610-3631. [PMID: 33624893 DOI: 10.1002/ptr.7050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/18/2022]
Abstract
Multiple Sclerosis (MS) is a demyelinating disease affecting the central nervous system, with no curative medicine available. The use of herbal drugs and dietary supplements is increasing among people with MS (PwMS), raising a need for knowledge about potential interactions between conventional MS medicine and herbal drugs/dietary supplements. This systematic review provides information about the safety of simultaneous use of conventional MS-drugs and herbal drugs frequently used by PwMS. The study included 14 selected disease-modifying treatments and drugs frequently used for symptom-alleviation. A total of 129 published papers found via PubMed and Web of Science were reviewed according to defined inclusion- and exclusion criteria. Findings suggested that daily recommended doses of Panax ginseng and Ginkgo biloba should not be exceeded, and herbal preparations differing from standardized products should be avoided, especially when combined with anticoagulants or substrates of certain cytochrome P450 isoforms. Further studies are required regarding ginseng's ability to increase aspirin bioavailability. Combinations between chronic cannabis use and selective serotonin reuptake inhibitors or non-steroidal antiinflammatory drugs should be carefully monitored, whereas no significant evidence for drug-interactions between conventional MS-drugs and ginger, cranberry, vitamin D, fatty acids, turmeric, probiotics or glucosamine was found.
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Affiliation(s)
- Malene J Petersen
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Dan Staerk
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Kandiah N, Chan YF, Chen C, Dasig D, Dominguez J, Han S, Jia J, Kim S, Limpawattana P, Ng L, Nguyen DT, Ong PA, Raya‐Ampil E, Saedon N, Senanarong V, Setiati S, Singh H, Suthisisang C, Trang TM, Turana Y, Venketasubramanian N, Yong FM, Youn YC, Ihl R. Strategies for the use of Ginkgo biloba extract, EGb 761 ® , in the treatment and management of mild cognitive impairment in Asia: Expert consensus. CNS Neurosci Ther 2021; 27:149-162. [PMID: 33352000 PMCID: PMC7816207 DOI: 10.1111/cns.13536] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/20/2020] [Accepted: 10/24/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Mild cognitive impairment (MCI) is a neurocognitive state between normal cognitive aging and dementia, with evidence of neuropsychological changes but insufficient functional decline to warrant a diagnosis of dementia. Individuals with MCI are at increased risk for progression to dementia; and an appreciable proportion display neuropsychiatric symptoms (NPS), also a known risk factor for dementia. Cerebrovascular disease (CVD) is thought to be an underdiagnosed contributor to MCI/dementia. The Ginkgo biloba extract, EGb 761® , is increasingly being used for the symptomatic treatment of cognitive disorders with/without CVD, due to its known neuroprotective effects and cerebrovascular benefits. AIMS To present consensus opinion from the ASian Clinical Expert group on Neurocognitive Disorders (ASCEND) regarding the role of EGb 761® in MCI. MATERIALS & METHODS The ASCEND Group reconvened in September 2019 to present and critically assess the current evidence on the general management of MCI, including the efficacy and safety of EGb 761® as a treatment option. RESULTS EGb 761® has demonstrated symptomatic improvement in at least four randomized trials, in terms of cognitive performance, memory, recall and recognition, attention and concentration, anxiety, and NPS. There is also evidence that EGb 761® may help delay progression from MCI to dementia in some individuals. DISCUSSION EGb 761® is currently recommended in multiple guidelines for the symptomatic treatment of MCI. Due to its beneficial effects on cerebrovascular blood flow, it is reasonable to expect that EGb 761® may benefit MCI patients with underlying CVD. CONCLUSION As an expert group, we suggest it is clinically appropriate to incorporate EGb 761® as part of the multidomain intervention for MCI.
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Affiliation(s)
- Nagaendran Kandiah
- National Neuroscience InstituteSingaporeSingapore
- Duke‐NUSSingaporeSingapore
- Lee Kong Chian‐Imperial CollegeSingaporeSingapore
| | | | - Christopher Chen
- Departments of Pharmacology and Psychological MedicineYong Loo Lin School of MedicineMemory Aging and Cognition CentreNational University of SingaporeSingaporeSingapore
| | | | | | | | - Jianping Jia
- Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - SangYun Kim
- Department of NeurologySeoul National University College of Medicine and Seoul National University Bundang HospitalSeoulKorea
| | - Panita Limpawattana
- Srinakarind HospitalFaculty of MedicineKhon Kaen UniversityKhon KaenThailand
| | - Li‐Ling Ng
- Changi General HospitalSingaporeSingapore
| | - Dinh Toan Nguyen
- Department of Internal MedicineUniversity of Medicine and PharmacyHue UniversityHue CityVietnam
| | | | | | | | | | - Siti Setiati
- Department of Internal MedicineCipto Mangunkusumo HospitalJakartaIndonesia
| | - Harjot Singh
- Dr Harjot Singh's Neuropsychiatry Centre and HospitalAmritsarIndia
| | | | - Tong Mai Trang
- Department of NeurologyUniversity Medical CenterHo Chi Minh CityVietnam
| | - Yuda Turana
- School of Medicine and Health ScienceAtma Jaya Catholic University of IndonesiaJakartaIndonesia
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Kandiah N, Ong PA, Yuda T, Ng LL, Mamun K, Merchant RA, Chen C, Dominguez J, Marasigan S, Ampil E, Nguyen VT, Yusoff S, Chan YF, Yong FM, Krairit O, Suthisisang C, Senanarong V, Ji Y, Thukral R, Ihl R. Treatment of dementia and mild cognitive impairment with or without cerebrovascular disease: Expert consensus on the use of Ginkgo biloba extract, EGb 761 ®. CNS Neurosci Ther 2020; 25:288-298. [PMID: 30648358 PMCID: PMC6488894 DOI: 10.1111/cns.13095] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 11/25/2022] Open
Abstract
Background The Ginkgo biloba special extract, EGb 761® has been widely used in the treatment of neuropsychiatric disorders, including Alzheimer’s disease (AD). Methods To guide clinical practice in the Asian region, the Asian Clinical Expert Group on Neurocognitive Disorders compiled evidence‐based consensus recommendations regarding the use of EGb 761® in neurocognitive disorders with/without cerebrovascular disease. Results Key randomized trials and robust meta‐analyses have demonstrated significant improvement in cognitive function, neuropsychiatric symptoms, activities of daily living (ADL) and quality of life with EGb 761®versus placebo in patients with mild‐to‐moderate dementia. In those with mild cognitive impairment (MCI), EGb 761® has also demonstrated significant symptomatic improvement versus placebo. World Federation of Societies of Biological Psychiatry guidelines list EGb 761® with the same strength of evidence as acetylcholinesterase inhibitors and N‐methyl‐D‐aspartate (NMDA) antagonists e.g. memantine (Grade 3 recommendation; Level B evidence). Only EGb 761® had Level B evidence in improving cognition, behaviour, and ADL in both AD and vascular dementia patients. Safety analyses show EGb 761® to have a positive risk‐benefit profile. While concerns have been raised regarding a possible increased bleeding risk, several randomized trials and two meta‐analyses have not supported this association. Conclusions The Expert Group foresee an important role for EGb 761®, used alone or as an add‐on therapy, in the treatment of MCI and dementias, particularly when patients do not derive benefit from acetylcholinesterase inhibitors or NMDA antagonists. EGb 761® should be used in alignment with local clinical practice guidelines.
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Affiliation(s)
- Nagaendran Kandiah
- Duke-NUS Singapore, National Neuroscience Institute, Singapore, Singapore
| | | | - Turana Yuda
- School of Medicine and Health Science, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Li-Ling Ng
- Changi General Hospital, Singapore, Singapore
| | - Kaysar Mamun
- Singapore General Hospital, Singapore, Singapore
| | | | - Christopher Chen
- Department of Pharmacology, National University of Singapore, Singapore, Singapore
| | | | | | | | | | | | | | | | | | | | | | - Yong Ji
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Ralf Ihl
- Alexian Hospital, Krefeld, Germany
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Abstract
PURPOSE OF REVIEW This study will review the research on the effect of ginkgo biloba extract (GBE) on patients with glaucoma. RECENT FINDINGS GBE appears to increase ocular blood flow in those with glaucoma. However, data on visual field outcomes are inconclusive. SUMMARY GBE has been shown to have antioxidant and vascular effects, making it potentially effective in treating glaucoma. Published data are limited but show an increase in ocular blood flow after GBE administration. Conclusive evidence is lacking regarding the effect of GBE on clinical outcomes in glaucoma patients such as visual field performance.
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Fong SYK, Efferth TH, Zuo Z. Modulation of the pharmacokinetics, therapeutic and adverse effects of NSAIDs by Chinese herbal medicines. Expert Opin Drug Metab Toxicol 2014; 10:1711-39. [PMID: 25307559 DOI: 10.1517/17425255.2014.970167] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Concomitant use of NSAIDs and Chinese herbal medicines (CHMs) is frequent, yet summarized information on their interactions is lacking. AREAS COVERED A systematic review of literature in four evidence-based English databases was performed. Articles which reported CHMs altering the pharmacokinetics, therapeutic and adverse effects of NSAIDs were identified and summarized. Such interactions may lead to beneficial, detrimental or no change in outcomes. The current review covers four therapeutic effects of NSAIDs, including: i) anti-inflammatory; ii) analgesic; iii) antiplatelet, cardiovascular and cerebrovascular; and iv) anticancer effects and four adverse effects of NSAIDs, including: i) gastrointestinal ulcer; ii) nephrotoxicity; iii) hepatotoxicity; and iv) antiplatelet effects and bleeding. EXPERT OPINION While majority of CHMs demonstrated effectiveness in alleviating NSAIDs-induced adverse effects and potentiating the therapeutic effects, this review provides insights for development of CHMs as add-on medications to NSAIDs therapies. However, since limited information was from well-designed clinical trials, the findings are not yet conclusive and more clinical studies are warranted to provide guidance for healthcare professionals. In future, researches on interactions between NSAIDs and CHMs are expected to grow and modern approaches such as pharmacogenomics might enhance the throughput and accuracy of identifying clinically relevant interactions.
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Affiliation(s)
- Sophia Yui Kau Fong
- The Chinese University of Hong Kong, School of Pharmacy, Faculty of Medicine , Shatin, New Territories , Hong Kong SAR
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Kanji S, Seely D, Yazdi F, Tetzlaff J, Singh K, Tsertsvadze A, Tricco AC, Sears ME, Ooi TC, Turek MA, Skidmore B, Ansari MT. Interactions of commonly used dietary supplements with cardiovascular drugs: a systematic review. Syst Rev 2012; 1:26. [PMID: 22651380 PMCID: PMC3534595 DOI: 10.1186/2046-4053-1-26] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 04/18/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND The objective of this systematic review was to examine the benefits, harms and pharmacokinetic interactions arising from the co-administration of commonly used dietary supplements with cardiovascular drugs. Many patients on cardiovascular drugs take dietary supplements for presumed benefits and may be at risk for adverse supplement-drug interactions. METHODS The Allied and Complementary Medicine Database, the Cochrane Library, EMBASE, International Bibliographic Information on Dietary Supplements and MEDLINE were searched from the inception of the review to October 2011. Grey literature was also reviewed.Two reviewers independently screened records to identify studies comparing a supplement plus cardiovascular drug(s) with the drug(s) alone. Reviewers extracted data using standardized forms, assessed the study risk of bias, graded the strength of evidence and reported applicability. RESULTS Evidence was obtained from 65 randomized clinical trials, 2 controlled clinical trials and 1 observational study. With only a few small studies available per supplement, evidence was insufficient for all predefined gradable clinical efficacy and harms outcomes, such as mortality and serious adverse events. One long-term pragmatic trial showed no benefit from co-administering vitamin E with aspirin on a composite cardiovascular outcome. Evidence for most intermediate outcomes was insufficient or of low strength, suggesting no effect. Incremental benefits were noted for triglyceridemia with omega-3 fatty acid added to statins; and there was an improvement in levels of high-density lipoprotein cholesterol with garlic supplementation when people also consumed nitrates CONCLUSIONS Evidence of low-strength indicates benefits of omega-3 fatty acids (plus statin, or calcium channel blockers and antiplatelets) and garlic (plus nitrates or warfarin) on triglycerides and HDL-C, respectively. Safety concerns, however, persist.
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Affiliation(s)
- Salmaan Kanji
- Clinical Epidemiology, The Ottawa Hospital Research Institute and the Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - Dugald Seely
- Clinical Epidemiology, The Ottawa Hospital Research Institute and the Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
- Department of Research & Clinical Epidemiology, The Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Fatemeh Yazdi
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Evidence-based Practice Center, Ottawa, ON, Canada
| | - Jennifer Tetzlaff
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Evidence-based Practice Center, Ottawa, ON, Canada
| | - Kavita Singh
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Evidence-based Practice Center, Ottawa, ON, Canada
| | - Alexander Tsertsvadze
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Evidence-based Practice Center, Ottawa, ON, Canada
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada
| | - Margaret E Sears
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Evidence-based Practice Center, Ottawa, ON, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Teik C Ooi
- Division of Endocrinology and Metabolism, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Michele A Turek
- Division of Cardiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Becky Skidmore
- Division of Cardiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Mohammed T Ansari
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Evidence-based Practice Center, Ottawa, ON, Canada
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Ihl R, Bachinskaya N, Korczyn AD, Vakhapova V, Tribanek M, Hoerr R, Napryeyenko O. Efficacy and safety of a once-daily formulation of Ginkgo biloba extract EGb 761 in dementia with neuropsychiatric features: a randomized controlled trial. Int J Geriatr Psychiatry 2011; 26:1186-94. [PMID: 21140383 DOI: 10.1002/gps.2662] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Accepted: 10/06/2010] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To test the efficacy and safety of a once-daily formulation of EGb 761 in the treatment of patients with dementia with neuropsychiatric features. METHODS Multi-centre trial of 410 outpatients with mild to moderate dementia (Alzheimer's disease, vascular dementia or mixed form) scoring between 9 and 23 on the SKT cognitive test battery, at least five on the Neuropsychiatric Inventory (NPI) and three or higher in at least one item of the NPI. Patients were randomly allocated to double-blind treatment with 240 mg of EGb 761 or placebo once daily for 24 weeks. Primary outcomes were the changes from baseline in the SKT total score and the NPI total score. The Alzheimer's Disease Cooperative Study Clinical Global Impression of Change (ADCS-CGIC), Activities of Daily Living International Scale (ADL-IS), NPI distress score, DEMQOL-Proxy quality-of-life scale and Verbal Fluency Test were secondary outcomes. RESULTS At endpoint, patients treated with EGb 761 (n = 202) improved by -1.4 (95% confidence interval -1.8; -1.0) points on the SKT and by -3.2 (-4.0; -2.3) on the NPI total score, whereas those receiving placebo (n = 202) deteriorated by +0.3 (-0.1; 0.7) on the SKT and did not change on the NPI total score (-0.9; 0.9). Both drug-placebo comparisons were significant at p < 0.001. EGb 761 was significantly superior to placebo with respect to all secondary outcome measures. Adverse event rates were similar for both treatment groups. CONCLUSIONS EGb 761, 240 mg once-daily, was found significantly superior to placebo in the treatment of patients with dementia with neuropsychiatric symptoms.
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Affiliation(s)
- Ralf Ihl
- Geriatric Psychiatry Centre, Alexian Hospital Maria-Hilf, Krefeld and Department of Psychiatry and Psychotherapy, University of Duesseldorf, Germany.
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Chan AL, Leung HW, Wu JW, Chien TW. Risk of Hemorrhage Associated with Co-Prescriptions for Ginkgo biloba and Antiplatelet or Anticoagulant Drugs. J Altern Complement Med 2011; 17:513-7. [DOI: 10.1089/acm.2010.0295] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Agnes L.F. Chan
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan
| | - Henry W.C. Leung
- Department of Radiation Oncology, Wan Fan Hospital, Taipei, Taiwan
| | - Jia-Wen Wu
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan
| | - Tsair-Wei Chien
- Department of Administration, Chi Mei Medical Center, Tainan, Taiwan
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Braun LA, Cohen M. Use of Complementary Medicines by Cardiac Surgery Patients; Undisclosed and Undetected. Heart Lung Circ 2011; 20:305-11. [DOI: 10.1016/j.hlc.2011.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 01/10/2011] [Indexed: 10/18/2022]
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Kellermann AJ, Kloft C. Is There a Risk of Bleeding Associated with StandardizedGinkgo bilobaExtract Therapy? A Systematic Review and Meta-analysis. Pharmacotherapy 2011; 31:490-502. [DOI: 10.1592/phco.31.5.490] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Kim BH, Kim KP, Lim KS, Kim JR, Yoon SH, Cho JY, Lee YO, Lee KH, Jang IJ, Shin SG, Yu KS. Influence of Ginkgo biloba extract on the pharmacodynamic effects and pharmacokinetic properties of ticlopidine: an open-label, randomized, two-period, two-treatment, two-sequence, single-dose crossover study in healthy Korean male volunteers. Clin Ther 2010; 32:380-90. [PMID: 20206795 DOI: 10.1016/j.clinthera.2010.01.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ginkgo biloba extract is an herbal medicine used in the treatment of vascular disorders that may be coadministered with antiplatelet agents such as ticlopidine. Regulatory authorities requested evaluation of the pharmacodynamic and pharmacokinetic interactions between these entities, according to the drug-development guidance for fixed-dose combination formulations in Korea. OBJECTIVE This study was performed to evaluate the potential pharmacodynamic and pharmacokinetic interactions between ticlopidine and Ginkgo biloba extract. METHODS An open-label, randomized, 2-period, 2-treatment, 2-sequence, single-dose crossover study was conducted in healthy Korean male volunteers. All volunteers were randomly assigned to a sequence group for the 2 treatments, which consisted of ticlopidine 250 mg alone and ticlopidine 250 mg with Ginkgo biloba extract 80 mg, separated by a 1-week washout period between the treatments. Bleeding time was determined just before dosing and at 5, 12, and 48 hours after dosing. Platelet aggregation was evaluated before dosing and at 4, 8, 26, and 48 hours after dosing. Blood samples (8 mL) from each of the volunteers were collected from an indwelling intravenous cannula inserted into a forearm vein before dosing and at 0.5, 1, 1.5, 2, 2.5, 3, 4, 6, 8, 12, 24, and 48 hours after dosing. Ticlopidine concentrations were determined by a validated method using HPLC and ultraviolet detection. Adverse events were identified using general health-related questions, vital signs, physical examinations, ECGs, and laboratory tests. RESULTS A total of 24 healthy men participated in the study (mean [SD] age, 24.1 [4.3] years; weight, 66.6 [7.4] kg; height, 174.7 [5.0] cm). The baseline corrected bleeding times were not significantly different between the ticlopidine-alone and ticlopidine/ Ginkgo biloba groups, and changes in platelet aggregation were not significantly different between the groups. Likewise, the pharmacokinetic parameters of ticlopidine were not significantly different between the groups; the geometric mean ratios of the ticlopidine/ Ginkgo biloba group to the ticlopidine-alone group were 1.03 (90% CI, 0.92-1.16) for C(max), 1.08 (90% CI, 0.98-1.19) for AUC(0-last), and 1.10 (90% CI, 1.00-1.20) for AUC(0-infinity). A total of 28 adverse events were reported: 11 in the ticlopidine-alone group and 17 in the ticlopidine/Ginkgo biloba group. The adverse events judged to be possibly related to ticlopidine in the ticlopidine-alone group were epigastric discomfort (2 cases), diarrhea (1), skin eruption (1), and a feeling of being cold (1) or hot (1). The adverse events judged to be related to ticlopidine or Ginkgo biloba in the ticlopidine/Ginkgo biloba group were epigastric discomfort (2), diarrhea (2), nausea (2), and headache (1). CONCLUSIONS In this small group of healthy Korean men, the addition of a single dose of Ginkgo biloba extract did not prolong the bleeding time and was not associated with additional antiplatelet effects compared with the administration of ticlopidine alone. The coadministration of Ginkgo biloba extract with ticlopidine was not associated with any significant changes in the pharmacokinetic profile of ticlopidine compared with ticlopidine administered alone.
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Affiliation(s)
- Bo-Hyung Kim
- Department of Pharmacology and Clinical Pharmacology, Seoul National University College of Medicine and Hospital, Seoul, Korea
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Kennedy DA, Seely D. Clinically based evidence of drug-herb interactions: a systematic review. Expert Opin Drug Saf 2010; 9:79-124. [PMID: 20021292 DOI: 10.1517/14740330903405593] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Healthcare practitioners are deeply concerned about drug-herb interactions and how concurrent administration may affect both the safety and effectiveness of prescribed drugs. Interactions between botanical medicines and synthetic drugs can be clinically relevant and it is important to understand what kinds of interactions are possible. Better knowledge in this area will help avoid negative interactions and may also help enable synergistic interactions. AREAS COVERED IN THIS REVIEW Includes articles related to the investigation of Western botanicals or whole herbal extracts in human subjects, investigating either the impact on Cytochrome P450 isoenzymes or an assessment of specific drug-herb interactions within a clinical trial. Searches were conducted in both Pubmed and EMBASE from inception to March 2009. WHAT THE READER WILL GAIN Knowledge regarding specific interactions to consider in clinical practice. The reader will also gain an appreciation of the complexities associated with the area of drug-herb interactions. Summary tables of relevant drug-herb interactions are presented both for the individual herbs included and at the level of the CYP450 enzymes. TAKE HOME MESSAGE Knowledge of drug-herb interactions is limited and much more research needs to be done to further document clinically relevant interactions. Even though preclinical data are often poorly generalizable to the human situation, caution must be taken in the absence of clinical evidence especially where drugs with narrow therapeutic windows are concerned.
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Affiliation(s)
- Deborah A Kennedy
- Department of Research & Clinical Epidemiology, The Canadian College of Naturopathic Medicine, 1255 Sheppard Avenue East, Toronto, ON M2K 1E2, Canada
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Taki Y, Yamazaki Y, Shimura F, Yamada S, Umegaki K. Time-Dependent Induction of Hepatic Cytochrome P450 Enzyme Activity and mRNA Expression by Bilobalide in Rats. J Pharmacol Sci 2009; 109:459-62. [DOI: 10.1254/jphs.08198sc] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Bone KM. Potential interaction ofGinkgo bilobaleaf with antiplatelet or anticoagulant drugs: What is the evidence? Mol Nutr Food Res 2008; 52:764-71. [DOI: 10.1002/mnfr.200700098] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chang LC, Huang N, Chou YJ, Kao FY, Hsieh PC, Huang YT. Patterns of combined prescriptions of aspirin–Ginkgo biloba in Taiwan: a population-based study. J Clin Pharm Ther 2008; 33:243-9. [DOI: 10.1111/j.1365-2710.2008.00911.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Bristol MN, Sonnad SS, Guerra C. Uninformed Complementary and Alternative Supplement Use: A Risky Behavior for Cardiovascular Patients. ACTA ACUST UNITED AC 2008. [DOI: 10.1177/1533210108317281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Growing use of complementary and alternative supplements (CAS) is of concern because of the potential for herb—drug interaction among cardiovascular patients. Literary searches were conducted on PubMed to identify reports of extent and purpose of CAS use, disclosure of use by patients, physician knowledge, and possible drug—CAS interactions for cardiovascular patients. Additional published studies were located through the Web sites of various organizations. Further searches of case reports, case series, controlled trials, and laboratory evidence were performed for each of the top 10 CAS and their possible cardiovascular drug interactions. More research is needed to understand supplement—drug interactions, particularly in terms of how this potentially affects patients taking cardiovascular drugs. With this lack of research and clarity on supplement—dug interactions and the underreporting of CAS use by many patients, physician education is also in need of improvement.
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Affiliation(s)
- Mirar N. Bristol
- School of Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania,
| | - Seema S. Sonnad
- School of Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania
| | - Carmen Guerra
- School of Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania
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Umegaki K, Taki Y, Endoh K, Taku K, Tanabe H, Shinozuka K, Sugiyama T. Bilobalide in Ginkgo biloba extract is a major substance inducing hepatic CYPs. J Pharm Pharmacol 2007; 59:871-7. [PMID: 17637180 DOI: 10.1211/jpp.59.6.0014] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
In a search for substances related to the marked induction of hepatic cytochrome P450 (CYP) by ginkgo biloba extract (GBE), mice were given either GBE (1000 mg kg(-1)) or fractions of GBE for 5 days. The content and activity of CYPs were induced markedly by a bilobalide-rich fraction, but not by flavonoid-rich fractions. The level of induction by the bilobalide-rich fraction was almost the same as that induced by the unfractionated GBE, suggesting that bilobalide is largely responsible for the CYPs induction. To confirm these findings, mice were given various doses of bilobalide (10.5, 21 and 42 mg kg(-1)), or GBE (1000 mg kg(-1), containing bilobalide at 42 mg kg(-1)). Treatment with bilobalide induced CYPs markedly and in a dose-dependent manner, and the level of induction was quite similar between bilobalide (42 mg kg(-1)) and GBE. Treatment with GBE and with bilobalide greatly induced pentoxyresorufin O-dealkylase activity. These findings indicate that bilobalide is the major substance in GBE that induces hepatic CYPs.
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Affiliation(s)
- Keizo Umegaki
- National Institute of Health and Nutrition, 1-23-1 Toyama, Shinjuku-ku, Tokyo 162-8636, Japan.
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