Current Drug Metabolism, 2010, 11, 171-181 171

An Update on Drug Interactions with the Herbal Medicine Ginkgo biloba

María José Abad*, Luis Miguel Bedoya and Paulina Bermejo

Department of Pharmacology, Faculty of Pharmacy, University Complutense, Ciudad Universitaria s/n, 28040, Madrid, Spain

Abstract: Medicinal plants are gaining in popularity due to the various advantages they offer, such as fewer side-effects, better patient
compliance, relatively low cost and high accessibility as well as their high acceptability due to a long history of use. There is a wide-
spread belief among the general public that herbal preparations are “good for humans” as they are “all natural”. However, the increasing
use of herbal medicinal products in the community where people are also receiving prescription medicines suggests that adverse herb-
drug interactions may be have significant public health consequences. There is little understanding or appreciation of the fact that these
“all natural” preparations are actually a combination of potentially biologically active compounds already existing in marketed products
in unknown quantities. Among the most popular herbal products used worldwide is Ginkgo biloba, used for the treatment of cerebral in-
sufficiency, peripheral vascular diseases, and frequently taken for the enhancement of memory function. Although the safety of Ginkgo
biloba is promising, accumulated data show evidence of significant interactions with medications, which can place individual patients at
great risk. In this review, we examined the literature from 2000 to 2008 and focused on the importance of the risk of drug interactions and
potential side effects when Ginkgo biloba is involved. The aim of this systematic review is to assess the clinical evidence on interactions
between Ginkgo biloba and drugs.
Keywords: Herb-Drug Interactions, Ginkgo biloba, Pharmacokinetic, Pharmacodynamic.

INTRODUCTION
Herbal medicines are becoming popular worldwide, despite the
scarcity of knowledge as to their mechanism of action, the lack of
evidence of efficacy, and inadequate toxicological data [1-4]. The
size of the worldwide market for herbal medicines is stimated to be
around 80 to 100 billion dollars, and this market is expected to
reach 2500 billion dollars by the year 2010. Herbal products are
covered by different regulations from pharmaceuticals and are con-
sidered in the same regulatory category as dietary supplements,
foods and nutrients. Herbal products can be purchased without con-
sulting with a licensed healthcare professional in most North
American and European countries. Moreover, herbals are often
used for less than specific indications and are not subject to stan-
dard pharmaceutical criteria for safety. Herbal medicines, unlike
conventional drugs, provide a complex mixture of bioactive enti-
ties, which may or may not provide therapeutic activity. Often there
is no complete characterization of all the chemical constituents
from a natural product and the chemical composition of a herbal
medicine may vary depending on the part of the plant processed
(stems, leaves, roots,…), seasonality and growing conditions. Com-
bination products composed of multiple natural products complicate
matters further.
Millions of people today use herbal therapies along with pre-
scription and non-prescription medications. Although considered
natural, many of these herbal therapies can interact with other
medications, causing either potentially dangerous side effects
and/or reduced benefits from the medications. There is currently
little published information available on herb drug interactions
whilst the use of herbs is progressively growing across the world
[5-19]. Among the most popular herbal products used worldwide is
Ginkgo biloba L., which has generated immense interest for its
reputed value in treatment of memory-related afflictions [20-27].
Over 7 billion dollars are spent annually on botanical medicines,
and Ginkgo biloba ranks first among herbal medications. Fifty mil-
lion Ginkgo biloba trees are grown, especially in China, France and
South Carolina, U.S.A., producing over 8000 tons of dried leaves
each year to address the commercial demand for Ginkgo biloba
products.
*Address correspondence to this author at the Department of Pharmacology,
Faculty of Pharmacy, University Complutense, Ciudad Universitaria s/n,
28040, Madrid, Spain; Tel: 34-91-3941871; Fax: 34-91-3941726;
E-mail: mjabad@farmm.vem.es
Ginkgo biloba is believed to be the oldest still living tree spe-
cies [28,29]. The term “living fossil” has been used to describe
Ginkgo biloba since it represents the only surviving species of the
Order Ginkgoales that existed when the dinosaurs roamed the earth,
i.e., more than 200 million years ago. Its survival without structural
modifications for such a long period of time may be due to its ex-
ceptionally long-life span, its resistance to bacteria, fungi and vi-
ruses (related to its inherent insecticidal and fungicidal properties),
its high level of adaptability to the environment, and the long time
span between generations, which diminishes the probability of ge-
netic mutations.
Medicinal Ginkgo products are made from the leaves of this
ancient tree. The use of this plant as therapy can be seen in all the
ancient cultures. The first publication concerning the internal use of
the leaves of Ginkgo biloba for medicinal purposes dates back to
1505 AD in a text by Wen-Tai, Ben Cao Pin Hue Jing Yaor. Engl-
bert Kaempfer, a German surgeon, first used the term “Ginkgo” in
1712, but it was Linnaeus who provided the binomial terminology
“Ginkgo biloba” in 1771. W. Schwabe, a German physician-
pharmacist, introduced extracts of Ginkgo biloba leaves into mod-
ern medical practice in 1965. The marketing of products containing
Ginkgo biloba extract targets the healthy non-diseased population,
primarily for the promotion and maintenance of optimal brain func-
tion, and not for the treatment or prevention of any specific patho-
logical state. However, recommendations can be found for the use
of Gingo biloba for a myriad of diseases that generally fall into one
of three categories: cerebrovascular, peripheral vascular or mitiga-
tion of tissue damage. Although the safety of Ginkgo biloba is
promising, accumulated data show evidence of significant interac-
tions with medications, which can place individual patients at great
risk. Since there is a need for an evidence-based approach that
evaluates herbal drug interactions, this article will review the cur-
rent evidence for some common drug interactions and potential side
effects involving Ginkgo biloba.
PHARMACOLOGICAL ACTIVITY AND CLINICAL STUD-
IES OF GINKGO BILOBA
Standardized extracts of Ginkgo biloba leaves are presently
used in Europe and the United States as one of the most commonly
prescribed drugs for treatment of age-related deterioration of mental
functions, as well as for treatment of vascular dementia and degen-
erative dementia of the Alzheimer type [30-50]. The dried leaves of
the Ginkgo biloba tree provide the crude drug from which the stan-

1389-2002/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd.

172 Current Drug Metabolism, 2010, Vol. 11, No. 2
dardized special Ginkgo biloba extract (EGb761) is obtained.
EGb761 extract contains 5-7% ginkgolides and bilobalide, collec-
tively called terpene trilactones, along with 22-24% of flavonoids,
for example, quercetin, kaempferol and isorhamnetin; and less than
5 ppm ginkgolic acids (also known as anacardic acids) [51-54].
EGb761 extract or one of its components has been extensively
studied in terms of its effects on the cognitive, physiological and
psychiatric sequelae associated with neurological and vascular con-
ditions [55-71]. Specific functions and conditions include re-
call/recognition memory, reaction time, attention, concentration,
psychomotor function, fatigue, mood, outcomes and information
processing speed. These actions suggest that there is no single
mechanism of action, but a complex interaction involving a multi-
tude of effects. The mechanism of action of EGb761 extract is be-
lieved to be produced by its functions as a neuroprotective agent, an
antioxidant, a free-radical scavenger, a membrane stabilizer and an
inhibitor of platelet-activating factor (PAF). It is not certain which
substances in EGb761 extract are responsible for the presumed
health-enhancing properties. It has been suggested that flavonoids
possess antioxidant activity, and ginkgolide B, also known as
BN52021, is a potent antagonist of the PAF receptor.
Accumulating evidence has suggested that many of the actions
of EGb761 extract are so-called “polyvalent” actions, i.e., the clini-
cal responses of EGb761 extract are the net effect of interactions
between the various biological activities of the individual sub-
stances of EGb761 extract. Some major biochemical/pharmacol-
ogical activities of EGb761 extract and/or its active constituents
are:
Free radical scavenger activity, thereby decreasing tissue levels
of reactive oxygen species (ROS) and inhibition of membrane lipid
peroxidation [57,61,72-88].
• Decreases in lipid blood viscosity and normalizes the abnormal
lipid profile and peroxidation [89-98].
• Anti-PAF activity, contributing to improvements in cerebral
insufficiency and asthma [60,99,100].
• Regulates copper homeostasis in the brain, contributing to a
neuroprotective effect [101].
• Stimulates endothelium-derived relaxing factor (EDRF), result-
ing in improved circulation in arteries, veins and capillaries
[102-113].
• Decreases the expression of the peripheral benzodiazepine re-
ceptor of the cerebral cortex [55,114,115].
• Inhibits age-related loss of muscarinergic cholinoceptors and

-adrenoceptors, and stimulation of choline uptake in the hip-
pocampus. EGb761 extract also inhibited the degeneration of
dopaminergic neurons in the striatum, suggesting that the inhi-
bition of the reuptake of dopamine and monoaminooxidase
(MAO) activity was involved in EGB761 extract-induced neu-
roprotection [35,62,67,116-122].
• Inhibits -amyloid deposition [123-130].
• Increases the respiratory control ratio of mitochondria by pro-
tecting against the uncoupling of oxidative phosphorylation,
thereby increasing ATP levels [131-133].
• Enhances neuronal plasticity [59,134-136].
• Anti-inflammatory effects and protective actions against brain
and bone damage [137-149].
• Attenuates apoptosis in several cell cultures such as hepatic
stellate cells, neurons, human retinal nerve, cerebellum of aging
SAMP mouse, pancreatic cancer cells, renal tubular epithelial
cells, human keratinocyte, human lung endothelial cells and rat
testicular cells [81,150-166].
• Increases stress resistance and extends organism’s life span
[55,65,167].
Abad et al.
• Antibacterial and antifungal properties [168-170].
• Some major clinical applications of EGb761 extract include:
• Improvement of peripheral arterial insufficiency including
Raynaud’s disease, acrocyanosis, post-phlebitis syndrome and
intermittent claudication [171-181].
• Treatment of cerebral disorders due to aging, including cogni-
tive decline, short-term memory, age-associated dementia,
multi-infarct dementia and neurosensory impairments not asso-
ciated with dementia [182-193].
• Treatment of circulatory diseases including cerebral atheroscle-
rosis, cerebral insufficiency, symptoms in Alzheimer’s disease,
cancer, Parkinson’s disease and rheumatoid arthritis [194-203].
• Reduction allergic reactions and inflammation, e.g., asthma,
bronchospam, allergic conjunctivitis,… [204].
• Counteraction of the cognitive deficits that follow stress or
traumatic brain injury [205-208].
• Treatment of tinnitus, acute cochlear deafness, vertigo and dis-
turbances in equilibrium, and prophylaxis of migraine with aura
[209-214].
• Ginkgo biloba has also been used experimentally in treating
premenstrual syndrome, macular degeneration, diabetic neph-
ropathy, dyslexia and olfactory dysfunction [215-221].
Ginkgo has generally been safe, and severe side effects are rare,
mild, transient and reversible. Documented effects include head-
ache, dizziness, short-term memory loss, sleeplesness, heart palpita-
tions, dermatologic reactions, gastrointestinal disturbances and
vomiting [20,23,25,51,222,223]. It should be noted, however, that
beside its beneficial attributes, Ginkgo leaves also contains ginkgo-
toxin, a B6 antivitamin which may cause epileptic convulsions and
other severe neuronal disorders, even death [224,225]. Although no
studies have been performed to support any restrictions on the use
of Ginkgo during pregnancy or lactation, in the absence of any data
it seems prudent not to administer Ginkgo [226,227].
Ginkgo biloba-DRUG INTERACTIONS
The interactions of drugs with herbal medicines is a significant
safety concern, especially for drugs with narrow therapeutic indexes
(e,g., warfarin and digoxin). Because the pharmacokinetics and/or
pharmacodynamics of the drug may be altered by combination with
herbal remedies, potentially severe and perhaps even life-
threatening adverse reactions may occur. Because of the clinical
significance of drug interactions with herbs, it is important to iden-
tify drugs and compounds in development that may interact with
herbal medicines.
As with conventional medicines, herbal medicines interact with
drugs in two general ways: pharmacokinetically and pharmacody-
namicaly [228-232]. Pharmacokinetic interactions result in altera-
tions in the absorption, distribution, metabolism or elimination of
the drug or natural medicine. These interactions affect drug action
by quantitative alterations, either increasing or decreasing the
amount of drug available which will have effect. Pharmacokinetics
interactions often occur as a result of activity changes of drug-
metabolizing and transporting proteins, especially cytochrome P450
(CYP) isoenzymes and P-glycoprotein (P-gp). Efflux mechanism
such as P-gp are responsible for transporting a broad range of com-
pounds out of the intestinal epithelial cells back into the intestinal
lumen, and plays an important role in oral drug absorption. Fur-
thermore, its expression and functions are increased with ageing.
Inhibition of P-gp may lead to enhanced absorption of drugs that
are substrates for this active transporter. Conventionally, drug me-
tabolism is broadly divided into phase I and phase II processes.
Phase I processes include oxidation, reduction, hydrolysis and hy-
dration. Of the phase I processes, the CYP superfamily is responsi-
ble for the metabolism of a variety of xenobiotics and endobiotics.
Human CYP isoforms that are involved in the biotransformation of
An Update on Drug Interactions with the Herbal Medicine Ginkgo biloba
xenobiotics include CYP1A1/2, CYP2B6, CYP2C8/9/19, CYP2D6,
CYP2E1, CYP3A4/5 and CYP4A. The activity of these enzymes
can be enhanced or inhibited by synthetic drugs as well as by natu-
ral products. Phase II processes include sulfation, methylation, ace-
tylation, glutathione conjugation, fatty acid conjugation and glucu-
ronidation. Pharmacodynamic interactions may occur when con-
stituents of herbal products have either synergistic or antagonist
activity in relation to a conventional drug. As a result, concentra-
tion-dependent activity of a therapeutic molecule is altered at the
drug-receptor level, at the site of action.
During the past 20 years, an estimated 2 billion daily doses of
Ginkgo have been sold. Ginkgo has generally been safe and has
displayed no verified adverse reactions, although during the past
few years Ginkgo-drug interactions have been well documented
[233-237]. It should be noted that because Ginkgo exhibits MAO
inhibitor properties, it could exert a synergistic effect when com-
bined with other MAO-inhibitor drugs [35].
In addition, because Ginkgo acts as anti-PAF agent, caution
should be used when it is administered with anticoagulant or anti-
platelet drugs. Several studies have noted that Ginkgo may increase
the risk of bleeding when co-administered with other antiplatelet
and anticoagulant agents [99,238-245]. Research suggests a bio-
logically plausible mechanism for an increased risk of bleeding
with Ginkgo through interactions with PAF and collagen that lead
to decreased platelet aggregation. Although a clear causality be-
tween Ginkgo intake and bleeding could not be established, these
observations have generally been explained by the PAF-
antagonistic action of ginkgolides, which represent characteristic
constituents of Ginkgo extract. Several controlled clinical studies
and case reports were undertaken, to investigate whether these
bleeding episodes have a pharmacodynamic, idiosyncratic or coin-
cidental basis. Results from controlled studies consistently indicate
that Ginkgo does not significantly impact haemostasis, nor ad-
versely affect the safety of coadministered aspirin, warfarin, or
antiplatelet drugs such as ticlopidine, cilostazol or clopidogrel
[239,242,245-249]. However, the possibility of an idiosyncratic
bleeding event due to Ginkgo use cannot be excluded on the basis
of the available information, especially in elderly patients or pa-
tients treated with drugs exerting relatively narrow therapeutic win-
dows.
In addition, many reports of Ginkgo biloba-drug interactions
are focused on the induction period of the drug metabolizing en-
zymes (Table 1) [234,250-253]. Several animal studies reported
that feeding of EGb761 extract to rats markedly induced hepatic
Table 1. Pharmacokinetic Interactions of Ginkgo biloba
Drug Result of Interaction
Nicardipine Reduced hypotensive action
Nifedipine Reduced hypotensive action
Talinolol Reduced hypotensive action
Cyclosporine Reduced bioavailability
Diltiazem Increased bioavailability
Midazolam Reduced bioavailability
Tolbutamide Increased hypoglycaemic action Inhibition CYP2C9 CYP3A4
Valproic acid Increased bioavailability
Propanolol Reduced bioavailability Induction CYP1A2 CYP2B1/2
Theophylline Reduced bioavailability
Omeprazole Reduced bioavailability
Current Drug Metabolism, 2010, Vol. 11, No. 2 173
drug metabolizing enzymes, and that pre-treatment with EGb761
extract decreased the hypotensive action of nicardipine, which is a
calcium channel blocker metabolized by CYP3A type [254,255].
Yoshioka et al. [256] investigated the effects of EGb761 extract in
rats on the pharmacokinetics of nifedipine, another calcium channel
blocker, which is a typical probe of CYP3A, but not a substrate of
the P-gp. These results suggest that the concomitant oral use of
EGb761 extract and nifedipine in rats appeared to reduce the first-
pass metabolism of the drug, by inhibiting CYP3A, but not P-gp.
These results were also demonstrated in healthy volunteers, con-
cluding that as far as possible EGb761 extract and nifedipine should
not be simultaneously ingested, and careful monitoring is needed
when administering both in humans [257]. Additionally, several
studies suggest that nifedipine inhibits the metabolism of flavonoids
from EGb761 extract, thus highlighting the caution that must be
taken when these drugs are used together clinically [258].
More recently, other investigations both in vitro and in humans
showed that EGb761 extract also inhibits P-gp. Fan et al. [259,260]
investigated the effects of single and repeated EGb761 extract in-
gestion on the oral pharmacokinetics of talinolol, another calcium
channel blocker, which is a substrate drug for P-gp in humans.
These results suggest that long-term use of EGb761 extract signifi-
cantly influenced talinolol disposition in humans, most probably by
affecting the activity of P-gp and/or other drug transporters. Other
studies also suggest that Ginkgo biloba extract significantly de-
creased the bioavailability of cyclosporine, a substrate for CYP3A4
and P-gp [261]. However, these results indicate that interactions
between cyclosporine and Ginkgo, which may be due to quercetin,
occurred mainly at the adsorption site, concluding that concurrent
intake of Ginkgo with this drug is best avoided in order to ensure
the efficacy of cyclosporin.
Reports on the interactions of Ginkgo biloba with other drugs
have also been found in the literature. Animal studies suggest that
the concomitant use of EGb761 extract in rats increased the
bioavailability of diltiazem by inhibiting both intestinal and hepatic
metabolism, at least in part, via a mechanism-based inhibition of
CYP3A [262]. Other studies in healthy subjects also suggest that
EGb761 extract may modulate CYP3A4 activity [263]. EGb761
extract may alter the exposure of drugs metabolized by CYP3A4,
such as midazolam, fexofenadine and human immunodeficiency
virus (HIV) protease inhibitors. These results suggest that Ginkgo
induces CYP3A4 metabolism, as assessed by a decrease in midazo-
lam concentrations. However, there was no change in the exposure
of lopinavir, probably due to ritonavir’s potent inhibition of
CYP3A4. Thus, EGb761 extract appears unlikely to reduce the
Possible Mechanism Comment Ref.
Induction CYP3A Animal studies [254-256]
Induction CYP3A Clinical studies [257]
Inhibition P-gp Clinical studies [259,260]
Inhibition P-gp, induction Animal studies [261]
CYP3A4
Inhibition CYP3A Animal studies [262]
Induction CYP3A4 Clinical studies [263]
Clinical and animal studies [264,265]
Inhibition CYP2C9 Clinical and animal studies [267,273]
Animal studies [275]
CYP3A1
Induction CYP1A2 Animal studies [276]
Induction CYP2C19 Clinical studies [277]
174 Current Drug Metabolism, 2010, Vol. 11, No. 2
exposure of ritonavir-boosted protease inhibitors, while concentra-
tions of unboasted protease inhibitors may be affected.
Similar interactions of Ginkgo biloba with other drugs might
occur through the mediation of CYP. These are adverse phenomena
in drug therapy and serve as an basic caution for the proper use of
drugs. For example, Uchida et al. [264] investigated in healthy
volunteers the influence of repeated oral administration of EGb761
extract on CYP2C9 and CYP3A4, which are the metabolizing en-
zymes of tolbutamide. The results suggest that the combination of
EGb761 extract and this drug is a cause for caution in view of the
potential interactions. These results were also confirmed in animal
studies, which demonstrated that the simultaneous and continous
intake of EGb761 extract significantly affects the hypoglycaemic
activity of tolbutamide, possibly via a hepatic CYP enzyme-
mediated mechanism, particularly in the aged rats [265].
Other studies indicate that the effects of EGb761 extract on
metabolizing enzymes are specific to rats and cannot be extrapo-
lated to humans. For example, EGb761 extract (100 mg/Kg daily
for 4 days) strongly increased liver CYP450 content and altered the
ex vivo transformation of androstendione as well as the metabolism
of endogenous steroids [266]. However, in human subjects no effect
on the urinary steroid profile was observed after intake of EGb761
extract for 28 days (240 mg daily). Additionally, in two open-label,
crossover pharmacokinetic studies in healthy subjects, using tolbu-
tamide and diclofenac as probe CYP2C9 substrates, no interactions
between Ginkgo biloba extract and CYP2C9 probe substrates were
observed in vivo, as evidenced by the lack of effect on the steady-
state pharmacokinetics of diclofenac, or on the urinary metabolic
ratio of tolbutamide. However, Ginkgo biloba extract decreased the
oxidative metabolism of valproic acid by CYP2C9 in hepatic mi-
crosomes from donors with the CYP2C9*1/*1 genotype, although it
was unclear whether the effect was due to the terpene trilactones or
flavonol glycosides in this experiment [267]. Other studies suggest
that the terpenoidic fraction inhibited only CYP2C9, whereas the
flavonoidic fraction of EGb761 extract showed high inhibition of
CYP2C9, CYP1A2, CYP2E1 and CYP3A4 [268-272]. These re-
sults were also confirmed in rats [273].
Interactions of Ginkgo biloba with other drugs might occur
through the mediation of CYP, and including the
-blocker pro-
panolol, the methylxanthine theophylline as a probe of CYP1A2,
and tanshinone, a Salviae miltiorrhizae extract, which are metabo-
lized by CYP1A1, CYP1A2 and CYP2B1 isoenzymes [274-276].
These are adverse phenomena in drug therapy and provide an es-
sential caution for the proper use of EGb761. Ginkgo biloba should
also be considered as a possible candidate for clinically relevant
drug-herb interactions with selected CYP2C19 substrates, such as
S-mephenytoin, an anticonvulsivant hydantoin, omeprazole and
chlorzoxazone, a muscle relaxant agent [232,277]. However, the
pharmacokinetic parameters of the antifungal voriconazole, another
CYP2C19 substrate, did not change significantly in the presence of
Ginkgo biloba extract in Chinese volunteers, genotyped as either
CYP2C19 extensive or poor metabolizers [278].
Several studies have been undertaken to investigate the mecha-
nism of action of CYP-Ginkgo interactions at molecular levels.
Pregnane X receptor is a ligand-activated transcription factor that
plays a role not only in drug metabolism and transport, but also in
various other biological processes. Yeung et al. [279] demonstrated
that treatment of primary cultures of rat hepatocytes with Ginkgo
biloba extract increases the mRNA expression of CYP3A23, which
is a target gene for rat pregnane X receptor. Ginkgo biloba extract
also activated mouse and human pregnane X receptor in a cell-
based reporter gene assay, and induced CYP3A4, CYP3A5 and P-
gp ABCB1 gene expression in human pregnane X receptor-
expressing LS180 cells. More recently, Li et al. [280] investigated
the hypothesis that the bioactive terpenoids and flavonoids of
Ginkgo biloba extract induce human hepatic drug metabolizing
enzymes and transporters through the selective activation of preg-
Abad et al.
nane X receptor, constitutive androstane receptor and aryl hydro-
carbon receptor. Cell-based reporter assays in HepG2 revealed that
ginkgolides A and B are potent activators of pregnane X receptor,
quercetin and kaempferol activate pregnane X, constitutive andro-
stane and aryl hydrocarbon receptors, whereas bilobalide exerts no
effects on these xenobiotic receptors. Notably, the flavonoids in-
duced the expression of UDP-glucuronyltransferase 1A1 and
CYP1A2 in HepG2 cells, but not in human primary hepatocytes.
These results indicate that the terpenoids and flavonoids of Ginkgo
biloba exhibit differential induction of drug metabolizing enzymes
through the selective activation of pregnane X, constitutive andro-
stane and aryl hydrocarbon receptors.
Reports on the interaction of Ginkgo biloba with other drugs
have also been found in the literature, although investigations have
shown that the concomitant use of EGb761 extract did not appear to
have any significant effect on the pharmacokinetics and pharma-
codynamics of these drugs. Examples included digoxin, donezepil,
efavirenz, flurbiprofen, alprazolam, dextromethorphan and
bupropion, which is an antidepressant and a tobacco use cessation
agent [281-287].
CONCLUSIONS
The growing use of herbal remedies has far exceeded the in-
crease in available information on their benefits, adverse effects and
drug interactions. Considering that the scalating appeal of herbal
medicines is likely to continue, such a stance is impractical and
potentially risky for patients. For this reason, it has become vital to
educate the medical and scientific establishement and show that
there are some features which are unique to phytotherapy and
which contribute both to the efficacy and safety of herbal medicine.
Once sold on the market, regulatory agencies need to act on suffi-
cient solid scientific reports of a healthcare concern to restrict
herbal product availability and usage. Based on current public per-
ceptions, many patients are unlikely to consider that herbal self-
medications carries risks or is associated with drug interactions and
are therefore not likely to tell their healthcare professionals of their
use. Conversely, healthcare professionals are not accustomed to
asking their patients about their consumption of herbal medicines.
Practitioners should consider including herbal supplement educa-
tion to improve the awareness of their uses and possible side ef-
fects. Providing sound information about herbs to patients and
“self-supplementing” consumers supports the integration of com-
plementary therapies as an adjuvant to overall sound nutrition and
healthful lifestyle.
With an aging population seeking solutions to troubling prob-
lems such as dementia and vasculopathy, Ginkgo biloba offers
some benefit as a mild vasoactive and neuroprotective phytomedi-
cine. It offers a relatively safe, inexpensive and modestly effective
treatment option when selected by patients or prescribing physi-
cians for multi-infarct or Alzheimer’s dementia. Evidence indicates
that it is effective in slowing disease progression and ameliorating
symptoms. The simplicity of treatment, ease of access and low cost,
today make Ginkgo biloba extract one of the most popular com-
plementary and alternative medicines for prevention and treatment
of primary dementias. However, Ginkgo is the second most com-
mon herb involved in drug interactions. The aim of the present
study was to conduct a review of literature on interactions between
conventional drugs and Ginkgo based on descriptions of the clinical
consequences, case series and case reports. The number of reported
cases of emerging Ginkgo-drug interactions is already on the rise,
and the actual number of cases may in fact be higher due to under-
reporting. It is now known that millions of patients take herbal and
conventional medicines concomitantly, often without the knowl-
edge of their physicians. Considering our present lack of under-
standing of herb-drug interactions, proper reporting of such cases,
careful vigilance, evidence-based appraisal and constantly updated
reviews of such information are very important to promote under-
An Update on Drug Interactions with the Herbal Medicine Ginkgo biloba
standing in this area. Additionally, physicians and other healthcare
providers must become familiar with the data, and advocate greater
research and access to information.
ACKNOWLEDGEMENTS
The technical assistance of Ms. Brooke-Turner is gratefully
acknowledged.
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