HERB-DRUG INTERACTIONS

1. Introduction (1 minute): Briefly introduce the topic of herb-drug interactions

and the significance of understanding these interactions in healthcare.

Plants have always provided an important source of medicines. Medicinal plants

were the major agents for primary health care for many centuries before the
advent of modern medicine. They may be used by natives in folk medicine and
later adopted by conventional Western medicine as their efficacy was confirmed.

Nowadays, more and more people consume herbal supplements as a means to

improve their health for various purposes. And with that widening spread of herbal
supplements amongst healthy people and patients alike, interactions between
herbs and drugs are even more likely to occur.

Similar to drug-drug interaction, herbal-drug interaction (or HDI) may increase or

decrease either component's pharmacological or toxicological effects in various
mechanism that leads to various consequences. They can be beneficial,
undesirable, or harmful. So, what is HDI and how does it work?

2. Overview of Herb-Drug Interactions (2 minutes): Explain the increasing

consumption of medicinal herbs globally and the potential implications of herb-
drug interactions on health outcomes.
Dietary supplements are defined as a variety of products, including herbs,
vitamins, minerals, and probiotics. This presentation focuses on drug interactions
with herbal dietary supplements, which are defined as supplements containing
whole plant or plant extracts only.
Herb-drug interactions, as the name implies, are interactions that occur between
herbal medicines and conventional drugs that alter the behavior of either
component.
The indications for herbal remedies are diverse as they are employed in the
treatment of a wide range of diseases. You can use it to improve a certain
condition you've got, to get better sleep, to protect your liver, or better yet, to
become younger and prettier.
Moreover, in most countries, regulations do not require the demonstration of
therapeutic efficacy, safety, or quality on the part of herbal remedies as most of
them are promoted as natural and harmless. You can easily get it without a
doctor's note and take it anytime you want.
Accordingly, there has been increasing concern over the potential for dietary
supplements, particularly herbal products, to interact with prescription
medications.
In clinical practice, polypharmacy is common, and to the mixture physicians
prescribe, patients add various over-the-counter medications, vitamins, herbs, and
foods. All ingested substances have the potential to interact. The concerns are
multiplied for those patients taking multiple medications, often prescribed by
multiple physicians who may or may not be in communication with each other
about their medical reasoning.
3. Mechanisms of Interaction (3 minutes): Discuss the identified mechanisms.
Herbal-drug interactions can occur through two main mechanisms:
pharmacokinetic and pharmacodynamic interactions.
- Pharmacokinetic interactions involve changes in ADME, that is: the
absorption, distribution, metabolism, or excretion of a drug due to the
presence of herbs.
The most common mechanism is their effects on drug metabolism, specifically -
the liver and its enzymes. The CYP superfamily is involved in almost every step of
the drug metabolism chain, with the CYP3A4 being the most abundant of all
isoforms. It takes part in the metabolism of about half of the drugs in use today.
Certain herbal products have been shown to be capable of inducing or inhibiting
CYPs, which results in alteration in plasma levels and then translates to therapeutic
efficacy. Induction of CYPs can cause lower drug concentration with therapeutic
failure as a possible clinical consequence, whereas inhibition might lead to high
plasma levels, toxicity, or drug accumulation. These effects will be of particular
concern in drugs with narrow therapeutic windows or steep dose–response
profiles.
Grapefruit (Citrus paradisi) has been proven to irreversibly inhibit CYP3A4 activity
in vitro, and consuming as little as 200 ml can result in significant increases in drug
concentration. So, let’s say you have your grapefruit juice and your cholesterol
medication on hand, and you take them together. Due to the presence of the
strong inhibitor (that is - the grapefruit juice), there is now more drug in your
system for a longer period. You have inadvertently created an interaction that, in
extreme cases, can lead to kidney failure.
- On the other hand, herb-drug interactions may manifest as
pharmacodynamic interactions, i.e: Direct pharmacologic actions of an
herbal supplement may antagonize or exacerbate the drug's clinical effects.
When a patient consumes herbal supplements, they think that it's to enhance their
health. They think it's natural, it must be safe. They're not thinking about risk, but
the fact of the matter is that herbal supplements are pharmacologically active.
They're biologically active so they can do things like change your blood sugar, your
blood pressure, your cholesterol, and promote bleeding. So the idea that that
could interact with medication also exists, meaning if you're trying to treat a
condition and now these herbal supplements have their own innate effects, you’re
working for or against the condition you’re trying to treat.
For instance, ginger, garlic, ginkgo biloba can increase the risk of bleeding when
taken with medications such as warfarin, aspirin, and NSAIDs. A hint to help you
remember: Three Gs can make you bleed.

Herbs Drugs Effects

Pharmacokinetics

Glycyrrhiza Warfarin, Lidocaine Decreases in therapeutic

uralensis (Cam efficiency.
thảo)

Ginseng Calcium channel blockers, Decreases in therapeutic

chemotherapy, certain efficiency.
antihypertension and statins,
some antidepressants

Pharmacodynamics

Ginger NSAIDs, anticoagulants Increase in risk of bleeding

Karela (Bitter Hypoglycemic drugs Potentiates drug effect

melon)

Ephedra species Central Nervous System (CNS) Induce hypertension, CNS

(Ma hoàng) drugs stimulation

4. Clinical Implications (1 minute): Highlight the importance of recognizing and

managing herb-drug interactions in clinical practice to ensure patient safety and
treatment efficacy.
What’s the difference between herb-drub interaction (HDI) and drug-drug
interaction (DDI)? - The difficulties, the challenges.
- Herbal products, unlike pharmaceutical drugs, have a much more complex
composition. They contain various components, multiple active ingredients,
chemicals, enzymes, etc…, according to which, their uses might vary. It
means there are more variables to take into account - that is, if we manage
to identify every single one of their components. Furthermore, labeling of
herbal products may not accurately reflect their contents, and adverse
events or interactions attributed to specific herbs may actually be due to
misidentified plants, pharmaceutical drugs, or heavy metals. All of that
results in an under-researched area of study and more difficulties in
anticipating and dealing with the interactions.
- The third challenge I’d like to introduce is the difference in the regulation of
herbal products. Unlike pharmaceutical drugs that are considered unsafe
before they’re proven to be safe, supplements, including herbal
supplements, are considered legally safe until they are proven to be unsafe.
 These products are widely consumed, getting more and more popular as
our quality of life improves, which complicates the predicting and managing
of potential interactions.
- Patients are less likely to disclose their use of dietary supplements. When
people use herbal supplements, they assume that it’s safe. They don’t feel
the need to inform their physician or include it in their medication history,
so pharmacists are more often than not unaware of the patient’s use of
herbal supplements when they provide them with pharmaceutical products,
which allows the interactions, if exist, to slip right under their noses.
As you can see, HDI might be extremely difficult to manage. More research and
trials would be needed in order to provide a better grasp of this specific type of
phenomenon.
On the other hand, pharmacists play a vital role in preventing drug-herb
interaction from occurring by appropriately dispensing medicine and taking due
care of the patient’s medication use. It is paramount that we stay up-to-date with
HDI discoveries and have a continuing, open dialogue with patients about their use
of dietary supplements, and in the case of a serious potential interaction, take due
measures to prevent it while ensuring the theurapeutic results.
5. Conclusion (1 minute): Summarize the key points discussed and emphasize the
need for further research and awareness in this area.
Herb-drug interaction, as we can see, can be as dangerous and complicated as
drug-drug interaction, more so when it comes to predicting and managing. In
conclusion, herb-drug interactions are an important consideration in healthcare, as
they can impact the safety and efficacy of both herbal remedies and medications.
Healthcare professionals and consumers ought to be aware of the potential for
herb-drug interactions and take steps to minimize the possible risks. By being
informed and proactive, healthcare providers and patients can work together to
ensure safe and effective use of both herbal remedies and medications.