It is critical for nurses to know about herbal therapy and to include herbal preparations as part of their assessment. Herbal products can have both positive and negative effects and important interactions with prescription and over-the-counter (OTC) medications. Nurses are in an excellent position to educate patients about these interactions.

An herb, according to MedlinePlus, is “a plant or plant part used for its scent, flavor or therapeutic properties. Herbal medicine products … are sold as tablets, capsules, powders, teas, extracts, and fresh or dried plants. However, some can cause health problems, some are not effective and some may interact with other drugs.”

Herbs have long been and continue to be sources of old and new drugs: foxglove (source of digitalis), snakeroot (source of reserpine), willow bark (source of aspirin), and Pacific yew tree (source of Taxol), to name just a few. The therapeutic value of phytomedicine (medicine derived from plants) relates to several factors, including dosage, potency, and purity. Research into the effects of herbal medicine is increasing.

Many Americans use herbal products for therapeutic or preventive reasons. Herbal therapy has surged in popularity; marketing and media have fueled the demand, with advertisements and promotions on television, in magazines, and on the Internet. It is estimated that herbal products are used by almost one third of Americans, many of whom do not share the use of these products with their health care providers. Worldwide annual sales of herbal products represent greater than $60 billion, and the strong market is expected to continue.

Few pharmacy schools in the United States offer courses in botanical remedies, but herbal therapy is being addressed in the professional literature with increasing frequency and seriousness. Health care providers and consumers are asking questions about herbal therapy’s effectiveness, potential toxicity, and reactions with conventional medications. Consumers are right to question advertisements that imply that herbs will cure anything. Herbs can be useful, but they can also be ineffectual or even dangerous (Herbal Alert 6-1).

Herbal Alert 6-1

Patient Responsibility

To optimize the therapeutic regimen, the patient has the responsibility to (1) consult with the health care provider before taking any herbal preparation, (2) report all herbal preparations taken to all health care providers, (3) inform health care providers of any allergy or sensitivity to any herbal products, (4) use caution if pregnant or lactating, and (5) not take a greater dose than recommended.

In 1992, Congress instructed the National Institutes of Health (NIH) to develop an Office of Alternative Medicine to support studies of alternative therapies. This office is now called the National Center for Complementary and Alternative Medicine (NCCAM). NCCAM lists current clinical trials with herbal products on their website (www.nccam.nih.gov/research/clinicaltrials). The Natural Standard Research Collaboration also reviews global literature on herbal studies by clinicians and researchers. These studies are important because botanical remedies cannot be patented, so their manufacturers generally cannot justify the expenses associated with safety and efficacy testing in an already booming conventional medicine economy.

This chapter describes selected aspects of herbal therapy, including (1) herbal monographs, (2) the Dietary Supplement Health and Education Act of 1994, (3) varieties of herbal preparations, (4) the most commonly used herbs, (5) herbs used to treat selected common ailments, (6) potential hazards of herbs, (7) tips for consumers and health care providers, and (8) herbal resources.

Herbal Monographs

The two primary types of herbal monographs are therapeutic and qualitative. Therapeutic monographs contain information on use, dosage, side effects, and contraindications. Qualitative monographs have information on areas such as compliance with compounding guidelines and standards of purity. Integrating herbs into the American health care system requires both types of monographs, which the United States currently does not have.

Work to develop these monographs is in progress by several organizations, including the United States Pharmacopeia (USP), the World Health Organization (WHO), the American Herbal Pharmacopeia (AHP), the European Scientific Cooperative of Phytomedicines (ESCOP), and the German Commission E.

The German Commission E, an oversight commission in Germany, works to determine the safety of an herbal product with “reasonable certainty.” The American Botanical Council has translated the German Commission E monographs into English in an effort to bring more information to the American public. Much work remains to be done related to the effects of preparations and the improvement of manufacturing and marketing processes.

Standardization is movement toward consistency and comparison of herbal preparations. A standardized herbal extract has one or multiple ingredients whose levels are guaranteed in the sold product. Examples of standardized herbal products are presented in Table 6-1.

TABLE 6-1

SELECTED HERBAL PRODUCTS WITH STANDARDIZED CONCENTRATIONS

HERB	STANDARDIZED CONCENTRATION OF ACTIVE INGREDIENT
Bilberry	25% anthanocyanosides
Feverfew	0.2% parthenolide
Ginkgo biloba	24% flavone glycosides; 6% terpene lactones
Goldenseal	8% to 12% alkaloid
Hawthorn	20% procyanidins
St. John’s wort	0.13% to 0.30% hypericin
Saw palmetto	85% to 95% fatty acids

Dietary Supplement Health and Education Act of 1994

The Dietary Supplement Health and Education Act of 1994 (DSHEA) clarified marketing regulations for herbal remedies. DSHEA reclassified herbals as “dietary supplements” distinct from food or drugs. Herbal supplements can be marketed with suggested dosages. Consumers are reminded that premarket testing for safety and efficacy is not required, and manufacturing is not standardized. The physiologic effects of the product can be noted, but no claims can be made about preventing or curing specific conditions. For example, a product label cannot claim that the agent “prevents heart disease,” but it can say that the agent “helps increase blood flow to the heart.” In addition, a disclaimer is required that indicates that the herb is not approved by the U.S. Food and Drug Administration (FDA) and that it is not meant to be used as a drug.

In January 2000, the FDA finalized rules for claims on dietary supplements, noting that supplements may make structure and function claims without FDA approval. However, it may not be claimed that the supplement can prevent, treat, cure, mitigate, or diagnose diseases. This ruling caused label changes on products but did not affect product availability or consumer access. Health maintenance claims (e.g., “maintains a healthy immune system”) and claims for relief of minor symptoms related to life stages (e.g., “alleviates hot flashes”) are acceptable because they do not relate to disease. Herbal products using a “may be beneficial” disclaimer rather than claims of definite benefit are appropriate legally. Dietary supplement manufacturers are still required to substantiate any claims they make.

Current Good Manufacturing Practices

The FDA proposed standards for marketing and labeling for dietary supplements in 2003. Known as the Current Good Manufacturing Practices (CGMPs), these standards are multifaceted and require that package labels give quality and strength of all contents and products be free of contaminants and impurities. Manufacturing quality control procedures are part of the CGMPs.

Additionally, a “seal of approval” is awarded to products meeting criteria similar to the CGMPs by four organizations (the USP, ConsumerLab, National Products Association, and NSF International). The fee-based tests provide information on herbal products’ identity, potency, dissolution, purity, and labeling accuracy.

Herbal Preparations

Herbal remedies are available in a variety of preparations and forms. Following is a description of selected preparations and forms of herbs, including dried herbs, fresh oils, salves, teas, tinctures, syrups, capsules, and tablets. The consumer and health care provider must be knowledgeable about the differences in dosages between extracts and powders as well as the issues associated with standardization.

Dried herbs are fresh herbs that have had the moisture removed by sun or heat. They can be stored for about 6 months. Extracts are made by isolating certain components, resulting in more reliable dosing. Dissolving the herb in a solvent such as alcohol or water is a common way to prepare an extract, which may or may not be standardized. Fresh herbs may decay after a few days because of enzyme activity; hence they have a short life.

Oils are made by soaking dried herb in olive or vegetable oil and heating it for an extended time. The oil promotes concentration of some of the herb’s active components, and it may last for months if stored correctly. These infused oils are not “essential oils” (volatile oils extracted from plants that produce an odor and stimulate taste sensations). Salves, semisolid fatty preparations, are made by melting a wax in oil (or crushing the herb and mixing it in a petroleum jelly base) and allowing it to cool and harden. If stored correctly, they last for several months as balms, creams, and ointments. Teas are made by steeping fresh or dried herbs in boiling water. Tea made from bark and roots is often simmered. It is recommended that only a 2- to 3-day supply be prepared at one time and that it be stored in the refrigerator. Teas may be used as a drink, added to baths, and applied topically in a compress. Tinctures are commonly made by soaking fresh or dried herbs in a solvent such as water or alcohol. Both water- and fat-soluble components are concentrated in the final form. Alcohol promotes preservation, yielding a shelf life of 1 year. Alcohol-free, glycerin-based tinctures are available for people who do not consume alcohol. Syrups are made by adding a sweetener, usually honey or sugar, to the herb and then cooking it. Syrups are used to treat colds, coughs, and sore throats.

Capsules commonly contain a powdered form of dried supplement, but they may hold juices or oils. They have a slower effect than liquids because of decreased absorption. They store and travel well. Tablets are similar to capsules; they are a powder compressed with stabilizers and binders.

Commonly Used Herbal Remedies

Most herbal therapies are used for chronic conditions, are unlikely to cause harm, and may provide some relief in selected situations. This section discusses some of the more commonly used herbs.

Aloe Vera (Aloe barbadensis)

The juice is used externally for treatment of minor burns, insect bites, and sunburn. Fresh aloe leaves are most effective. There has been some success with the treatment of dandruff, oily skin, and psoriasis. Taken internally, aloe vera is a powerful laxative. Menstrual flow is increased with small doses.

Black Cohosh (Cimicifuga racemosa)

Herbal Alert 6-2

Black Cohosh

Do not confuse black cohosh with blue cohosh, an herbal preparation said to induce labor in pregnant patients.

Chamomile (Matricaria recutita)

Dried flower heads of Matricaria recutita are the ingredients of a popular tea for relief of digestive and gastrointestinal (GI) complaints. Chamomile tea’s antispasmodic and anti-inflammatory effects on the GI tract make it useful for relief of irritable bowel syndrome and infant colic. In addition, chamomile may have sedative effects.

Chamomile tea is prepared by steeping 1 teaspoon of flower heads for 10 to 15 minutes in boiling water; suggested use is three to four times per day. An extremely rare reaction of urticaria and bronchoconstriction may occur in an individual who is allergic to daisy or ragweed-type plants. Pharmacokinetics and pharmacodynamics are not known.

Dong Quai (Angelica sinensis)

Dong quai, an all-purpose woman’s tonic herb, has long been popular in China and Japan for the treatment of menstrual cramps and to regulate the menstrual cycle. This herb has not been well studied, and preparations are frequently mixed with fillers. Dong quai contains vitamin B₁₂, which may promote manufacture of blood cells. Rare side effects include fever and excessive menstrual bleeding. Pharmacokinetics and pharmacodynamics are not known. The recommendation is to avoid the use of this herb.

Echinacea (Echinacea angustifolia)

Echinacea, a popular oral and topical supplement, is used as an immune enhancer; it acts by furthering phagocytosis by means of increasing leukocytes and spleen cells and activating granulocytes. In addition, echinacea inhibits hyaluronidase activity and increases the release of tumor necrosis factor. The leaf preparation is given for respiratory and urinary tract infections. The root extract is used to treat flulike symptoms. German Commission E recommends that echinacea preparations be avoided by persons with autoimmune diseases and those with abnormal T-cell functioning (e.g., human immunodeficiency virus [HIV], acquired immunodeficiency syndrome [AIDS], tuberculosis).

Echinacea should be purchased only from reliable sources. There are many reports of fraudulent substitution with other plants and varying potency. Recommendations for duration of treatment are inconsistent. However, treatment should begin immediately with the onset of symptoms to “catch it early.” German Commission E recommends the use of echinacea for up to 8 weeks; others recommend a week-long “drug holiday” (i.e., not taking the preparation for a specific time period) before continuing therapy. Pharmacokinetics is not known. Immunosuppression may occur after extended therapy.

Evening Primrose (Oenothera biennis)

Evening primrose is a native North American biennial plant. Oil in its seeds contains gamma-linolenic acid (GLA), a fatty acid believed to help prevent cirrhosis, eczema, premenstrual syndrome, hypertension, hardening of the arteries, and heart disease. It aids in lowering cholesterol and relieving pain and inflammation. The bark and leaves have astringent qualities, and the oil affects uterine muscles, metabolism, and the nervous system. It should not be used during pregnancy and lactation. It may lower the seizure threshold if taken with anticonvulsants; the anticonvulsant dose may need modification, or it should not be used concurrently. Pharmacokinetics and pharmacodynamics are not known.

Feverfew (Tanacetum/Chrysanthemum parthenium)

The plant compound parthenolide is believed to inhibit platelet aggregation and act as a serotonin antagonist in mediating vascular headaches. Feverfew is popular for prophylaxis and for relief of migraine headaches and their accompanying nausea and vomiting. Postfeverfew syndrome (fatigue, headache, joint pain, nervousness) is experienced by some. Local ulceration and irritation may result from chewing feverfew leaves. Only standardized extracts should be used. Wide variation in the amount of active compound in plants and commercial capsules is a potential dosing problem. Pharmacokinetics and pharmacodynamics are not known.

Garlic (Allium sativum)

Garlic is reported to lower cholesterol and triglyceride levels, decrease blood pressure, and reduce the clotting capability of blood (increases precursor of nitric oxide). It also acts as an antibiotic to treat infections and wounds both internally and externally. Warm garlic oil is used in the ear for treatment of earache. Garlic may be used for some types of heavy-metal poisoning. Pharmacokinetics and pharmacodynamics are not known.

Ginger (Zingiber officinale)

Ginger boosts the immune system. It is used to treat migraine headache, stomach problems, and digestive disorders, including motion sickness. Long-time use for relief from nausea is validated by modern research. In addition, it may provide relief from pain, swelling, and stiffness of both osteoarthritis and rheumatoid arthritis (dosage 500 to 4000 mg/day). Information on pharmacokinetics and pharmacodynamics is limited. Metabolites are excreted via urine within 24 hours, and it is 90% protein-bound.

Ginkgo (Ginkgo biloba)

Ginkgo biloba, an extract of one of the oldest plant species, is the most commonly prescribed herbal remedy worldwide. When it crosses the blood-brain barrier, ginkgo has central nervous system (CNS) effects, increasing both cerebral arterial dilation and uptake of oxygen and glucose. It assists cells during periods of hypoxia (e.g., during transient ischemic attacks) and decreases free-radical damage to neurons. In addition, there is inhibition of platelet adhesion and degranulation. German Commission E Monograph #55 lists the use of ginkgo for dementia syndromes, intermittent claudication, vertigo, and tinnitus when these symptoms are secondary to diminished blood flow. There is some evidence that ginkgo improves cognition and may be helpful in Alzheimer’s disease, early stroke, and Raynaud’s phenomenon. Some men take ginkgo to treat erectile dysfunction.

Ginkgo biloba is generally given as 120 to 240 mg/day in two to three divided doses for up to 90 days. Rare side effects include headache and GI disturbances. Limited information is available on pharmacokinetics and pharmacodynamics. Bioavailability is not affected by food; urinary excretion is less than 30% metabolites.

Ginseng (Panax ginseng)

Preparations of ginseng are taken for short-term relief of stress, to boost energy, and to give digestive support. Ginseng tends to support the immune system and assist in the prevention of chronic infections. Red Korean or Chinese ginseng may be overstimulating in chronic inflammatory conditions such as arthritis. Pharmacokinetics and pharmacodynamics are not known.

Goldenseal (Hydrastis canadensis)

Goldenseal is frequently used with echinacea to ward off infection and promote wound healing. Common uses include treatment of GI ulcers, mouth ulcers, bladder infection, eye and skin irritation, and postpartum hemorrhage. It is used to treat congestion associated with the common cold. In addition, it is used as a tonic and astringent. Active ingredients are deactivated in the stomach. Goldenseal is expensive and scarce; thus it is frequently adulterated with fillers. Its ability to stimulate the immune system has been questioned, and it can be toxic if overused. Goldenseal is contraindicated during pregnancy (stimulates uterus). Pharmacokinetics and pharmacodynamics are not known.

Kava (Piper methysticum)

Kava promotes sleep and muscle relaxation and is an antiepileptic, antidepressant, and antipsychotic. Kava also promotes wound healing. Tea can help with urinary tract infections. Kava may be used in combination with other herbs, such as valerian and St. John’s wort, for relaxation. Kava may cross the placenta and be present in breast milk. In 2002, the FDA issued a consumer advisory about the potential for liver damage with kava use. Long-term use may result in a pellagra-like skin disorder that disappears when kava is discontinued. Little is known about its pharmacokinetics and pharmacodynamics.

Licorice (Glycyrrhiza glabra)

Licorice may have physiologic effects similar to aldosterone and corticosteroids related to glycyrrhizin, a major ingredient. Licorice may help with chronic fatigue syndrome. The deglycyrrhizinated form is used to treat ulcers. It relieves heartburn and indigestion by decreasing stomach acid; it also has a laxative effect. Side effects from excessive licorice include increased blood pressure, headache, lethargy, water retention, increased potassium excretion, and, rarely, heart failure. Licorice root is considered safe in dosages of 5 to 15 mg when taken as tea. Its recommended use is limited to 6 weeks. Pharmacokinetics and pharmacodynamics are not known (Herbal Alert 6-3).

Herbal Alert 6-3

Black Licorice

Consuming 2 ounces of black licorice daily for 14 days may cause arrhythmia in people age 40 years and older.

Milk Thistle (Silybum marianum)

This herbal extract has the remarkable ability to prevent damage to liver cells and stimulate regeneration of liver cells. Milk thistle is widely used in Europe to treat hepatitis, cirrhosis, and fatty liver associated with drug and alcohol abuse. Pharmacokinetics and pharmacodynamics are not known.

Peppermint (Mentha piperita)

Peppermint stimulates appetite and aids in digestion when taken internally. The digestive tract is protected by the tannins, and peppermint is used in the treatment of bowel disorders. Hot peppermint tea stimulates circulation, reduces fever, clears congestion, and helps restore energy. Peppermint oil is an effective treatment for tension headache when rubbed on the forehead. In research in Germany, peppermint has been shown to be comparable with acetaminophen (extra-strength Tylenol) in relieving headache. Pharmacokinetics and pharmacodynamics are not known.

Sage

Sage has a long history of use for medicinal and culinary purposes. Sage tea is used as an aid for sore throat and cough; it may also be used as a gargle to decrease inflammation of mouth, gums, and throat. According to clinical studies, antibacterial, antifungal, and antiviral effects are found in sage and result in its medicinal effects. Its recommended use is limited to 2 weeks to avoid the toxic effects of tannins.

St. John’s Wort (Hypericum perforatum)

Current research suggests that St. John’s wort is not effective when used by individuals with moderate to severe depression. Botanical experts indicate that it is to be used for mild depression. St. John’s wort has at least 10 pharmacologically active components. The compound used for standardization is hypericin. Researchers recommend that prospective trials be conducted to compare St. John’s wort with standard antidepressant medication and to identify dosages, effectiveness in different stages of depression, and implications of long-term use. St. John’s wort has been nicknamed “herbal Prozac” because of its great popularity in the United States and its use as a “tonic” for the nervous system. St. John’s wort is used in combination with yarrow to treat enuresis. When taken concomitantly with a prescription antidepressant, an adverse effect of St. John’s wort may be suicidal ideation. This herbal remedy is considered a dietary supplement in the United States and has not been FDA approved. In Germany, it is licensed for relief of anxiety, depression, and insomnia. The 1984 German Commission E monograph on hypericin indicated that the agent was an experimental monoamine oxidase inhibitor (MAOI) for use in depression, anxiety, and psychogenic disturbances. The mechanism of action is unknown.

The usual dose of St. John’s wort is 300 mg of extract three times a day (standardized to 0.3% hypericin). A tea can be prepared from 1 to 2 teaspoons of herb steeped for 10 minutes. One to two cups of tea per day for 4 to 6 weeks is recommended. Users should apply sunscreen freely when outdoors, although phototoxicity has not been reported in humans. St. John’s wort crosses the blood-brain and placental barriers and may enter breast milk. Minimal information is known about the pharmacokinetics and pharmacodynamics.

Saw Palmetto (Serenoa repens)

Double-blind studies indicate that saw palmetto relieves symptoms of benign prostatic hypertrophy and urinary conditions. Saw palmetto has earned the nickname “plant catheter.” Individuals who use saw palmetto can get false-negative test results for PSA. Other indications for this herb include use as an expectorant and a treatment for colds, asthma, bronchitis, and thyroid deficiency. The recommended dose is 160 mg of standardized extract twice a day. Pharmacokinetics and pharmacodynamics are not known.

Valerian (Valeriana officinalis)

Valerian, a mild sedative and sleep-inducing agent, has an effect similar to benzodiazepines. It is popularly known as “herbal Valium.” Most researchers report no hangover effect. A “dirty socks” odor is related to the dried plant, resulting in low risk of overdose. Preparations from fresh root are reported to be better relaxants and have a sweet aroma. There have been no reports of habituation and addiction. Drowsiness may occur, as with any relaxant. The dosage depends on the symptoms, such as insomnia and anxiety. To treat insomnia, 400 mg of tincture extract or 2.5 to 5 mg of solid extract is recommended at bedtime. For anxiety, a tea steeped with 1 teaspoon of dried herb is taken several times a day. About 5% to 10% of users report a stimulant effect. Pharmacokinetics and pharmacodynamics are not known.

Table 6-2 describes aspects of selected herbs. Vitamins and elements commonly used in conjunction with herbal therapy are vitamins B₆, A, C, and E; selenium; and zinc. The American Herbal Products Association has categorized herbal products based on “reasonable use” into four classes. See the note at the end of Table 6-2 for a description of the classes.

TABLE 6-2

SUMMARY OF SELECTED HERBS*

HERB	ACTIONS AND USES	DOSAGE	INTERACTIONS/PRECAUTIONS	SIDE/ADVERSE EFFECTS
*Common and Botanical* Names**
*Class and Part Used*
aloe/aloe vera Aloe barbadensis Class 1 Leaf gel Class 2b/2d Dried, juice Class 2d Topical bladelike leaf	Uses: Internal for constipation; externally to relieve pain and promote healing of burns, wounds, sunburn, psoriasis	Internal: Tincture/extract: 50-300 mg External: t.i.d. or PRN	Internal use contraindicated if pregnant or lactating, and in children <12 y Consult with HCP before taking if have ulcerative colitis or Crohn’s disease or if taking cardiac glycosides, antiarrhythmics, thiazide diuretics, licorice, or corticosteroids Monitor electrolytes	Internal: Overdose/long-term use: arrhythmias, neuropathies, edemas, albuminuria, hematuria (side effects are rare)
bilberry Vaccinium myrtillus L. Class 4 Extract of dried fruit and leaf	Uses: Fruit may promote healthy vision, increase visual pigment regeneration; decrease diarrhea in children Leaf used for diabetes, arthritis, dermatitis, gout	Fruit extract: 80-160 mg t.i.d. (St: 25% anthocyanosides) Leaf: no information	Avoid use if pregnant or lactating, and in children No reported significant interaction with fruit Leaf: May decrease blood sugar and triglyceride levels; may increase action of anticoagulants and NSAIDs; monitor for dose adjustments	Leaf: Long-term higher doses (in animals): anemia, icterus, excitation, death
black cohosh (bugwort, snakeroot, squaw root) Cimicifuga racemosa Class 2b/2c Root	Suppresses luteinizing hormone, optimizes estrogen levels Uses: Antispasmodic, astringent, diuretic, vasodilator, PMS, dysmenorrhea, infertility, menopausal symptoms	Cap/tab: 20 mg b.i.d. Tincture: 2-5 mg b.i.d.	Avoid use if pregnant or lactating, and in children Limit use to 6 mo; no data on long-term use Under supervision of qualified herbalist, increases action of antihypertensives; may alter effects of HRT May decrease iron absorption	Higher doses: dizziness, headache, nausea, change in heart rate
chamomile (green chamomile) Matricaria recutita Class 2b Dried flower tops	Stimulates normal digestion, antiinflammatory, antispasmodic, mild sedative, mild diuretic, mild antibacterial with topical use Uses: Anxiety, insomnia, indigestion, inflammatory skin conditions	Between meals: Cap/tab: 2-3 g t.i.d., Tea: 1-4 c/d Tincture: max: 1 tsp t.i.d.	Avoid use if allergic to daisy family (e.g., ragweed, asters, chrysanthemums) May increase effects of sedatives and interfere with action of anticoagulants H/F, H/H: None known	None known
cranberry Vaccinium macrocarpon Ait. Class 4 Berries	Prophylaxis (not treatment) of urinary tract infections; to treat kidney stones	Extract: 300-400 mg concentrated juice b.i.d. Cocktail: 300 mL/d commercial cranberry juice	Caution: Avoid use with oliguria and anuria. Patients with DM should use sugar-free cranberry juice; lactating patients, children <12 y, and patients with history of oxalate kidney stones limit to 1 L/day. H/D, H/F, H/H: None known	Doses of >3 L/day may produce diarrhea
dong quai Angelica Sinensis Class 2b (root) Roots, rhizomes	Phytoestrogen activity; vasodilation, small muscle relaxation Decreased IgE antibody production Uses: PMS, menopausal symptoms, cardiovascular support	Tea: 1-4 c/d (equivalent 1-2 g dried herb) Tincture: 0.5-4 mL, Max: 6 times a day	Caution: Avoid use with prescription anticoagulants, history of bleeding disorders, or if pregnant or at risk for breast cancer H/D: additive bleeding effect with anticoagulants, aspirin, NSAIDs	Rash and photosensitivity; fever, bleeding
echinacea (purple coneflower) E. purpura; E. angustifolia, E. pallida Class 1 (root/seed) Aerial parts of E. pallida; root of E. pallida and E. angustifolia	Stimulates immune system; antibacterial, antiviral, antipyretic Antifungal as topical Uses: Prevention and early treatment of colds and flu; recurrent respiratory, ear, and urinary tract infections Topical: Canker sores, fungal infections Investigational use: Stimulate immune system of HIV/AIDS patients.	Tab: 500 mg-1 g t.i.d. Tea: 1-5 c/d Tincture: max: 2 tsp t.i.d.	Short-term use: 2 wk; 8 wk if low dose; may be hepatotoxic if taken continuously Avoid use with immunosuppressants such as corticosteroids (may counteract) and with chronic systemic disease of immune system (e.g., SLE, HIV, TB, MS) Safety not determined in pregnancy, lactation, and children <2 y	Lozenge/tincture: Temporary numbness or tingling of tongue Cross-sensitivity in patients allergic to daisy family, GI upset, diarrhea
evening primrose Oenothera biennis Class 4 Oil of seed	Natural estrogen promoter Uses: PMS, problems with synthesis of fatty acids, abnormal prostaglandin production, diabetic neuropathies, chronic inflammatory conditions (eczema), overactive immune systems	Take with meals (increases absorption): Oil: PMS: 3-6 g/d for 6 mo, 14 days before menses Inflammatory conditions: 4-8 g/d for 3-4 mo MS: 500 mg/d for 3 wk with exacerbation	Avoid use if pregnant or lactating May lower seizure threshold if taken with anticonvulsants; anticonvulsant dose may need modification, or do not use concurrently H/F, H/H: None known	GI upset, nausea, headache, rash Immunosuppression with long-term use
feverfew Tanacetum parthenium; chrysanthemum parthenium Class 2b (whole herb) Leaves, flowering tops	Interferes with platelet aggregation, inhibits release of serotonin from platelets, blocks proinflammatory mediators, digestive relaxant Uses: Prevention and long-term management of migraine headaches; rheumatoid arthritis; menstrual problems; allergies	Cap/tab (at least 2% parthenolide) 125 mg/d; increase to 1-2 g with acute attack	May be 4-6 wk before effect; use continuously for best outcome Cross-sensitivity to plants in daisy family Avoid use if pregnant or lactating, with prescription anticoagulants, and in children <2 y Consult HCP before use if taking prescription NSAIDs (decreases effectiveness) May interfere with SSRI antidepressants (e.g., Prozac)	Possible gastric distress or mouth sores if using raw leaves; muscle stiffness; may have rebound headache if discontinued abruptly
garlic Allium sativum Class 2c Bulb	Detoxifies body and increases immune function; decreases platelet aggregation; increases HDL and decreases cholesterol and triglycerides, broad antimicrobial activity, mild antihypertensive; hypoglycemia Uses: Hypercholesterolemia, mild HTN, colds and flu	Caps (enteric coated): (ED of 5000 mcg/d of allicin in divided doses) Raw garlic clove is best source; minimum: 1/d	Avoid use if pregnant or lactating (may stimulate labor or cause infant colic) and in hypothyroidism Blood pressure may decrease in 30 min and return to baseline in about 2 hr Caution: Use with caution with prescription anticoagulants because of increased fibrinolysis and decreased platelet aggregation; modify antidiabetic doses H/F: None; H/H: Acidophilus decreases absorption of garlic	Heartburn, flatulence, gastric irritation, decreased RBCs; dizziness, diaphoresis
ginger Zingiber officinale Class 1 (fresh root) Class 2b/2d Dried root, rhizome	Stimulates digestion, increases bile and motility; antispasmodic; decreased platelet aggregation; decreases absorption and increases excretion of cholesterol; antioxidant Uses: Nausea, pregnancy morning sickness (short term, low dose ONLY); motion sickness; gastric protection with NSAIDs	Take with food Cap/tab/tea: 2-4 g in 2-3 divided doses For motion sickness, start 2 d to 2 hr before travel Inflammatory joint disease: 4 g in 2-3 divided doses Nausea (pregnancy related): 1 g in divided doses for 1-4 d Tincture: 1.5-3 mL in 8 oz juice q.i.d., PRN	Avoid long-term use with pregnancy, thrombocytopenia (abortifacient in large amounts) Caution: Use with caution with prescription anticoagulants (additive effect) Consult with HCP before use if have gallstones May increase absorption of all PO medications H/F, H/H: None known	May cause gastric discomfort if not taken with food; anorexia
Ginkgo biloba Gingko folium Class 1 (leaf) Leaves	Antioxidant; peripheral vasodilation and increased blood flow to CNS, reduces platelet aggregation Uses: Allergic rhinitis, Alzheimer’s disease, anxiety/stress, dementia, Raynaud’s disease, tinnitus, vertigo, impotence, poor circulation; altitude sickness	Cap/tab: 120-240 mg/d in 2-3 divided doses (standardized to at least 24% ginkgo flavone glycosides and 6% Terpene lactones) Tincture: 5-10 mL b.i.d., t.i.d. Circulation/memory: 120 mg/d in 2-3 divided doses Alzheimer’s dementia, tinnitus: up to 240 mg/d in 2-3 divided doses	Effects seen in 2-3 wk; 12-wk course recommended Avoid use if pregnant or lactating, in children, and with MAOIs Caution: Use with caution with prescription anticoagulants; monitor bleeding and prothrombin times. Use with extra caution if using ginger, garlic, or feverfew May increase BP if used with thiazide diuretics Discontinue use 2 wk before surgery Ginkgo fruit may result in severe rash; seeds are toxic H/F, H/H: None known	Initially, mild transient headache that usually stops in 2 d; mild gastric distress Toxicity: vomiting, diarrhea, dermatitis, irritability
ginseng, eleuthera, or Siberian Eleutherococcus senticosus, Acanthopanax senticosus Class 2b/2c/2d Root	Supports adrenal glands, enhances energy levels by inhibiting alarm phase SNS response, stimulates RBC production, decreases blood sugar levels, protects from cellular mutation from carcinogens Uses: Cold and flu prevention, adaptation to stress, chronic fatigue syndrome, SLE, HIV, mental fatigue and physical exhaustion, following chemotherapy or radiation treatments, recovery from chronic or long-term illness	Cap/tab: 2-3 g/d in 3-4 divided doses Tea: 1-4 c/d Tincture: 5-20 mL/d in 3-4 divided doses	Take for 6-8 wk; then 1 wk drug holiday, and resume for total of 3 mo Avoid use with BP >170/90, if pregnant or lactating, in children, and with bipolar or psychic disorders, DM, and anticoagulants (may increase or decrease anticoagulants, dependent on species) May increase effects of caffeine and HRT, falsely elevate digoxin levels, and interact with antipsychotic drugs H/F: Overstimulation may occur with caffeinated coffee, cola, and tea; H/H: None	Hypertension, palpitations, occasional diarrhea, possible insomnia if taken at bedtime Ginseng abuse syndrome: Edema, insomnia, hypertonia; may be life threatening
goldenseal Hydrastis canadensis Class 2b Root, rhizome	Stimulates immune system and bile secretion, antipyretic, broad-spectrum antibiotic activity Uses: For infection: respiratory, digestive, urinary tract, mucous membranes, cholecystitis, cirrhosis	Cap/tab: 2-4 g/d in divided doses (standardized to 8%-12% alkaloid content)	Avoid use if pregnant or lactating, with HTN, and in children Higher dosing >5-7 d may increase liver enzymes or malabsorption of B vitamins May decrease effect of heparin, anticoagulants, cardiac glycosides; increased effect of antiarrhythmics, antihypertensives, beta blockers, and CNS depressants Caution: Use with caution in patients with cardiovascular disease, DM, or glaucoma	High doses may be hepatotoxic Toxicity: CNS depression, restlessness, seizures, cardiovascular collapse Endangered plant species
hawthorn Crataegus laevigata, C. oxycantha, C. monogyna Class 1 Ripe fruit, leaves, flowers	Peripheral dilation and increased coronary circulation, improves cardiac oxygenation, antioxidants, mild diuretic, decreases proinflammatory substances Uses: Mild HTN, early HF, stable angina	Cap/tab: 100-900 mg/d in divided doses (standardized to 20% procyanidins) Average dose: 100-250 mg t.i.d. Tea: 2.5-5 mL t.i.d. Tea: 1 c t.i.d. (4-5 g dried/day)	May need to modify doses of beta blockers, digitalis, and ACE inhibitors Increased effects of digitalis, beta blockers, ACE inhibitors, and CNS depressants High doses contraindicated with chronic atrial fibrillation and hypotension from dysfunction of valve H/F: None known; H/H: increases action of Lily of the Valley	Hypotension, fatigue Sedation, nausea, vomiting, anorexia
kava Piper methysticum Class 2b/2c/2d Dried rhizome, roots	CNS sedation without loss of mental acuity or memory Uses: Anxiety, insomnia, skeletal muscle spasm Good with psychotic disorders, no risk of tolerance	Cap/tab: Anxiety: 50-100 mg up to t.i.d. Insomnia: 180-210 mg at bedtime (standardized to 70% kavalactones) Max: 300 g/wk	Avoid use if pregnant or lactating, with parkinsonism, and if taking levodopa; not for young children Avoid alcohol use and if patient needs to be alert or will operate machinery Increases CNS-sedating drugs, especially benzodiazepines Fat soluble, so may have delayed effects H/F: increased absorption when taken with food; H/H: None known Unstable gait, numb tongue, mild GI upset	Leaf: Long-term higher doses (in animals): anemia, icterus, excitation, death High doses: may cause loss of balance, pulmonary hypertension May cause liver toxicity Banned in several European countries Use >3 mo may turn skin yellow: discontinue drug if HTN, headache, weakness
licorice Glycyrrhiza glabra Class 2b/2c/2d (root) Root, leaf	Antiinflammatory, antibacterial, antiviral, hepato- and gastric-protective, antidepressant, estrogenic, laxative Uses: Viral infection, upper respiratory infection, inflammation, Addison’s disease, depression, ulcers Topically: Herpes, psoriasis, eczema DCL: IBS, mouth ulcers	Cap/tab: 200-600 mg glycyrrhizin in 3 divided doses; max: 4-6 wk Tea: 3 c/d (equivalent to 1-2 g/d) Tincture: 2.5-5 mL t.i.d. DGL: 300-380 mg; max: 1200 mg/d in chewable form 20 min before meals for 8-16 wk	Avoid use if pregnant or lactating, with HTN, with kidney or liver disorders, or if at risk for hypokalemia; avoid in children Caution with DM Increased aldosterone effect with increasing dose and duration Antagonizes antihypertensive drugs and spirolactone Potentiates corticosteroids and digitalis H/F: none known; H/H: may cause hypokalemia if used with aloe vera	Doses >5000 mg/d result in aldosterone-like syndrome that reverses when herb is discontinued
milk thistle (Mary thistle, wild artichoke) Silybum marianum Class 1 Seeds of dried flowers	Increased regeneration of liver cells; increases antioxidant activity Uses: Liver disease (hepatitis), cholecystitis, psoriasis	Cap/tab: Initially: 500 mg/d in 3 divided doses for 6-8 wk With improvement: 120-240 mg/d in divided doses; may take 7-10 d for effect; 4-8 wk if liver is diseased with alcohol Tincture: 1 mL t.i.d. (avoid ETOH-based tinctures)	Avoid use if pregnant or lactating, in children, and with drugs metabolized by P-450 enzyme Does not reverse cirrhotic liver changes, but may slow the disease and increase quality of life H/F, H/H: None known	Diarrhea first days of therapy, nausea, vomiting, menstrual changes
peppermint Mentha piperita, var. officinalis or vulgaris Class 4 Aerial parts	Antispasmodic, increase bile flow, carminative, external analgesic Uses: IBS, indigestion, cholecystitis, infant colic, nasal decongestant Topically: Musculoskeletal pain, itching, colds	Cap/tab: enteric coated: 1-2 t.i.d. between meals Tea: 2-3 c/d (equivalent 3-6 g dried herb) Tincture/oil: 6-12 gtts/d diluted in divided doses	Consult HCP before taking if have cholecystitis or obstructed bile duct No known drug interactions; may interfere with iron absorption	None known
psyllium Plantago psyllium Class 4	Uses: Laxative, treatment of hemorrhoids, colitis, Crohn’s disease, IBS Herb of longevity, poultice: wound healing effects	tsp soaked in water for 15-60 min at bedtime with at least 8 oz water PO extract: 1-4 mL t.i.d.	Major ingredient in Metamucil May decrease lithium absorption Avoid use if pregnant or lactating, and in children	None known
sage Salvia officinalis Class 2b/2d (leaf) Whole plant	Gargle tea for sore throat, dries up mother’s milk, decreases hot flashes Antidepressant and antiviral activity	Take with food Cap/tab: (standardized to at least 0.1% hypericin) 300 mg t.i.d.	Limit use to 2 wk to avoid toxic effects of tannins Caution patients with DM and seizure disorders	Nausea, vomiting, anorexia, oral irritation
St. John’s wort Hypericum perforatum Class 2d Flowers	Uses: Mood swings, mild to moderate depression, anxiety, sleep disorders Topically: Burns/wounds	Tea: 1-2 c/d for 4-6 wk Tincture: 1-2 mL t.i.d.	Long-term use recommended; effects seen in 4-8 wk Avoid use if pregnant or lactating; with prescription antidepressants, MAOIs, and indinavir; and in children <2 y May decrease effect of digoxin related to bioavailability Monitor serum digoxin levels Use with amphetamines, trazodone, or tricyclic antidepressants may cause serotonin syndrome Interferes with absorption of iron and other minerals; high doses may increase liver enzymes	Skin photosensitivity, headache, occasional GI upset, dry mouth, dizziness, confusion
saw palmetto Serenoa repens, Sabal serrulata Class 4 Berries	Decreases size of prostate; increases breakdown of estrogen, progesterone, and prolactin: antiandrogenic Diuretic Uses: BPH, chronic cystitis; sexual potency	Cap/tab: 230 mg/d in 1-2 doses (standardized to 85%-95% fatty acids) Tea: 1 c t.i.d. (equivalent dose 1-2 g/d) Liquid extract: 5-6 mL daily	Recommend 45-90 d of treatment; effects seen after 30 d. If effective, may take long term Avoid use if pregnant or lactating, in children, and in patients with breast cancer Effectiveness of prophylactic treatment not shown May interfere with PSA test; discontinue use 1-2 wk before test May increase or decrease effects of antiinflammatories and immunostimulants; may antagonize hormone therapy	Headache, dysuria, back pain Gastric disturbance (rare)
valerian Valeriana officinalis Class 1 Root	Sedative/hypnotic, antispasmodic, increases deep sleep Uses: Insomnia, stress headaches, mild anxiety, muscle cramps and spasms	Cap/tab: (standardized to 0.5% essential oils, equivalent to 2-3 g up to b.i.d.) Tea: 1-3 c/d or at bedtime Tincture: 1-3 mL; may repeat 2-3 times over 6 h	Effects may take several doses For long-term use; monitor liver function, and discontinue use if elevated Avoid if pregnant or lactating, in children, and with prescription sedative/hypnotics, MAOIs, and anticoagulants Increased sedative effect with barbiturates; negates effects of phenytoin Foul smell; no dependence or tolerance	Anxiety, headache, occasional GI upset and hangover effect with high doses, CNS depression

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Oct 8, 2016 | Posted by admin in NURSING | Comments Off

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