On completion of this chapter, the reader will be able to: 1. Identify the legal standards that affect herb and supplement use. 2. Describe the altered effects of herbs and supplements on the older adult. 3. Discuss the information that older adults should know about the use of select herbs and supplements. 4. Discuss the role of the gerontological nurse when assisting the older adult who uses herbs and supplements. 5. Describe the effects of select commonly used herbs and supplements on the older adult. 6. Develop a nursing care plan to prevent adverse reactions related to herb or supplement use. 7. Identify the important aspects of client education related to the use of herbs and supplements with the older adult. 8. Describe the effects of herbal supplements on the older adult with chronic disease. 9. Describe the effects of herbal supplements on the older adult who is experiencing altered health conditions. Herbs and other supplements have been used by humans for thousands of years to treat illness, but during most of the past century in the United States, they took a back seat to the burgeoning increase in prescription and over-the-counter (OTC) products available. The use of herbs and supplements resurged in the 1990s, and they now make up one of the largest groups of alternative pharmaceuticals used by millions of Americans, especially those 65 years of age or older (Yoon and Schaffer, 2006; Bardia et al., 2007; Cheung et al., 2007; R. Nahin et al., 2009). The 2007 National Health Interview Survey (NHIS) estimated that about 38% of American adults use these and other forms of complementary and alternative medicine (CAM), spending $33.9 billion (no prescription coverage) for those CAM services and products and $14.8 billion for nonvitamin–nonmineral natural products (R.L. Nahin et al., 2009). Several popular examples of nonherbal supplements used by older adults are melatonin for sleep; coenzyme Q10, sometimes advised for cardiac strengthening; glucosamine for painful, arthritic joints; and saw palmetto for prostatic hypertrophy. Herbs are considered dietary supplements. Yeh and colleagues (2006) reported on the 2002 National Health Interview Survey that examined the use of complementary and alternative medicine (CAM) for cardiovascular disease. The most common CAM therapies used were herbal and mind–body therapies. Echinacea, garlic, ginseng, Ginkgo biloba, and glucosamine with or without chondroitin were the herbs/supplements used most often. Wold and colleagues (2005), studying medication and supplement records of men and women ages 60 to 99 years, found glucosamine to be the most frequently used supplement with ginkgo, chondroitin, and garlic following. Women favored over time such supplements as black cohosh, evening primrose, flaxseed oil, chondroitin, ginkgo, glucosamine, grape seed extract, hawthorn, and St. John’s wort. Men were partial to α-lipoic acid, ginkgo, and grape seed extract. Weng and associates (2004), surveying 318 people in a retirement community, found that 20% of both men and women used herbal supplements, and most (97%) used vitamin and mineral supplements. More than half said that they received information related to supplement use from physicians or nurses. In most studies, women are the majority responders. Cheung and colleagues (2007) found that 62.9% of 445 community-dwelling older adults used CAM—28.3% used megavitamins and 20.7% used herbals. Yoon and Horne (2001), studying for one year community-dwelling women 65 years of age and older, found that more than 40% used an average of 2.5 herbs; 85% of these herbal remedies were used continually. In addition, the study noted that these women used an average of 3.2 prescribed medications and 3.8 OTC supplements and medications. Typically, the women did not tell their health care providers about the use of such alternative therapies. This finding has been supported by other research (Cheung et al., 2007). A large national survey found that 49% of older adults taking herbs never reported them to the provider (Bruno and Ellis, 2005), and 50% were found in another. Persons over 50 years of age may be more likely than younger persons to share information about their use of supplements with their providers (Durante et al., 2001; Israel and Youngkin, 2005). In a study of older persons with a mean age of 84.8 years who lived in assisted living facilities in the states of Oregon and Washington, 84.4% were using self-prescribed OTC medications and dietary supplements (Lam and Bradley, 2006). Nutritional supplements (vitamins and minerals) were used by 32%, gastrointestinal products by 17%, products to relieve pain by 16.3%, and herbal products by 14.4%. Other products used included topicals and cough and cold drugs. For 51% of the participants, what we call “misuse” occurred through duplication of the active ingredients, the occurrence of drug–illness–food interactions, and inappropriate use. Most thought the products were helping them. In a study of the perceptions of older users and nonusers of herbal supplements, many believed that they are derived from harmless “natural” plants or substances and therefore were not concerned about, or aware of, any dangers (Snyder et al., 2009). A small 2009 study of older persons’ use of herbal supplements found that 55% used herbal supplements, and that 95% of these as well as 75% of nonusers generally believed them to be safe because they could be bought OTC in many places and were natural (Snyder et al., 2009). Those who used herbal supplements perceived supplements to be safe and were not as satisfied with their medical care as those who did not use herbal supplements (Shahrokh et al., 2005). Herbs and supplements are likely to be used by persons in all ethnic groups. Of 130 older adults (mean age, 71.4 yr) living along the United States–Mexico border, 38.5% were taking five or more drugs (prescription and dietary supplements) daily; 31.5% were at risk for drug interactions (Loya et al., 2009). Zeilmann and associates (2003) studied white Hispanic and non-Hispanic adults 65 years of age and older and reported 49% herb use within the past year. A 1999 to 2000 National Health and Nutrition Examination Survey assessed the prevalence of dietary supplement use (Radimer et al., 2004). Non-Hispanic white, older, normal-to-underweight women with more education were found to use supplements more than any other racial/ethnic, age, or gender groups. Yoon (2006) found no differences in reported herb use between white American and African-American women 65 years of age and older. There was a significant association between the number of herbs and number of nonprescribed medications used, and their use seemed intended to be complementary to, rather than a replacement for, prescribed therapies. A study of 95 urban older African Americans’ use of CAM found that 29.5% used herbs and home remedies (Ryder et al., 2008). Although most subjects in this study (77.3%) disclosed their use of herbs/home remedies to their health care providers, the researchers nonetheless urged providers to probe for persons’ use of alternative therapies (Ryder et al., 2008). The increasing use of herbs and supplements by older adults is related to their hopes of preventing illness, promoting and maintaining health, treating a particular health problem, or replacing some currently missing dietary component (Eskin, 2001; Yoon and Horne, 2001; Yoon et al., 2004; Bruno and Ellis, 2005; Cheung et al., 2007). Elders with chronic conditions and symptoms of a health problem are more likely to use supplements and herbs in addition to their traditional therapies (Stupay and Sivertsen, 2000; Cheung et al., 2007; Ryder et al., 2008). People perceive that such products will give them more control of their health and bodies. Gerontological nurses must anticipate that older persons may use a variety of alternative therapies, including herbs and supplements, in addition to prescribed and OTC drugs. The nurse has a significant obligation to ask the right questions and obtain specific information related to use—reason, form, frequency, duration, dose, any side/adverse effects, plans for continuing, and communication with providers about use. Before 1962 all herbs were regarded as medications. In 1962 the U.S. Food and Drug Administration (FDA) required that all products considered “medications” be evaluated for safety and efficacy, yielding standardization between manufacturers of the same product. The role of the FDA also expanded to that of monitor. In response, herbal manufacturers declared their products as “food” and therefore not subject to FDA regulations (Youngkin and Israel, 1996). In 1994 some regulation was placed over herbs through the Dietary Supplement Health and Education Act (DSHEA), and they were reclassified as “dietary supplements.” By regulation, herbs and other supplements may not be labeled for prevention, treatment, or cure of a health condition of any kind unless the claim has been substantiated by research and recognized by the FDA. Of all the identified herbs, only a handful are FDA approved, such as aloe, psyllium, capsicum, witch hazel, cascara, senna, and slippery elm. Nevertheless, any herb may be hazardous if improperly used, and all adverse events must be reported to the FDA. Only then it will be investigated for possible removal from the market (Allen and Bell, 2002). Because herbs are not typically under the protection of patent laws, companies have been less inclined to participate in clinical trials to determine their effectiveness, although the market for herbs and supplements is growing so fast that some companies now are conducting more scientific study of their safety and efficacy. However, the lack of consistency among the methods different companies use to produce herbal products makes analytical analyses of them difficult (Allen and Bell, 2002). Despite the fact that few dietary supplements are FDA approved, not every such product is unsafe or ineffective for use (Israel and Youngkin, 2005). The World Health Organization (WHO, Geneva, Switzerland) and regulatory agencies of individual countries across the world are answering the call for safety and efficacy information based on scientific evaluation (Blumenthal et al., 2000; Israel and Youngkin, 2005). Increasing and valuable scientific information is available to consumers from numerous sources, such as from the National Center for Complementary and Alternative Medicine (NCCAM, Bethesda, MD); however, more systematic scientific trials and reviews are needed. Thus the consumer must be alert to possible adverse effects and risks from use. Risks include the product containing the wrong parts of the herb, containing no or so little active ingredient that it is ineffective, or being adulterated with one or more unaccounted-for substances that may be dangerous. Mixed herbal supplement therapies, such as some weight loss products, can cause hazardous effects on blood pressure and heart rate and rhythm and can be particularly risky because actually determining what the product contains may be difficult. For example, bitter orange (Citrus aurantium) was used to replace ephedra in many weight loss products after its removal from the general market by the FDA in 2004, but bitter orange has synephrine (epinephrine-like) effects that can lead to cardiac arrest and ventricular fibrillation, and thus is unsafe for use (Swanson, 2006). Different parts of an herb may have uses and actions that are unrelated. The bulb of the garlic plant contains the active essence, whereas the leaf of chamomile is used (Israel and Youngkin, 2005). Herbs are manufactured in several forms; most popular are capsules, extracts, oils, tablets, salves, teas, and tinctures. Efficacy varies depending on the form of the herb that is used and how it is prepared. An extract is a fluid or solid form of the herb that is concentrated. It is made by mixing the crude herb with alcohol, water, or some other solvent that is then distilled or evaporated (Libster, 2002; Skidmore-Roth, 2005). Oils are found in two forms. Essential oils are aromatic, volatile, and can be derived from various parts of the fresh plant. To be therapeutic, they are usually diluted. Infused oils, on the other hand, are developed when the volatile oil of one herb is mixed with that of another. Herbal oils are often used in massage therapy or aromatherapy (Libster, 2002; Skidmore-Roth, 2005). When an herb is soaked in water, alcohol, vinegar, or glycerin for a specific time and the liquid is then strained to dispose of the plant remains, a tincture is formed. The liquid is used therapeutically at a concentration of 1 : 5 or 1 : 10 (Libster, 2002; Skidmore-Roth, 2005). A salve is a type of ointment—a semisolid substance that is used topically. Salves and ointments can be purchased or prepared by “simmering two tablespoons of the herb in 220 grams of a petroleum-based jelly for about ten minutes” (Eliopoulos, 1999, p. 103) or by using herb-infused oil or plain oil with drops of the essential oil or some other wax base and the essential oil (Libster, 2002). The consumer should know that teas are both foods and herbs, are not regulated, may be highly concentrated if grown at home, and may be mixed with other substances—a good reason to always check labels. Tea is consumed by millions around the world, second only to water, and newly reported research indicates that some teas may have very positive effects, especially related to cardiovascular disease. Researchers found that drinking three cups of green tea daily was associated with a decreased mortality risk (Kuriyama et al., 2006). Women and nonsmokers seemed to benefit the most from green tea. Animal studies suggest that green tea antioxidants may offer eye tissue protection (Chu et al., 2010); antioxidants in tea and raspberry juice may decrease plaque formation and help decrease the risk of atherosclerosis (Rouanet et al., 2009); and tea alone may lower serum cholesterol levels (Singh et al., 2009). Drinking green tea has also been associated with a decreased risk of some cancers, such as prostate cancer in men and breast and stomach cancers in women (Boehm et al., 2009; Inoue et al., 2009; Shrubsole et al., 2009). Consuming more than four cups of tea daily was associated with a reduced risk of type 2 diabetes in adults (Huxley et al., 2009), and drinking more than four cups of green tea daily was associated with a reduced risk of depression in adults 70 years of age and older (Niu et al., 2009) and in breast cancer survivors (Chen et al., 2010). The consumer needs to remember that tea is generally safe but in excess may be harmful. For instance, senna leaf tea may cause serious fluid and electrolyte imbalance effects if used in excess and for a prolonged period (Israel and Youngkin, 2005). Consumption of more than the recommended amounts of certain teas may cause illness and possible death. For example, comfrey tea has been linked with serious liver disease (Youngkin and Israel, 1996), and drinking very hot tea too fast is associated with an increased risk of esophageal cancer (Islami et al., 2009). Chamomile (Matricaria recutita or Chamomilla recutita), also known as German chamomile or Hungarian chamomile,) is usually taken in tea form (Jellin, 1995-2011a). Its many uses include as an antiinflammatory and antispasmodic (said to relax smooth muscle), and to relieve gastrointestinal upset, sleep disorders, and anxiety (Israel and Youngkin, 2005; Natural Standard [a], 2010). Srivastava and associates (2009) found that chamomile extract operates similarly to a nonsteroidal antiinflammatory. A University of Pennsylvania study showed that chamomile use was associated with a reduction in anxiety symptoms as compared with a placebo (Amsterdam et al., 2009). When combined with several other herbs, including peppermint leaf, this type of chamomile is associated with improvement in dyspepsia (acid reflux, pain in the epigastrium, nausea, cramping, vomiting). However, chamomile use has mixed, less clear, and inadequate scientific evidence of value (Basch and Ulbricht, 2005; Natural Standard [a], 2010). In large doses it may cause gastrointestinal (GI) upset, and contact dermatitis and hypersensitivity reactions have been reported. It should be used cautiously with persons who report allergies to ragweed, asters, or chrysanthemums, as life-threatening allergic reactions are reported (Natural Standard [a], 2010). Use with benzodiazepines and other sedative-causing drugs is not advised, and it may inhibit some cytochrome P450 substrates. Taking it with warfain may increase warfarin’s effect and increase the risk of bleeding. Chamomile capsules or tablets taken alone are in divided oral doses of 400 to 1600 mg daily or, if used as a tea, one to four cups daily made from tea bags is suggested (Basch and Ulbricht, 2005; Natural Standard [a], 2010). Echinacea (Echinacea angustifolia, E. purpurea, E. pallida), also known as Sampson root and purple coneflower, is used for the prevention and treatment of upper respiratory infections. The E. purpurea variety is suggested as best for upper respiratory infection therapy (Natural Standard [b], 2010). Annual U.S. sales reported by Jellin (1995-2011b) were about $20 million, second only to garlic. Study results indicate that echinacea decreases the risk of developing the common cold and decreases the duration of a cold by at least 1 day (Shah et al., 2007; Natural Standard [b], 2010). Using the purple coneflower extract when a cold first begins and before symptoms become “full-blown” reduced the incidence of colds by 58% and the duration by 1.4 to 1.9 days (Kerr, 2006; Natural Standard: News [b], 2010). Jellin (1995-2010b) indicates modest improvement with the use of this herb at the start of symptoms; Natural Standard: News [a] (2010) and Natural Standard [b] (2010) indicate mixed scientific findings for prevention and treatment. Echinacea seems to have immune-stimulant qualities but significant benefits are unclear (Natural Standard [b], 2010). Some adverse reactions including fever, sore throat, allergic reactions, diarrhea, nausea and vomiting, and abdominal pain have been reported, but side effects for most (if the drug is taken as directed and indicated) are few (Jellin, 1995-2011b); Natural Standard [b], 2010). Persons allergic to daisy family plants or who have human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or an autoimmune disease should use this herb with caution. It may interfere with the clearance of drugs eliminated by CYP3A or CYP1A2 in the liver (Gorski et al., 2004). Combining echinacea with acetaminophen and other drugs or herbs that could cause liver damage is discouraged because it may cause liver inflammation (Natural Standard [b], 2010). It is available commercially as capsules, tea, juice, extract, and tincture. If taken in capsule form, 500 to 1000 mg orally for five to seven days is used commonly in research (Natural Standard [b], 2010). Consumed as a tea, the dose ranges from 0.3 to 1 g (Scorza, 2002; Israel and Youngkin, 2005). In tablet form, it is advised three times daily and should contain 6.78 mg of the crude extract when the herb content equals 95% (Jellin, 1995-2011b). Begun at the first sign of a cold or flu, it is taken up to 10 days and should not be continued longer than the package directions advise (Basch and Ulbricht, 2005; Israel and Youngkin, 2005; Jellin, 1995-2011b). Garlic (Allium sativum bulb), known by names such as clove garlic and camphor of the poor, is thought to protect against stroke and atherosclerosis. Composed of more than 200 chemicals, a sulfur called allicin is thought to be garlic’s primary active health ingredient (Anonymous, 2006). When the garlic clove is crushed, chewed, or chopped, allicin is released. Benefits of garlic are reported to be many, but scientific evidence is mixed (Basch and Ulbricht, 2005; Jellin, 1995-2011c; Natural Standard [c], 2010). Use is associated with decreased blood clots. It has been shown to reduce low-density lipoprotein (LDL) cholesterol, but its impact on high-density lipoprotein (HDL) cholesterol is not clear (Basch and Ulbricht, 2005; Natural Standard [c], 2010). Two meta-analyses showed that garlic use reduces blood pressure in persons with hypertension (Ried et al., 2008; Reinhart et al., 2008). Garlic may have some anticancer activity, particularly gastrointestinal (Anonymous, 2006; Natural Standard [c], 2010), and has been associated with lowered blood glucose in animal studies but unclear results in humans (Natural Standard [c], 2010). Possible adverse reactions include allergic reactions (sometimes severe), increased flatulence, bleeding if taken with drugs or supplements with anticoagulant properties or specific heart drugs, and upper GI irritation with nausea and heartburn, the latter of concern in persons with ulcers or acid reflux (Anonymous, 2006; Natural Standard [c], 2010; Tachjian et al., 2010). Some drugs metabolized by the CYP450 system in the liver may be altered by garlic, and topical garlic preparations can cause skin irritation (Scorza, 2002; Natural Standard [c], 2010). There is no standard dose or accepted standard for which form is best—oil, powder, deodorized extract, or whole clove (Anonymous, 2006; Natural Standard [c], 2010). One suggested dose is dehydrated, noncoated powder, 600 to 900 mg divided into three doses daily (Natural Standard [c], 2010). Ginkgo (Ginkgo biloba leaf abstract), also known as maidenhair tree, fossil tree, and wonder of the world, comes from the oldest living tree species (Waddell et al., 2001; Jellin, 1995-2011d). It is prepared in capsule, extract, tablet, and tea form. The usual dose varies depending on its purpose and administered in two or three oral divided doses (Jellin, 1995-2011d; Natural Standard [d], 2010). EGb 761 is the active ingredient (Anonymous, 2003). Many studies, often very small, have examined ginkgo use for innumerable problems ranging from vertigo, tinnitus, macular degeneration, depression, altitude sickness, to acute hemorrhoids but adequate scientific evidence to support its use for such concerns is unclear and inconsistent (Natural Standard [d], 2010). It is widely believed that ginkgo has positive cognitive events, including attributions that it can be used to treat dementia. Researchers studying data from multiple clinical trials of healthy subjects to learn whether Ginkgo biloba improves cognitive functioning found no scientific evidence to support use in healthy subjects for any reason related to cognitive function (Canter and Ernst, 2007). A large randomized, double-blind, placebo-controlled clinical trial—the Ginkgo Evaluation of Memory (GEM) Study—was conducted over 6.1 years (2000 to 2008) with more than 3000 seniors ages 73 to 96 years in many academic medical centers with funding from the National Center for Complementary and Alternative Medicine (R. Nahin et al., 2009; NCCAM [a], 2010). GEM Study data analysis of ginkgo versus placebo also found no scientific evidence that ginkgo impacted cognitive impairment, memory, attention, language, visual–spatial ability, and executive functions or reduced prevalence of dementia and Alzheimer’s disease. Blood pressure was not different between ginkgo and placebo users nor did heart attack, stroke, or mortality occurrences differ (NCCAM [b], 2010). A positive finding from a small component of the GEM Study is that peripheral arterial disease (PAD) improved in the ginkgo versus placebo users (R. Nahin et al., 2009; NCCAM [c], 2010). A Cochrane Database review (Birks and Grimley Evans, 2009) also countered the previously described findings, noting that there is no predictable, reliable evidence that is clinically significant of the herb benefiting persons with cognitive decline or dementia. In this review, the herb seemed safe without excess side effects when compared with placebo. Use of ginkgo is generally tolerated well in research trials (comparable to placebo). However, ginkgo is implicated as causing dangerous interactions with heart medications (Tachjian et al., 2010). One of the more serious side effects of ginkgo use is bleeding (Natural Standard [d], 2010). Persons taking drugs that increase bleeding risk or who have bleeding disorders should take ginkgo with caution and with provider oversight, and report any abnormal response such as bleeding, bruising, dizziness, headache, and blurred vision (Kuhn, 2002). Pre-surgery, ginkgo needs to be stopped according to surgeon directions, generally at least one week or more before the surgery to prevent excessive bleeding during and after surgery. Many other herbs increase the risk of bleeding, such as Panax ginseng, ginger, and garlic (Kuhn, 2002; Natural Standard [d], 2010). Some of the reported side effects of ginkgo include GI upset, headache, hypersensitivity, palpitations, dizziness, muscle weakness, and constipation (Israel and Youngkin, 2005; Jellin, 1995-2011d; Natural Standard [d], 2010). Possible significant interaction effects of ginkgo are reported with certain prescribed drugs (e.g., warfarin, heparin, monoamine oxidase [MAO] inhibitors), OTC drugs (e.g., aspirin, NSAIDs), herbs (e.g., St. John’s wort), supplement drugs (melatonin), to name only a few, and some health conditions are worsened by its use. Ginkgo seeds can be toxic, and consumption may lower the seizure threshold (Allen and Bell, 2002; Jellin, 1995-2011d; Natural Standard [d], 2010). Nurses must carefully assess persons taking ginkgo for complications. American Ginseng (a Chinese perennial herb), and variations such as Asian ginseng, Chinese ginseng, and Korean ginseng, may be of special interest to older adults. It has had numerous applications over thousands of years’ use, but is best known for its use to improve well-being and help with stress adaptation, although research results are mixed (Jellin, 1995-2011e; Natural Standard [e], 2010). Ginseng may benefit persons with heart disorders by reducing LDL cholesterol, lower blood sugar levels in type 2 diabetes, and enhance the immune system, but more research is needed in these areas (Basch and Ulbricht, 2005; Jellin, 1995-2011e; Natural Standard [e], 2010). Research support for the belief that ginseng is possibly effective in improving mood in postmenopausal women and some cognitive functions (such as abstract thinking, math skills, and how quickly one reacts) is not strong; it is not effective in improving memory as a single-use product (Natural Standard [e], 2010). It is associated with improvement in erectile dysfunction in some men (Hong et al., 2002; Natural Standard [e], 2010). For all applications, more controlled studies are recommended. Ginseng root provides the most active constituents, ginsenosides or panaxosides, but contains other constituents that may also play a role (Jellin, 1995-2011e). The most common preparations are capsules, extracts, teas, and tinctures. Dosages vary with the type of ginseng, the preparation, frequency of consumption, and strength of dose. For example, 100 to 200 mg of standardized ginseng extract (4% ginsenosides) in capsule form taken orally once or twice daily for up to 12 weeks is reported (Natural Standard [e], 2010). Side effects are many (Box 10-1). Persons with hypertension, cardiac problems, or diabetes must use ginseng with significant caution. Ginseng can increase blood pressure (Tachjian et al., 2010) and may interact with other medications and products (Table 10-1). Persons who have had strokes may have increased bleeding if they take ginseng and blood-thinning medications at the same time (Lee et al., 2008). Allergic reactions are reported in people allergic to plants in the Araliaceae family. TABLE 10-1 SELECT HERB–MEDICATION INTERACTIONS*
The Use of Herbs and Supplements
Use of Herbs and Supplements in the United States
http://evolve.elsevier.com/Ebersole/TwdHlthAging
Standards in Manufacturing
Herb Forms
Teas
Select Commonly Used Teas, Herbs, and Supplements
Chamomile
Echinacea
Garlic
Ginkgo biloba
Ginseng
HERB
MEDICATION
COMPLICATION
NURSING ACTION
Garlic
Any anticoagulant or antiplatelet drug such as warfarin sodium
Anticlot drugs such as streptokinase
Aspirin, other NSAIDs
Risk of bleeding may increase
Advise person not to take without provider approval
Antihypertensives
Increased hypotensive effect
Advise provider approval with use
Antivirals, such as ritonavir
Altered drug effect
Advise against use
Antimetabolites such as cyclosporine
Risk of less effective response
Advise against use
Insulin or oral hypoglycemic agent such as pioglitazone or tolbutamide
Serum glucose control may improve; less antidiabetic drug needed
Monitor blood glucose levels
Ginkgo
Aspirin, other NSAIDs
Heparin sodium, warfarin sodium, any anticoagulant
Antiplatelet drugs such as ticlopidine
Risk of bleeding may occur
Teach person not to take without approval of provider
Antidiabetic drugs: insulin, oral DMT2 drugs such as metformin
May alter blood glucose levels
Monitor blood glucose closely
Antidepressants, MAOIs, SSRIs
May cause abnormal response or decrease effectiveness
Advise not to take with these drugs
Antihypertensives
May cause increased effect
Monitor blood pressure
Antiseizure drugs
Risk for seizure if history of seizure
Advise against use
Ginseng
Insulin and oral antidiabetic drugs
Blood glucose levels may be altered
Monitor blood glucose levels closely
Anticoagulant and antiplatelet drugs
Aspirin and other NSAIDs
May increase bleeding
Advise use with caution and provider oversight
MAOIs such as isocarboxazid
Headaches, tremors, mania
Advise against use
Antihypertensives, cardiac drugs such as calcium channel blockers
May alter effects of drug
Advise against use unless provider monitors closely
Immunosuppressants
May interfere with action
Advise against use
Stimulants
May cause additive effect
Advise against use
Fenugreek
Decreased blood glucose
Monitor closely
Green tea
Warfarin sodium
May alter anticoagulant effects
Advise against use
Stimulants
May cause additive effect
Advise to use with care
Hawthorn
Digoxin
May cause a loss of potassium, leading to drug toxicity
Monitor blood levels
β-Blockers and other drugs lowering blood pressure and improving blood flow
May be additive in effects
Monitor blood pressure meticulously; advise that this concern holds true for erectile dysfunction drugs also
Red yeast rice
Fibrate drugs; other cholesterol drugs
May cause additive effects
Avoid concomitant use
Drugs for diabetes management
May alter blood sugar levels
Monitor blood sugar carefully
Anticoagulants, antiplatelet drugs, NSAIDs
May increase risk of bleeding
Warn patient and monitor carefully
St. John’s wort
Triptans such as sumatriptan, zolmitriptan
May increase risks of serotonergic adverse effects, serotonin syndrome, cerebral vasoconstriction
Advise against use
HMG-CoA reductase inhibitors
May decrease plasma concentrations of these drugs
Monitor levels of lipids
MAOIs
May cause similar effects as with use with any SSRI
Advise against use
Digoxin
Decreases the effects of the drug
Advise against use
Alprazolam
May decrease effect of drug
Advise against use
Amitriptyline
May decrease effect of drug
Advise against use
Ketoprofen
Photosensitivity
Advise sun block use
Tramadol and some SSRIs
May increase risk of serotonin syndrome
Advise against use
Olanzapine
May cause serotonin syndrome
Advise against use
Paroxetine
Sedative–hypnotic intoxication
Advise against use
Theophylline
Albuterol
Increases metabolism; decreases drug blood level
Monitor drug effects
Warfarin
May decrease anticoagulant effect
Advise against use
Amlodipine
Lowers efficacy of calcium channel
Advise against use
Estrogen or progesterone
May decrease effect of hormones
Advise that this effect may occur
Protease inhibitors or nonnucleoside reverse transcriptase inhibitors in HIV/AIDS treatment; antivirals
May alter drug effects
FDA advises avoidance of this herb for patients taking these drugs 
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The Use of Herbs and Supplements
