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The Relationship of Drugs and Dietary Supplements

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Interactions between dietary supplements and drugs will become a more serious concern as supplement makers adopt better manufacturing practices. Some of these interactions are positive to the patients health, while others are not. Mary Hardy, M.D., is a member of the Integrative Medicine Department of Cedars-Sinai Medical Center in Los Angeles. According to Dr. Hardy. Once these substances are properly labeled, properly documented, and properly used by consumers, we can expect that their most serious interactions are likely to involve pharmaceutical drugs. Dr. Hardy believes. As pharmacists, you can look for the pharmacokinetic issues that will affect the bioavailability or metabolism of the drug. Also, pharmacodynamic interactions are more individualized, less predictable, and more qualitative.

Herbs can counteract a drugs therapeutic effect but, not all drug-herb counteractions are negative. Two examples of positive drug-herb interactions are seen with ginger and ginkgo biloba. Ginger is found to limit low-grade nausea related to chemotherapy. Ginkgo biloba can be used to treat sexual dysfunctions that are sometimes associated with the use of selective serotonin reuptake inhibitors (SSRIs).

Occasionally, herbs and drugs with entirely different mechanisms of action reinforce each other. A study has shown that ginseng is known to be hypoglycemic. Other high fiber hypoglycemic herbs can possibly reduce the absorption of carbohydrates in the intestines. Dr. Hardy emphasizes that the blood sugar levels of diabetic patients taking either type of herb and receiving insulin will need to be monitored more closely.

According to studies, St. Johns Wort has been shown to decrease the bioavailability of protease inhibitors. Protease inhibitors are the pharmaceuticals used to treat AIDS patients. In one study, the trough level observed in sixteen healthy patients declined 82% a level deep enough to allow for the emergence of resistant viruses in patients with active AIDS. Dr. Hart emphasizesThis is a clinically significant interaction, especially because St.Johns Wort has been shown in vitro to be highly active against HIV. HIV patients are very likely to take it and to use high doses.

An article printed in the August 2000 issue of Pharmacy Practice News reports that some herbs can change the level of drug absorption, either by increasing binding or by precipitating the drug in the gut. For example, hydrocoilldal fiber herbs such as fenugreek, slippery elm, or even psyllium and bran can change absorption levels. Dr. Hardy also points out the reality of double-dipping. Herbs that share the same active ingredients as a drug can enhance its therapeutic action. Combinations such as ma huang and cold remedies containing pseudoephedrine, or foxglove and the cardioglycoside digoxin are like double-dipping.

Even if the herbs and drug do not contain the same active ingredients, doubling can happen. A drugs effect can be intensified if both the drug and the herb share the same mechanism of action. If a patient is taking a barbiturate and adds valerian to the diet, then the patient is reinforcing the drugs sedative effect. Some additive side effects are seen between dietary supplements and drugs. If a patient is taking a diuretic and depleting his or her potassium supply, licorice should not be consumed. Licorice greatly increases potassium wastage. Kathryn L. Grant, Pharm D, Assistant Professor of Pharmacy at the University of Arizonas College of Pharmacy in Tucson believes. As we learn more about the pharmacodynamics and pharmacokinetics of botanicals, we will more readily predict potential interactions.

Some herbal therapies have normal but toxic reactions. The occurrence and severity of these reactions depend on the dosage and preparation of the supplement. This problem has been aggravated by the use of more concentrated preparations based on distilled alcohol. Liver toxicities and carcinogenic properties have been reported from this.

Adulterants have also been discovered in herbal products. Contaminants have included diuretics, nonsteroidal anti-inflammatories (NSAIDS), benzodiazepines, and heavy metals. In a documented case, a patient taking a protein supplement displayed symptoms of lead poisoning. When analyzed, the supplement contained 2.88% lead.

I believe theres a lot to learn by taking a systematic look at case series and cohort studies, Dr. Hardy stresses. You have to know your manufacturer when you buy these medications, Dr. Hardy cautions. Direct research and adoption of better manufacturing procedures are essential if pharmacists are to anticipate positive and negative drug-herb interactions.

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