Sunday, July 15, 2012



Herbal supplements may not mix with heart medicines


Some herbal supplements can have dangerous interactions with heart medications.

By Mayo Clinic staff Herbal supplements are natural, so they must be safe, right? Not necessarily. Herbal supplements can have strong effects in the body, and some can interact with prescription medications used to treat heart and circulatory problems, such as high blood pressure and heart failure. Some of these interactions can even be dangerous.

Herbal supplements and prescription medications

At least a quarter of adults who take prescription medications also take dietary supplements, including herbal supplements. That number is even higher among adults older than age 70 — three-quarters report using both prescription medications and dietary supplements.
Yet many herbal supplements interact with medications for cardiovascular disease — which are widely prescribed for older adults. The chances of herbs and drugs interacting are high. Indeed, 8 of the 10 most widely used supplements interact with the blood-thinning medication warfarin (Coumadin). Here are just a few of the herbal supplements that can affect warfarin:
  • Danshen
  • Dong quai
  • Evening primrose oil
  • Garlic
  • Ginkgo
  • Ginseng
  • St. John's wort
That's why it's so important to talk with your doctor before taking herbal supplements if you take prescription medications. Your doctor and pharmacist can help you avoid risky interactions. 

Herbal supplements may not mix with heart medicines

Herbal supplements and drug interactions

This table shows popular herbal supplements and interactions with common heart medications. It's not a complete list, however, so be sure to discuss with your doctor the medications and supplements you take.
Herbal supplementMedicationPotential effect
  • Aspirin
  • Clopidogrel (Plavix)
  • Warfarin (Coumadin)
Increases risk of bleeding
  • Aspirin
  • Warfarin
Increases risk of bleeding
  • Warfarin
Decreases effectiveness of warfarin
  • Beta blockers, such as atenolol (Tenormin), nadolol (Corgard) and propranolol (Inderal, Innopran XL)
Increases blood pressure and heart rate
  • Calcium channel blockers, such as diltiazem (Cardizem, Dilacor, others), nifedipine (Procardia) and verapamil (Calan, Covera-HS,Verelan)
  • Nitrates, such as nitroglycerin (Nitro-Bid, Nitrostat,others) and isosorbide (Monoket, Isordil)
Decreases blood pressure
  • Digoxin (Lanoxicaps, Lanoxin)
Increases effects of digoxin
  • Warfarin
Decreases levels of warfarin
St. John's wort
  • Calcium channel blockers
  • Digoxin
  • Warfarin
  • Dabigatran (Pradaxa)
  • Rivaroxaban (Xarelto)
  • Statins, such as atorvastatin (Lipitor), lovastatin (Mevacor) and simvastatin (Zocor)
Reduces effectiveness of drugs

Playing it safe with herbal supplements

If your doctor tells you it's OK to use an herbal supplement combined with a medication, make sure you follow dosing instructions carefully. Watch for any unusual signs or symptoms that you could be having a drug interaction, such as rapid heartbeat, low blood sugar or changes in blood pressure. 

There are many medicines that you'll need to avoid when you have heart failure. Some are over-the-counter drugs that you can buy without a prescription. Others are drugs that a doctor may prescribe.
Do not start taking any of the medicines listed in the table below unless your doctor says it is okay and he or she knows that you have heart failure. If your heart failure is mild, you may be able to use some of the medicines for a short time, but it's very important to ask your doctor first.
If you are already taking a medicine on the list below, be sure to ask your doctor or pharmacist if it is okay to take it.

Medicines you may need to avoid

Over-the-counter medicines you may need to avoid (talk to your doctor or pharmacist) Prescription medicines you may need to avoid (talk to your doctor or pharmacist)
Pain relievers called NSAIDs
  • Ibuprofen, such as Advil and Motrin
  • Naproxen, such as Aleve
  • Aspirin, such as Bayer
    • If your doctor has told you to take a low-dose aspirin every day for your heart problems, it's probably okay to take it. Low-dose aspirin can help prevent blood clots and may prevent a stroke or a heart attack.
    • Higher doses of aspirin may make your heart failure worse. Do not take aspirin for pain, such as from headaches or arthritis. Use acetaminophen, such as Tylenol, instead.
Pain relievers
  • Celecoxib
  • Etodolac
  • Indomethacin
  • Ibuprofen
  • Ketoprofen
  • Nabumetone
  • Naproxen
  • Piroxicam
  • Sulindac
Cold, cough, flu, or sinus medicines
  • Be sure to check the label. Do not take medicines that contain pseudoephedrine, ephedrine, phenylephrine, or oxymetazoline, such as:
    • Sudafed.
    • Nose sprays (decongestants), such as Afrin and Dristan.
    • Herbal remedies, such as ma huang and Herbalife.
  • Make sure your cough and cold medicines don't contain aspirin or ibuprofen.
  • These are drugs used to treat a fast or uneven heart rhythm. You may need to avoid the following:
    • Disopyramide
    • Dofetilide
    • Flecainide
    • Procainamide
    • Propafenone
    • Quinidine
    • Sotalol
Antacids or laxatives that contain sodium
  • Check the label for sodium or saline. Examples include:
    • Antacids, such as Alka-Seltzer.
    • Laxatives, such as Fleet Phospho-Soda.
Calcium channel blockers
  • People with a certain kind of heart failure may need to avoid the following medicines:
    • Diltiazem
    • Verapamil
  • If you need to take a calcium channel blocker for another health problem, such as high blood pressure, your doctor will watch your health carefully.
Certain diabetes medicines
  • Most diabetes drugs are safe to take, but avoid the following:
    • Metformin
    • Rosiglitazone and pioglitazone1
Certain antibiotics
  • Some antibiotics may interfere with how your body uses the medicine digoxin. If you take digoxin, talk with your doctor before taking antibiotics.


  1. Kaul S, et al. (2010). Thiazolidinedione drugs and cardiovascular risks: A science advisory from the American Heart Association and American College of Cardiology Foundation. Circulation, 121(16): 1868–1877.
Last Revised: April 26, 2012
Author: Healthwise Staff
Medical Review: Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology & Margaret Hetherington, PHM, BsC - Pharmacy

Garlic, ginkgo, St John's Wort could all upset bleeding/clotting balance, study found

THURSDAY, May 13 (HealthDay News) -- People taking the prescription blood thinner warfarin (Coumadin) may up their risk for health complications if they also take herbal or non-herbal supplements, new research reveals.
In fact, eight out of the 10 most popular supplements in the United States could spark safety concerns with respect to warfarin, while also impacting the drug's effectiveness.
"I specifically looked at warfarin use, but the real issue is that even though herbal supplements fall under the category of food, and they're not regulated like prescription drugs, they still have the effects of a drug in the body," cautioned study author Jennifer L. Strohecker, a clinical pharmacist at Intermountain Medical Center in Salt Lake City.
"Warfarin is a very high-risk medication, which can be associated with severe consequences when it's not managed properly," she added. "However, warfarin is derived from a plant, sweet clover. In fact, many of our prescription drugs came from plants. So, it's very important for patients to recognize that just because an herb is marketed not like a prescription drug [that] doesn't mean it doesn't have similar effects in the body."
Strohecker and her colleagues are slated to present their findings Thursday at the Heart Rhythm Society annual meeting in Denver.
The authors note that almost 20 percent of Americans currently take some type of herbal or non-herbal supplement.
To gauge how these products might interact with warfarin, the researchers ranked the 20 most popular herbals and 20 most popular non-herbal supplements based on 2008 sales data, and then looked at how their use affected both clotting tendency and bleeding.
More than half of the herbal and non-herbal supplements were found to have either an indirect or direct impact on warfarin. Nearly two-thirds of all the supplements were found to raise the risk for bleeding among patients taking the blood thinner, while more than one-third hampered the effectiveness of the medication.
An increase in bleeding risk was specifically linked to the use of cranberry, garlic, ginkgo and saw palmetto supplements, the team said.
Glucosamine/chondroitin, essential fatty acids, multi-herb products, evening primrose oil, co-enzyme Q10, soy, melatonin, ginseng and St. John's wort all affected warfarin's effectiveness so much so that they prompted a need for adjustments in the drug's prescribed dosage.
"I'm not against herbal supplement use at all," Strohecker stressed. "But physicians need to proactively discuss this issue with their patients because of the consequences that can occur."
Dr. Richard L. Page, a cardiologist and chair of medicine at University of Wisconsin, Madison, and president of the Heart Rhythm Society, believes the larger problem here is poor patient-doctor communication.
"Doctors don't always know what their patients are taking," he said. "Supplements may perform a very good service. Or they may not be providing the sort of care that patients are looking for when they're essentially self-medicating. And where this becomes especially important is that these supplements can interact with the prescription drugs that your doctor may be giving you."
"This report is important," Page said, "because they look at a very common drug, warfarin, which has a narrow therapeutic window. Which means too much is bad cause you bleed, and too little is bad because it won't do the job of thinning the blood that you want. So the bottom line is, be careful of adding new supplements if you are on existing prescription medications, and talk to your doctor if you do."
A representative of the supplements industry took a slightly different view.
Duffy MacKay, vice president of scientific and regulatory affairs for the D.C.-based Council for Responsible Nutrition, the leading dietary supplement industry trade association, said that, "the issue here is really more with warfarin."
"It's just a very sensitive medication," he said. "Warfarin itself has a huge list of drugs, foods and over-the-counters that it interacts with. If you take too much or too little, it can become dangerous."
"So it's sort of a form of sensationalism to suggest that here you have this situation with dietary supplements specifically," MacKay added.
More information
There's more on warfarin at the U.S. National Institutes of Health.

Herbal Remedies May Be Risky 

With Heart Drugs

       Researchers Say Some Supplements Should be Avoided by Patients Taking Heart Drugs
 By WebMD Health News Reviewed by Louise Chang, MD
Feb. 1, 2010 -- Patients taking heart drugs are at risk for potentially dangerous interactions when they also take herbal supplements such as ginkgo biloba, St. John's wort, and garlic, an analysis shows.
Investigators with the Mayo Clinic identified herbal and alternative products that they say should be avoided by patients with heart disease.
They claim the products could cause problems when taken with drugs commonly prescribed to lower blood pressure, control cholesterol, stabilize heart rhythms, or prevent blood clots.
The research analysis appears in the Feb. 9 issue of the Journal of the American College of Cardiology.
Researcher Arshad Jahangir, MD, tells WebMD that heart patients often fail to tell their doctors about the alternative remedies they take because they don't recognize the potential for harm.
"Many people think that natural is synonymous with safe," he says. "Many of these herbal remedies have been used for centuries, but they may not be safe in the current era when used by patients taking many other medications."

Older Patients Most at Risk

Jahangir says the danger is especially great in elderly heart patients, who are often also taking drugs for other chronic conditions and who may already have an increased risk for bleeding.
Bleeding was one of the most frequently cited interaction risks identified by the Mayo researchers, along with reducing or increasing the potency of the prescribed medications.
Some specific examples they cited included:
  • St. John's wort, which is typically used to treat depression, anxiety, and sleep problems, has been shown in some studies to decrease the effectiveness of the arrhythmia drug digoxin, as well as blood-pressure-lowering medications and cholesterol-regulating statins. 
  • The herbal remedies alfalfa, dong quai, bilberry, fenugreek, garlic, ginger, and ginkgo biloba were all identified by the researchers as increasing bleeding risk when combined with the widely prescribed anti-clotting drug Coumadin (warfarin). Ginseng and green tea were identified as decreasing Coumadin's effects. 
  • The banned herbal product ephedra (ma-huang) has been linked to stroke, heart attack, seizures, and death from cardiac arrhythmia in otherwise healthy adults who used the product to boost energy or lose weight.
Not all interactions identified by the researchers involved herbal or alternative remedies.
Jahangir says taking heart medications with grapefruit juice is a common cause of drug toxicity.
For almost two decades, researchers have known that grapefruit juice can increase dosages of some drugs to toxic levels by inhibiting a key enzyme in the intestine that breaks down medications.
He says patients on cholesterol-lowering statins who take the drugs with grapefruit juice may end up with blood statin levels that are three to four times higher than intended.
"I think it is a good idea for anyone taking medication to avoid grapefruit juice because the effects can last as long as 24 hours," he says.
The Mayo researchers conclude that there is a clear need for increased regulation to protect the public from herbal and alternative supplements that can harm them.

Supplement Industry Reaction

A spokesman for the dietary supplement industry's leading trade group was highly critical of the claim and the research analysis in general in a written statement released today.
Council for Responsible Nutrition Vice President for Scientific and Regulatory Affairs Douglas MacKay, ND, writes that the analysis represents a "biased, poorly written and contrived attack on herbal supplements," which contained "sweeping generalizations, often not backed by relevant citations, and copious factual errors."
He faults the researchers for not acknowledging recent changes in federal law that require dietary supplement manufacturers to report serious adverse events to the FDA.
According to MacKay, in the first full year the law was in effect, the FDA reported 1,080 adverse events linked to the use of vitamins and minerals, as well as herbal, sports, and weight loss supplements. A total of 672 adverse events were considered serious.
"For the same year, FDA received over 526,000 adverse event reports related to drugs and biologic products, overn 300,000 of which were considered serious, including close to 50,000 deaths," he writes.

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Weight loss supplement - conjugated linoleic acid - shows nasty side effects

A supplement some people turn to in hopes of losing a few pounds may have some previously unknown, unsavory side effects, suggest two new studies.

Researchers studied how mice and rats responded to the supplement conjugated linoleic acid, an essential amino acid found in trace amounts primarily in beef, lamb and milk. Synthetic forms of conjugated linoleic acid are marketed as supplements that help reduce body fat, and some manufacturers also tout conjugated linoleic acid for reducing the risk of diabetes and certain types of cancer.
The mice and rats responded in very different ways to conjugated linoleic acid, said Martha Belury, the lead author of both studies and an associate professor of human nutrition at Ohio State University.
Mice fed a conjugated linoleic acid-supplemented diet lost weight very fast, but also accumulated excessive amounts of fat in their livers – a common side effect of rapid weight loss. Excessive fat accumulation in the liver is linked to insulin resistance, a hallmark of Type 2 diabetes.
Yet conjugated linoleic acid didn't help rats lose weight they had gained prior to taking the supplement. But it effectively decreased the amount of fat that had accumulated in the animals' livers due to the weight gain. In turn, the rats were less resistant to insulin.
“Many people take conjugated linoleic acid as a supplement in hopes of trimming body fat, and it seems to work,” Belury said. “But we're not sure what else it does to the body. Studying conjugated linoleic acid's effects in two different animal models may help us to better understand any additional effects in humans.
“It seems that these mice and rats represent a continuum of possible side effects induced by conjugated linoleic acid,” she continued. “The question is, are humans more like mice or rats? We're probably somewhere in between.”
The current mouse study appears in a recent issue of the Journal of Lipid Research, while the rat study will appear in an upcoming issue of the Journal of Nutritional Biochemistry.
In a study from 2003, Belury found that conjugated linoleic acid supplements lowered body mass and blood sugar levels of diabetics. The study participants took conjugated linoleic acid supplements for two months.
Researchers fed two groups of mice different diets. The first group ate a diet containing conjugated linoleic acid for four weeks, followed by four weeks of a diet without conjugated linoleic acid.
The second group of animals ate a conjugated linoleic acid-free diet for two weeks followed by two weeks of a diet that included conjugated linoleic acid. During the latter two weeks, some of the mice received daily injections of the anti-diabetes drug rosiglitazone. Rosiglitazone makes the body more sensitive to insulin. Mice serving as controls for both groups did not consume conjugated linoleic acid.
The researchers monitored insulin sensitivity in all mice throughout the study. They also monitored levels of adiponectin, a hormone secreted by fat tissue and thought to play a role in insulin resistance.
“Adiponectin helps regulate insulin levels,” Belury said. “Lowered levels are associated with obesity and type 2 diabetes.”
The researchers found that conjugated linoleic acid supplementation significantly decreased body fat in the first group of mice, but at the same time excessive amounts of fat accumulated in the animals' livers. Belury and her colleagues linked this accumulation of fat in the liver to increased insulin resistance.
When conjugated linoleic acid was removed from the diet, the animals gained weight but lost fat in the liver. The mice also became less resistant to insulin.
“When we took conjugated linoleic acid away, we lost that suppressive effect on body fat, but we were actually able to restore insulin sensitivity,” Belury said.
But the group of mice given rosiglitazone injections while on a conjugated linoleic acid-rich diet neither lost weight nor became insulin resistant.
“The drug kept adiponectin levels steady during the weeks the mice consumed conjugated linoleic acid,” Belury said. “We think that's what kept the animals from becoming resistant to insulin.
“While this is an interesting finding, it doesn't mean that someone taking conjugated linoleic acid should also take an anti-diabetic drug,” she continued. “It's too soon to tell if that would be the case in humans.”
In the rat study, Belury and her colleagues studied a special kind of rat model bred to gain weight quickly. These rats were also less susceptible to conjugated linoleic acid-induced weight loss. All rats ate a high-fat diet for four weeks. For the remaining four weeks of the study, half of the rats ate a low-fat diet supplemented with conjugated linoleic acid, while the rest of the animals ate a low-fat diet without conjugated linoleic acid.
The supplement didn't help the rats lose weight. But it seemed to keep fat from accumulating in the animals' livers, compared to the rats eating the diet without conjugated linoleic acid.
Belury pointed out that up to 75 percent of people with obesity and diabetes develop an illness called non-alcoholic fatty liver disease in which fat accumulates in the liver and can ultimately make a person insulin resistant.
conjugated linoleic acid may or may not have a similar effect on humans, and it will take time to determine how the human body responds to the supplement. But clinical trials are underway – Belury is currently working with researchers from Ohio State's medical center who are conducting a clinical trial of the effects of conjugated linoleic acid on women with diabetes.
Belury conducted the studies with Aparna Purushotham and Angela Wendel, both graduate fellows in human nutrition; and Li-Fen Liu and Gayle Shrode, both graduate research associates in human nutrition.
Support for the work was provided by Cognis North America, a manufacturer of synthetic conjugated linoleic acid headquartered in Cincinnati. Support also came from the Carol S. Kennedy research award and the Anita R. McCormick fellowship.

The Side Effects of Conjugated Linoleic Acid

Jun 3, 2011 | By A.M. Tacon

 Photo Credit Hemera Technologies/ Images

Conjugated linolenic acid or CLA is a naturally occurring derivative of the essential fatty acid known as linoleic acid. Specifically, CLA is an omega-6 fatty acid found primarily in meat and dairy foods, according to Memorial Sloan-Kettering Cancer Center. In recent years, it has gained prominence as a weight loss aid with body fat-reducing properties; also, marketing claims include other benefits such as reducing cholesterol, and protecting against certain types of cancer, yet more research is needed. Unwanted side effects are possible with CLA.
Gastrointestinal Distress

Gastrointestinal upset may occur if you start taking CLA supplements, according to Memorial Sloan-Kettering Cancer Center. Gastrointestinal symptoms include upset stomach, nausea, or diarrhea; however, such effects are temporary and should subside as the body gets used to the CLA supplementation. If you experience diarrhea, you need to drink plenty of water to reduce the risk of becoming dehydrated. Notify your physician if gastrointestinal symptoms persist or worsen.

A potentially adverse reaction to supplementing your diet with CLA involves severe fatigue. This side effect may impact your daily routine and performance of required duties. If you experience this degree of fatigue, you may need to initially reduce your daily activities temporarily and get more sleep as your body adjusts to the supplement.
Macular Degeneration

Linoleic acid may seriously affect your vision, as indicated by the Encyclopedia of Alternative Medicine. CLA may increase an individual's risk of developing age-related macular degeneration, or ARMD. ARMD is an eye disease associated with progressive deterioration of vision that ultimately results in blindness. It is imperative that you speak with your doctor when considering CLA if you have a family history of eye disease.

Heart Disease

Research data indicate that CLA supplementation can affect your blood vessel function; consequently, this effect may increase your risk of developing heart disease, as reported by the University of Michigan Health System. In the cited study that consisted of healthy volunteers, participants took 4.5 g of CLA daily for 12 weeks. This time period of taking CLA produced an impairment of blood vessels associated with cardiovascular dysfunction. In sum, these findings suggest that long-term use of CLA may lead to heart disease.

Research data show that taking CLA supplements also may produce insulin resistance and increase your blood glucose or sugar levels, states Memorial Sloan-Kettering Cancer Center. Therefore, if you are diabetic, caution is warranted since CLA supplementation may exacerbate diabetic symptoms.

    Memorial Sloan-Kettering Cancer Center: Conjugated Linoleic Acid
    Encyclopedia of Alternative Medicine: Linoleic Acid
    University of Michigan Health System: Conjugated Linoleic Acid


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