Copyright © 2002 F.A.

Davis Company

Appendix 1

QUICK GUIDE TO HERB-DRUG

INTERACTIONS

The rapid increase in the use of herbal medicines has created a rapidly growing
database of known herb-drug interactions, many of which are presented in the table
below. Keep in mind, however, that our knowledge of the interactions among pre-
scription medicines, over-the-counter medicines, and herbal medicines continues to
change constantly.
To help detect possible herb-drug interactions, encourage patients to be open about
all medicines they may be taking, whether prescription, over the counter, or herbal. Ask
them to bring all of their medications with them to their next appointment. Caution
patients not to take herbal medicines in higher doses or more often than recommended.
Also, caution them not to experiment with herbal medicines. Urge them to tell all of their
health-care practitioners about all of the medicines they take.
If patients are known to have adverse drug reactions, such as allergies, chronic
skin rashes, or pre-existing liver disease related to prescription medicines, warn them
that they have a higher risk of side effects from herbs as well. Reinforce the importance
of reporting any side effects of prescription, over-the-counter, and herbal medicines to
a health-care practitioner. Elderly patients, pregnant women, and children have an
increased risk of interactions and side effects from herbal medicines and should be
referred to a practitioner with specialized training in the field of herbal medicine.Also,
make a point of telling pregnant women that some herbs are unsafe to take during
pregnancy and breast-feeding.

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SOURCE OF
HERB DRUG INTERACTION INFORMATION
ALOE GEL/JUICE Glyburide Increased hypo- Yongchaiyudha
glycemic effect et al., 1996
ALOE LATEX Antiarrhythmics May potentiate the Blumenthal et al.,
Cardiac glycosides action of 1998
Corticosteroids cardiac glyco-
Licorice root sides and anti-
Thiazide diuretics arrhythmic
agents (as do
the other drugs
listed)
ASTRAGALUS Acyclovir Increases effects DeSmet &
ROOT Interleukin-2 D’Arcy, 1996
Azathioprine Caution use
Cyclosporine
Methotrexate
BITTER MELON Chlorpropamide Increases hypo- Aslam &
glycemic effect Stockley, 1979
BORAGE Anticonvulsants May lower seizure Miller, 1998
threshold
BROMELAIN Anticoagulants Increases Blumenthal et al.,
bleeding 1998
Tetracycline Increases plasma Neurauer, 1961
and urine drug
levels
Chloramphenicol Enhances drug Neurauer, 1961
Erythromycin levels
Novobiocin
Penicillin
5-fluorouracil Can improve Taussig & Batkin,
Vincristine efficacy 1998
BREWER’S YEAST MAO inhibitors Increased blood Blumenthal et al.,
pressure 1998
BUCKTHORN Cardiac glyco- May potentiate Blumenthal et al.,
BARK, BERRY sides toxicity with 2000
Quinidine long-term use
BUGLEWEED Thyroid Contraindicated Blumenthal et al.,
preparations 1998
Thyroid McGuffin et al.,
treatments 1997

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SOURCE OF
HERB DRUG INTERACTION INFORMATION
BUPLEURUM Alcohol May increase WHO, 1999
CNS depressants sedation
Sedatives
CASCARA Cardiac glyco- May potentiate Blumenthal et al.,
SAGRADA BARK sides toxicity with 2000
Quinidine long-term use
CHASTE TREE Dopamine- May weaken Blumenthal et al.,
BERRY receptor antag- effect (animal 1998
onists (such as studies)
haloperidol)
Metoclopramide Possible inter- Blumenthal et al.,
actions 2000
Hormone therapy Contraindicated Blumenthal et al.,
Oral contracep- 2000
tives
CAYENNE PEPPER Aspirin Reduced mucosal Yeoh et al., 1995
damage if
cayenne taken
30 minutes
before aspirin
CINCHONA BARK Anticoagulants Increases effects Blumenthal et al.,
1998
COLA NUT Caffeine Contraindicated Blumenthal et al.,
Psychoanaleptic 1998
drugs
DEVIL’S CLAW Antiarrhythmics Contraindicated ESCOP, 1999
ROOT
DONG QUAI Coumadin May increase Heck et al., 2000
effects of
medication
ECHINACEA Amiodarone If ⬎8 weeks, Miller, 1998
Anabolic steroids potential for
Ketoconazole hepatotoxicity
Methotrexate
Corticosteroids Antagonistic
Cyclosporin effects
EPHEDRA Cardiac glyco- Cardiac arrhyth- Blumenthal et al.,
(MA HUANG) sides mias 1998
Halothane
Guanethidine Enhances sympa- Blumenthal et al.,
thomimetic effect 1998

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SOURCE OF
HERB DRUG INTERACTION INFORMATION
MAO inhibitors May cause fatal Blumenthal et al.,
hypertension 1998
Ergotamine Hypertension WHO, 1999
Oxytocin
EUCALYPTUS OIL Drugs weakened Affects liver Blumenthal et al.,
(EXTERNAL OR or shortened detoxification 2000
INHALED)
EVENING Anticonvulsants May lower seizure Miller, 1998
PRIMROSE OIL threshold
FENNEL Ciprofloxacin Affects absorption, Zhu et al., 1999
distribution,
elimination
FENUGREEK Hypoglycemic May exaggerate Natural Medi-
agents effects cines, 2000
Sulfonylureas
FEVERFEW Aspirin May increase Herbst, 1999
Coumadin bleeding time Miller, 1998
Nonsteroidal anti- Inhibits effects of Miller, 1998
inflammatory herb
drugs
FLAXSEED Conventional May delay Blumenthal et al.,
medicines absorption 1998
Antidiabetic May slow glucose Blumenthal,
medications absorption 2000
GARLIC Coumadin May increase Sunter, 1991
bleeding time Herbst, 1999
Miller, 1998
Ottariano, 1999
GINGER Anticoagulants May increase Lumb, 1994
bleeding time Herbst, 1999
Miller, 1998
GINKGO BILOBA Aspirin May increase Rosenblatt, 1997
Coumadin bleeding time Herbst, 1999
Miller, 1998
Papaverine May potentiate Sikora et al.,
effects of drug 1989
Trazodone May cause severe Prescriber’s Let-
CNS depression ter, September
2000

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SOURCE OF
HERB DRUG INTERACTION INFORMATION
GREEN TEA Coumadin May increase Heck et al., 2000
effects
GURMAR LEAVES Glyburide May have additive Baskaran et al.,
Tolbutamide effects 1990
Insulin May reduce insu- Shanmugasun-
lin requirements daram et al.,
1990
HAWTHORN LEAF Cardiac glyco- May enhance Blumenthal,
WITH FLOWER sides effects of drug 2000
Adenosine May increase Blumenthal,
Caffeine coronary artery 2000
Epinephrine dilatation
Papaverine (controversial)
Sodium nitrate
Theophylline
Digoxin May affect drug Miller, 1998
level monitoring
KARELA Biguanides May cause Miller, 1998
Insulin interactions
Sulphonylureas
KAVA KAVA Alcohol May potentiate Herbst, 1999
Barbiturates effects
Benzodiazepines
Levodopa May reduce effects Schelosky et al.,
1995
LICORICE ROOT Spironolactone May increase loss WHO, 1999
of potassium Miller, 1998
Amiloride May increase loss WHO, 1999
Cardiac glyco- of potassium
sides
Thiazide diuretics
Digoxin May create prob- Miller, 1998
lems with drug
monitoring
MARSHMALLOW All May decrease Blumenthal et al.,
LEAF AND ROOT absorption of 1998
medications
OAK BARK All May decrease Blumenthal et al.,
absorption of 1998
medications

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SOURCE OF
HERB DRUG INTERACTION INFORMATION
PAPAYA Coumadin Increases effect of Shulman, 1997
medication
PANAX GINSENG MAO inhibitors May interact Blumenthal et al.,
Phenelzine 1998
Miller, 1998
Coumadin May alter bleeding Miller, 1998
times
Corticosteroids May have additive Miller, 1998
Estrogens effects
Digoxin May affect drug Miller, 1998
levels
Biguanides Should not admin- Miller, 1998
Insulin ister together
Sulfonylureas
PSYLLIUM Conventional May delay Blumenthal et al.,
medicines absorption 1998
Antidiabetic May slow glucose Blumenthal et al.,
drugs absorption 1998
RHUBARB ROOT Antiarrhythmics Increases toxic WHO, 1999
Cardiac glyco- effects
sides
Corticoadrenal
steroids
Thiazide diuretics
SARSAPARILLA Bismuth Increases Blumenthal et al.,
ROOT Digitalis glyco- absorption 1998
sides
Hypnotics Accelerates Blumenthal et al.,
elimination 1998
SAW PALMETTO Iron May limit Miller, 1998
absorption
SCOTCH BROOM MAO inhibitors May cause hyper- Blumenthal,
tensive crisis 2000
SENNA Cardiac glyco- Long-term use can Blumenthal,
sides increase loss of 2000
Quinidine serum potassium
SIBERIAN Kanamycin May enhance Vereshchagin et
GINSENG Monomycin effects of drugs al., 1998
STINGING Diclofenac Increased anti- Chrubasik et al.,
NETTLES inflammatory 1997
effects

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SOURCE OF
HERB DRUG INTERACTION INFORMATION
ST. JOHN’S WORT Selective serotonin Nausea, headache, Lantz et al., 1999
reuptake inhibitors tremors Roundtree, 2001
Anticonvulsants Contraindicated Roby et al., 2000
Antifungals because of Piscitelli et al.,
Antiretrovirals possible break- 2000
Calcium channel through bleeding,
blockers lowered blood
Chemotherapeutics levels, de-
Cyclosporine creased drug
Macrolide anti- effectiveness
biotics
Nonsedating anti-
histamines
Oral contracep-
tives
Warfarin
Tetracycline Increased risk of Herbst, 1999
blood clots
Iron May limit Miller, 1998
absorption
VALERIAN Alcohol May potentiate Upton, 1999
Barbiturates effects Herbst, 1999
McCaleb et al.,
2000

*The Food and Drug Administration has a list of unsafe herbs. The Internet address is:
http://lep.cl.msu.edu/msueimp/htdoc/modO3/03900066.html

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Appendix 2

HERBS THAT MAY INCREASE

CLOTTING TIMES OR INTERACT WITH
ANTICOAGULANTS

• Astragalus • Ginkgo biloba

• Bilberry • Ginseng
• Bromelain • Green tea
• Capsaicin • Horse chestnut
• Dong quai • Red clover
• Evening primrose oil • Skullcap
• Feverfew • Sheep sorrel
• Garlic • Willow bark
• Ginger
Sources: Heck et al., 2000 and Ottariano, 1999.

Appendix 3

HERBS THAT MAY HAVE A

LAXATIVE EFFECT

• Aloe latex • Elder

• Boneset • Fennel
• Buckthorn • Milk thistle
• Cascara sagrada • Psyllium
• Dandelion root and leaf • Senna
Sources: Ottariano, 1999 and McGuffin, 2000.

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Appendix 4

HERBS THAT SHOULD NOT BE TAKEN

INTERNALLY

LIVER TOXICITY:
• Comfrey • Germander
• Chaparral • Life root
CANCER-CAUSING EFFECTS:
• Sassafras
LIFE-THREATENING TOXICITY IN ANIMALS:
• Pennyroyal oil (has killed some animals after use as a flea repellent.)

Warning: Many plants are toxic and should never be used internally; consult a book on poisonous
plants.

Appendix 5

HERBS THAT SHOULD NOT BE TAKEN

DURING PREGNANCY

• Agave • Blue cohosh root

• Alder • Black cohosh
• Aloe (oral use) • Black walnut
• Angelica • Buchu
• Buckthorn • Cascara
• Barberry • Castor oil
• Basil • Chaste tree berry
• Bilberry leaves • Coltsfoot
• Birthroot • Comfrey

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Appendices

• Cotton root bark • Lobelia

• Damiana • Milk thistle
• Devil’s claw root • Mistletoe
• Dong quai • Mugwort
• Ephedra • Myrrh
• Ergot • Oregon grape
• False unicorn • Osha
• Feverfew • Pennyroyal leaf, flower,
• Ginger and oil
• Ginkgo biloba (Egb) • Pleurisy root
• Ginseng • Red clover
• Goldenseal • Rue leaf
• Gotu kola • Rhubarb
• Green tea (caffeine content) • Sarsaparilla
• Hawthorn • Scotch broom
• Hops • Senna
• Horehound • Shepherd’s purse
• Horse chestnut • Southernwood
• Horseradish • St. John’s wort
• Horsetail • Tansy leaf
• Hyssop • Uva ursi
• Juniper berries • Wormwood
• Kava kava • Yarrow
• Licorice • Yellow dock

Warning: Urge patients to use all herbs cautiously during pregnancy. Some herbs in the list above
may induce abortion or stimulate the uterus to contract. Other herbs may have a laxative effect.
Advise patients against exceeding recommended dosages, and tell patients to consult with their
health-care practitioners about the length of time to take any herbal medicine. For more information
on herbs that may or may not be used safely in pregnancy, consult the Botanical Safety Handbook.

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Appendix 6

HERBS THAT SHOULD NOT BE TAKEN

WHILE BREAST-FEEDING

• Aloe (oral use) • Garlic

• Barberry • Ginseng
• Bilberry leaves • Goldenseal
• Black cohosh • Green tea (caffeine content)
• Bladderwrack • Hawthorn
• Borage • Horse chestnut
• Buckthorn • Horseradish
• Bugleweed • Hyssop
• Cascara sagrada • Kava kava
• Chaste tree berry • Licorice root
• Coltsfoot • Psyllium
• Comfrey • Senna
• Elecampane • Stillingia
• Ephedra • Wormwood
• Feverfew • Yellow dock
Warning: Other herbs may be unsafe also. Tell patients to consult a health-care practitioner before
taking any herb while breast-feeding.

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