DOI:10.1111/j.1365-2125.2006.02759.

x British Journal of Clinical Pharmacology

Pharmacodynamic interaction studies of Ginkgo biloba

with cilostazol and clopidogrel in healthy human subjects

D. Aruna1 & M. U. R. Naidu2

1
Department of Clinical Pharmacology, Osmania General Hospital and 2Department of Clinical Pharmacology and Therapeutics, Nizam’s
Institute of Medical Sciences, Hyderabad, India

Correspondence Aims
Dr D. Aruna, C/O Dr R. V. Kumar, 2- Ginkgo biloba is available as an over-the-counter drug and reported to cause haem-
2-1144/22/A/2, New Nallakunta, orrhage when coadministered with other antiplatelet agents. We set out to study the
Street No.3, Hyderabad-500044, interactions of G. biloba with cilostazol and clopidogrel.
Andhra Pradesh, India.
Tel: + 91 040 3092 1264 Methods
Cell: + 91 040 98 4892 3036 A randomized, open-label, crossover study of 10 healthy male volunteers. The dosage
E-mail: adonepudi@yahoo.co.in, schedules were 120 mg G. biloba , 240 mg G. biloba , 100 mg cilostazol, 200 mg
kumarrv@rediff.com cilostazol, 75 mg clopidogrel, 150 mg clopidogrel, 120 mg G. biloba + 100 mg
cilostazol and 120 mg G. biloba + 75 mg clopidogrel. Platelet aggregation, platelet
count, bleeding time and clotting time were measured 0 and 6 h after drug admin-
istration. Platelet aggregation was performed using a dual channel aggregometer, by
Keywords the turbimetric technique using adenosine diphosphate 5 µmol and 10 µmol, and
bleeding time, Ginkgo biloba, healthy collagen 1 µg ml −1.
volunteers, pharmacodynamic
interaction, platelet aggregation Results
Platelet inhibition with the combination of G. biloba and clopidogrel or cilostazol was
not statistically significant compared with individual doses of drugs, with all the three
aggregants. There was significant ( P < 0.05) potentiation of prolongation of bleeding
time with the combination of cilostazol and G. biloba compared with individual doses
Received
of both the drugs. There was no significant change in clotting time and platelet count.
31 May 2006
Accepted
Conclusions
1 June 2006
Coadministration of G. biloba either with cilostazol or clopidogrel did not enhance
Published OnlineEarly
antiplatelet activity compared with individual agents. Ginkgo biloba potentiated the
29 September 2006
bleeding time prolongation effect of cilostazol. There was no significant correlation
between prolongation of bleeding time and inhibition of platelet agg regation.

Introduction These products are available to consumers as over-the-

The use of herbal supplements has become increasingly
popular in recent years. Herbal medicines fall into the
category of alternative/complementary medicines. These
are not regulated by governments with the same scrutiny
as conventional drugs. In the USA their regulation by
the Food and Drug Administration is restricted as a
result of the Dietary Supplement Health and Education
Act (DSHEA) passed by the US Congress in 1994.
counter items in various forms of preparations and doses
[1]. Several factors contribute to the increased use of
herbal products: (i) easy accessibility, (ii) the perception
that herbs are safe, (iii) the desire for self-medication,
(iv) they are less costly, and (v) most of all, enactment
in 1994 of the DSHEA, which broadly defined herbal
products as nutritional supplements. However, herbal
products are not as safe as they are believed to be. Most

© 2006 The Authors Br J Clin Pharmacol 63:3 333–338 333

Journal compilation © 2006 Blackwell Publishing Ltd
 D. Aruna & M. U. R. Naidu
studies reveal that heavy metals, particularly lead, have
been a regular constituent of Indian remedies [2], thus
causing serious harm to patients taking such remedies.
Concern has recently been expressed regarding the
safety of these products, in particular the potential inter-
action of these drugs with conventional drugs. It has been
documented that as many as 31% of patients use herbal
supplements concurrently with the prescribed conven-
tional drugs and 70% of them do not report the use of
these products to their healthcare providers [1]. It is
therefore likely that healthcare professionals will encoun-
ter patients who use herbal supplements and who may
seek help concerning herb–drug interactions. In order to
tackle this problem and provide a better healthcare service
to such patients, practitioners should have knowledge of
at least commonly occurring or anticipated interactions
between herbal supplements and conventional drugs [1].
Despite the widespread use of herbal medicines, docu-
mented herb–drug interactions are sparse.
Ginkgo biloba is commonly used and one of the seven
top-selling herbal medicines [3]. It is used mainly in the
management of intermittent claudication and other vas-
cular disorders to improve circulation. The antiplatelet
drug clopidogrel and the newer phosphodiesterase
inhibitor, cilostazol, have been recently introduced for
management of peripheral arterial disease (PAD). Both
these agents are known to cause prolongation of bleed-
ing time and cause haemorrhage [4–6]. In view of the
known antiplatelet activity of G. biloba [7], there is a
possibility that concurrent use of G. biloba, cilostazol
and clopidogrel in patients with PAD may potentiate the
antiplatelet activity and cause prolongation of bleeding
time, thus increasing the risk of haemorrhage. The
present study was conducted to evaluate the pharmaco-
dynamic interactions of G. biloba with clopidogrel and
cilostazol, after single-dose administration.
Materials and methods
The present interaction study was conducted in the
Department of Clinical Pharmacology and Therapeu-
tics of Nizam’s Institute of Medical Sciences, Hydera-
bad. It was a randomized, open-label, crossover study
of 10 healthy male subjects. The mean age was
27 ± 4 years (24–35 years). The mean body weight
was 64 ± 9 kg (50–80 kg) and the mean height was
166 ± 6 cm (156–174 cm). Exclusion criteria were sub-
jects hypersensitive to study drugs, chronic smokers or
alcoholics, and a history of gastrointestinal surgery that
could interfere with absorption of study drugs. The
study was approved by Institutional Review Board of
the institute and written informed consent was obtained
from all subjects.
334 63:3 Br J Clin Pharmacol
The subjects were given one of the following dosage
regimens orally, according to randomization after over-
night fasting. The dosage schedules were a single dose
of (i) 100 mg cilostazol, (ii) 200 mg cilostazol, (iii)
120 mg G. biloba, (iv) 240 mg G. biloba, (v) 75 mg
clopidogrel, (vi) 150 mg clopidogrel, (vii) 120 mg G.
biloba + 100 mg cilostazol and (viii) 120 mg G. biloba
+ 75 mg clopidogrel. The wash-out period was 48 h.
Platelet aggregation, bleeding time, clotting time and
platelet count were measured 0 and 6 h after drug admin-
istration, haemodynamic parameters blood pressure
(BP), diastolic time, heart rate, pulse duration time B/A
and C/A ratios were measured 0, 1, 2, 4 and 6 h by using
a data acquisition system (Dicrowin, Genesis Medical
Systems, Hyderabad, India). In this, digital pulse volume
was recorded by connecting the photo transducer to the
right-hand index finger of the subject, lying in supine
position. The pulse curves were analysed by in-house
developed computer software. Measurement of platelet
aggregation [8–10] was done by using a dual-channel
aggregometer (chronolog) by the turbimetric method,
using adenosine diphosphate (ADP) 5 and 10 µmol and
collagen 1 µg ml−1. Nine millilitres was collected from
the antecubital vein in a plastic test tube containing 1 ml
of sodium citrate. The aggregometer was switched on
about 30 min before the test to allow the heating block
to warm up to 37°C. Platelet-rich plasma (PRP) was
prepared by centrifuging blood at 110 g for 15 min. Plate-
let-poor plasma (PPP) was then prepared from the
remaining blood by centrifuging at 2400 g for 20 min.
PRP (0.5 ml) was taken into a small plastic tube and a
stir bar was added and placed in the heating block. The
transmission was set to zero on the chart recorder. PRP
was allowed to warm to 37°C for 2 min and then 2.5 µl
containing ADP 5 µmol was added.
The change in absorbance was recorded until the
response reached a plateau or for 6 min, whichever was
sooner. This procedure was repeated with ADP 10 µmol
and collagen 1 µg ml−1. Bleeding time was measured by
Ivy’s method [9].
The primary purpose was to discover any significant
change in platelet aggregation from baseline. More than
20% change in platelet aggregation was considered to
be a positive response. Secondary aims were to detect
changes in coagulation parameters and haemodynamic
parameters. Subjects were allowed to leave the depart-
ment after 6 h if there were no side-effects.
Statistical analysis
Data are presented as mean, SD, SE and 95% confidence
interval. Baseline and data obtained after 6 h in all
groups were compared using ANOVA. Differences within
 PD interaction studies of Ginkgo biloba with cilostazol and clopidogrel

each group were analysed using Wilcoxon’s signed rank
test, as the platelet aggregation data did not follow nor-
mal distribution. For parametric data, paired and
unpaired t-tests were applied. The level of significance
was set at 0.05 with a power of 80%.
Results
In the present investigation, 16 healthy human
volunteers were screened for inclusion in the study. Out
of 16 subjects, four were excluded at screening because
of abnormal laboratory investigations, two withdrew
voluntarily, leaving 10 to be recruited. The mean peak
platelet aggregation of eight dosage schedules at base-
line were 75 ± 5%, 79 ± 4% and 86 ± 3 with ADP
5 µmol, 10 µmol and collagen 1 µg ml−1, respectively.
The mean peak platelet aggregation induced with ADP
5 µmol before and after administration of each drug and
their combinations is shown in Table 1. The maximum
inhibition of platelet aggregation was seen with 150 mg
of clopidogrel. The peak platelet aggregation with
150 mg of clopidogrel was found to be 32 ± 6% at 6 h
compared with 73 ± 4% at baseline (P < 0.0001). The
combination of G. biloba with either cilostazol or clo-
pidogrel did not potentiate the inhibition of 5 µmol
ADP-induced platelet aggregation.
The mean platelet aggregation obtained with 10 µmol
of ADP is shown in Table 2. It was observed that there
was higher peak platelet aggregation with 10 µmol of
ADP. The highest percentage inhibition was noted with
150 mg of clopidogrel (similar to ADP 5 µmol),
48 ± 7% (P < 0.05). The coadministration of G. biloba
with either cilostazol or clopidogrel did not enhance
antiplatelet activity compared with individual agents.
Collagen was found to be the most potent platelet
aggregating agent compared with 5 and 10 µmol of
ADP. None of the individual doses of drugs or their
combinations was able to produce statistically signifi-
cant inhibition of collagen-induced platelet aggregation.
In our study, both doses of cilostazol, G. biloba, clo-
pidogrel and their combinations produced marked pro-
longation of bleeding time. The mean bleeding time
obtained in all groups is given in Table 3. The highest
bleeding time of 211 ± 70 s (P < 0.001) was seen with
the combination of G. biloba 120 mg and cilostazol
100 mg. There was significant potentiation in prolonga-
tion of bleeding time with the combination of cilostazol
and G. biloba compared with individual doses of both
drugs. It was observed that there was no statistically
significant correlation (r = −0.01) between prolongation
of bleeding time and inhibition of platelet aggregation.
There were no significant changes in clotting time or
platelet count in any of the treatment groups.
There was a significant increase in mean heart
rate from 63 ± 10 to 65 ± 10 beats min−1 (P < 0.05)

Table 1
Maximum platelet aggregation percentage with adenosine diphosphate (5 µmol)

95% CI 95% CI
Mean SD SE (lower) (upper)

Cilostazol 100 mg (n = 10) 0h 74 19 6 60 89

6h 47* 32 11 23 72
Cilostazol 200 mg (n = 10) 0h 75 16 6 62 88
6h 51** 26 9 31 72
Ginkgo 120 mg (n = 10) 0h 69 18 6 57 82
6h 44** 22 7 28 60
Ginkgo 240 mg (n = 10) 0h 81 13 4 71 90
6h 59** 24 8 42 76
Clopidogrel 75 mg (n = 10) 0h 70 15 5 57 83
6h 52* 26 9 30 73
Clopidogrel 150 mg (n = 10) 0h 73 10 4 64 82
6h 32** 16 6 18 45
Clopidogrel + Ginkgo (n = 10) 0h 75 9 3 67 83
6h 49*† 21 8 31 67
Cilostazol + Ginkgo (n = 10) 0h 84 8 3 77 90
6h 57* 22 8 39 75

*P < 0.05 compared with baseline. **P < 0.001 compared with baseline. †P < 0.05 compared with 150 mg clopidogrel.

Br J Clin Pharmacol 63:3 335

 D. Aruna & M. U. R. Naidu

Table 2
Maximum platelet aggregation percentage with adenosine diphosphate (10 µmol)

95% CI 95% CI
Mean SD SE (lower) (upper)

Cilostazol 100 mg (n = 10) 0h 79 17 6 66 92

6h 59* 13 10 36 82
Cilostazol 200 mg (n = 10) 0h 82 14 5 72 93
6h 65* 27 9 44 86
Ginkgo 120 mg (n = 10) 0h 75 11 3 67 82
6h 85* 5 2 81 89
Ginkgo 240 mg (n = 10) 0h 85 11 3 77 93
6h 66* 21 7 51 82
Clopidogrel 75 mg (n = 10) 0h 77 11 4 68 86
6h 60* 23 8 41 79
Clopidogrel 150 mg (n = 10) 0h 75 11 4 66 84
6h 48* 19 7 32 64
Clopidogrel + Ginkgo (n = 10) 0h 75 10 4 75 92
6h 56* 19 7 61 92
Cilostazol + Ginkgo (n = 10) 0h 83 8 3 68 81
6h 77 20 7 39 73

*P < 0.05 compared with baseline.

Table 3
Bleeding time (s)

95% CI 95% CI
Mean SD SE (lower) (upper)

Baseline, n = 80 107 33 4 99 115

Cilostazol 100 mg (n = 10) 150* 42 14 118 182
Cilostazol 200 mg (n = 10) 138** 30 10 115 161
Ginkgo 120 mg (n = 10) 144* 28 9 124 164
Ginkgo 240 mg (n = 10) 133* 30 10 110 157
Clopidogrel 75 mg (n = 10) 141 59 21 91 190
Clopidogrel 150 mg (n = 10) 159* 56 20 113 206
Clopidogrel + Ginkgo (n = 10) 148* 78 28 83 213
Cilostazol + Ginkgo (n = 10) 211*† 70 25 153 270

*P < 0.05 compared with baseline. **P < 0.001 compared with baseline. †P < 0.05 compared with 150 mg of clopidogrel.

and pulse duration time from 962 ± 150 to
1037 ± 182 ms (P < 0.05) with cilostazol 200 mg at
2 h after drug administration (Table 4). The pulse
duration time was also increased with the combina-
tion of cilostazol 100 mg and G. biloba 120 mg
from 932 ± 140 to 1036 ± 123 ms at 2 h (P < 0.01).
There was no significant change in systolic BP in
any of the groups, but diastolic BP decreased signifi-
cantly (P < 0.001) from 74 ± 5 to 68 ± 6 mmHg
with cilostazol 200 mg. No significant change was
observed in diastolic time, upstroke time, B/A and
C/A ratios. No significant side-effects were observed
during the study period. All treatments were well
tolerated.

336 63:3 Br J Clin Pharmacol

 PD interaction studies of Ginkgo biloba with cilostazol and clopidogrel

platelet aggregation induced by 5 µmol of ADP only. It

Table 4 produced no significant inhibition against a higher dose
Pulse duration time (ms) at 2 h of ADP (10 µmol) or collagen. Chung et al. [16] have
reported that a Ginkgo glide mixture given to human
Cilostazol Cilostazol Cilostazol + volunteers caused significant inhibition of platelet-
100 mg 200 mg Ginkgo activating factor-induced platelet aggregation, after
0h 2h 0h 2h 0h 2h ingestion of single doses of 80 and 120 mg. An inhibi-
tory effect of G. biloba on oxidative stress-induced
Mean 915 937 962 1037* 932 1036* platelet aggregation [17] has also been reported in mice.
SD 142 168 150 182 140 123
To observe a significant and consistent effect of G.
SE 50 59 53 64 49 44
95% CI (l) 796 796 837 884 815 933
biloba on platelet aggregation, it has been suggested that
95% CI (U) 1034 1077 1087 1189 1049 1139 Ginkgo must be taken continuously for 2–3 weeks [18].
Coadministration of a single dose of G. biloba
*P < 0.05 compared with baseline.
120 mg with either 100 mg cilostazol or 75 mg clopi-
dogrel did not significantly enhance the inhibition of
platelet aggregation. There was an apparent, but not
statistically significant, increase in the percentage of
Discussion platelet inhibition. In one study [13] antiplatelet and
The increased use of herbal supplements worldwide, antithrombotic effects of an oral combination of ticl-
particularly in recent years, has contributed significantly opidine (50 mg kg−1 day−1) and G. biloba (40 mg kg−1
to the information available about potential herb and day−1) in rats was comparable to a large dose (200 mg
drug interactions. This is particularly important for kg−1 day−1) of ticlopidine in ADP-induced platelet aggre-
modern drugs frequently coprescribed or used by gation. In another study [14] of a 33-year-old woman
patients. There is documented theoretical evidence in taking a G. biloba, administration of paracetamol was
the literature about interactions between herbal products found to have induced spontaneous bilateral subdural
and modern drugs [1]. Ginkgo biloba is one of the most haemotomas. In our study we have used a single dose
popular herbal products, available in various countries of G. biloba (120 mg) with a single dose of cilostazol.
and commonly used for its beneficial effects in cerebral It may be possible that chronic administration of these
and peripheral arterial disease (i.e. dementia and clau- agents may be associated with significant change in
dication) [7]. Reports have shown that coadministration antiplatelet activity.
of G. biloba with commonly coprescribed drugs in We found that, in healthy subjects, the mean bleeding
peripheral vascular disease causes interactions [11–15]. time was increased from baseline after administration of
In the present study, we have evaluated in healthy sub- two doses of individual drugs as well as their combina-
jects a pharmacodynamic interaction of G. biloba with tions (Table 3). Compared with other treatment groups
the most commonly used antiplatelet agent, clopidogrel, in our study, the combination of G. biloba with cilo-
and with the recently introduced phosphodiesterase stazol, produced a significant prolongation of bleeding
inhibitor, cilostazol, used in the treatment of PAD. The time. Bleeding has also been reported when G. biloba
study was conducted to determine the effect of these has been administered with aspirin [11], rofecoxib or
drugs on platelet function. Two doses of ADP 5 and warfarin [12]. However, there was no change in clotting
10 µmol and collagen 1 µg ml−1 were used as platelet time or platelet count.
aggregation-inducing agents. In our study, both agents Evaluation of haemodynamic parameters in the
produced characteristic platelet aggregation of PRP present study suggests that there is a moderate effect
within 6 min of incubation. The onset of aggregation only with cilostazol 200 mg. No other treatment groups
with 5 µmol of ADP was comparatively slow and less produced any significant change in BP, heart rate or
than with 10 µmol of ADP. Collagen produced rapid and pulse duration time.
high platelet aggregation (86 ± 3%). The maximum Cilostazol 200 mg produced an increase in heart rate
mean platelet aggregation with 5 µmol of ADP was and pulse duration which was associated with a signifi-
75 ± 5% (range 69–84%) compared with 10 µmol of cant fall in diastolic BP after 2 h. We found no signifi-
ADP (79 ± 4%, range 75–85%). Our data are in accor- cant change in systolic BP. Our data are in accordance
dance with an earlier report [8]. with a study of a single oral dose of 100 mg cilostazol
In our study, a single administration of 120 and in 20 healthy volunteers, reporting an increase in heart
240 mg of G. biloba produced significant inhibition of rate of 13%, with a decrease in diastolic BP [19].

Br J Clin Pharmacol 63:3 337

 D. Aruna & M. U. R. Naidu
Chronic oral administration of cilostazol in human sub-
jects has been reported to cause a small increase in heart
rate (>10 beats min−1) [20]. These effects are due to pho-
phodiesterase inhibition. All the healthy subjects well
tolerated the study drugs and their combinations.
In conclusion, coadministration of G. biloba either
with cilostazol or clopidogrel did not enhance antiplate-
let activity compared with individual agents. Ginkgo
biloba potentiated the bleeding time prolongation effect
of cilostazol. No statistically significant correlation
exists between prolongation of bleeding time and inhi-
bition of platelet aggregation. The results of our prelim-
inary study need further confirmation of interactions of
G. biloba with these drugs on chronic administration.
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