Table 6 Assessment of Herb/Dietary Supplements (HDS) -Conventional Medicine (CM) Interactions

Cod liver oil

Aspirin [4]

Clopidogrel [1]

Warfarin [1]

Simvastatin [3]

Atorvastatin [2]

Rosuvastatin [1]

Heparin [1]

Both have antiplatelet properties, but the combination did not cause any problems in any of the 4 patients and no previous clinical reports are available.

Both have antiplatelet properties, but the combination did not cause any problems and no previous clinical reports are available.

Cod liver oil and warfarin both increase INR. This combination has not caused any problems in the patient, no clinical reports are available, and was assessed as unlikely to be harmful.

Both have cholesterol-lowering properties. The combination did not cause problems in the patients.

As for simvastatin.

As for simvastatin

Cod liver oil has antiplatelet effects and increase INR, and heparin is an anticoagulant, but the but the patient did not experience problems, possibly due to being monitored for heparin effects.

Glucosamine

Insulin [1]

Doxorubicin [1]

Epirubicin [1]

Paracetamol [4]

Endogenous glucosamine is involved in glucose metabolism but studies suggest that it is unlikely to affect diabetic control in patients taking insulin.

Glucosamine has produced a modest resistance to doxorubicin in colon and ovary cancer cells in vitro but the effect has not been confirmed in vivo, and was assessed as unlikely to be harmful.

As for doxorubicin, and therefore assessed as unlikely to be harmful.

Glucosamine sulphate may reduce the efficacy of paracetamol (2 previous reports), by increasing paracetamol sulfate conjugation, but the combination did not cause any problems in our 4 patients.

Omega 3

Dipyridamole [1]

Aspirin [4]

Simvastatin [1]

Pravastatin [1]

Omega-3 oils and dipyridamole all have antiplatelet properties. However, this combination did not cause ADEs in the patient, and was assessed as unlikely to be harmful.

Omega-3 oils and aspirin both have antiplatelet properties. However, it did not cause ADEs in the patient, no other clinical reports are available so it was assessed as unlikely to be harmful.

Omega-3 oils and simvastatin have cholesterol-lowering properties. However, the combination did not cause ADEs in the patient.

As above (for simvastatin) as omega-3 oils and pravastatin have cholesterol-lowering properties.

Fish oil

Simvastatin [2]

Warfarin [1]

Fish oil and simvastatin both have cholesterol-lowering properties. This combination did not cause any problems in the two patients taking it.

Fish oil and warfarin both increase INR, but the patient did not experience problems, possibly due to being carefully monitored for warfarin effects.

Garlic

Atorvastatin [1]

Heparin [1]

Garlic and statins lower plasma cholesterol but the but the patient did not experience problems.

Garlic has antiplatelet effects and increases INR, and heparin is an anticoagulant, but the patient did not experience problems, possibly due to being carefully monitored for heparin effects.

Senna

Paracetamol [3]

It has been suggested that senna may reduce the absorption of paracetamol based on weak experimental evidence but our 3 patients did not experience problems.

St John’s wort

Omeprazole [1]

St John’s wort may lower plasma concentrations of omeprazole but there are no clinical reports.

Eicosapentaenoic acid (EPA)

Dalteparin [1]

EPA has antiplatelet properties and may add to the effects of anticoagulants such as dalteparin. However, the patient has not experienced any adverse effects.

St John’s wort

Amitriptyline [1]

St John’s wort may lower plasma concentrations of amitriptyline but no harmful clinical reports have been recorded and the patient did not experience any problems.

Green tea

Clopidogrel [1]

It has been suggested that green tea may have additive effects with antiplatelet drugs such as clopidogrel but no clinical reports are available and the combination was assessed as not harmful.

Garlic

Lisinopril [1]

A single report of garlic with lisinopril in 1996 suggested the combination lowered blood pressure more than expected, but the patient did not experience any problems and garlic is taken widely.

Ginkgo

Omeprazole [1]

Risperidone [1]

A clinical study found that ginkgo modestly induced the metabolism of omeprazole but a later study concluded that it was not clinically relevant. The patient reported no harmful effects.

Priapism was previously reported in a patient taking risperidone and ginkgo. Risperidone alone causes priapism (rarely) and our patient did not experience this.

St-John’s Wort

Amlodipine [1]

St-John’s Wort is an inducer of CYP3A4 so the combination may lower plasma concentrations of amlodipine, decreasing hypotensive effects. However, the patient was being checked regularly and reported no ADEs, so the combination was assessed in retrospect as not harmful.

St-John’s Wort

Sertraline [1]

The combination of St John’s wort and sertraline may lead to serotonin syndrome (reported in 4 previous studies). This combination is contra-indicated but the patient was no longer taking it.