The Natural Medicines Comprehensive Database rates herbal-drug interactions with a traffic-light grading system (Table 4). Red-light interactions should be avoided, as these supplement-medication combinations are contraindicated and serious adverse outcomes could occur. Yellow-light interactions indicate caution and perhaps avoidance of the combination unless the benefits outweigh the risks. Green-light interactions indicate minimal risk of combination therapy. Both of these databases report interactions according to likelihood of occurrence, severity, and level of evidence, which aids in validating concurrence of data (Table 5). Regardless, patients should always be advised to be aware of warning signs of a potential interaction, however insignificant the reaction may seem. Table 4: The Natural Medicines Comprehensive Database Level of Interaction Significance for Herbal- Drug Interactions Likely Probable Possible Unlikely High Moderate Mild Insignificant Red = Major risk; do not use the combination; contraindicated; strongly discourage patients from using this combination; a serious adverse outcome could occur. Yellow X = Moderate risk; use cautiously or avoid the combination; warn patients that a significant interaction or adverse outcome could occur. Green = Minor risk; be aware that there is a chance of an interaction; advise patients to watch for warning signs of a potential interaction. Note. Adapted from “About Natural Medicines Comprehensive Database,” by the Natural Medicines Comprehensive Database, n.d.a, retrieved from http://naturaldatabase.therapeuticresearch. com/Content.aspx?cs=&s=ND&page=aboutdbhtml&xsl=generic #ratings
Table 5: Additional Modifiers Regarding the Likelihood of Occurrence and Severity of Herbal-Drug Interactions Likelihood of Occurrence Likely Clinical research indicates that this interaction is likely to occur in most patients. Probable Clinical research or pharmacokinetic studies in humans suggest that this interaction will occur in a significant portion of patients.
Possible
Clinical research, pharmacokinetic data in humans or animals, or in vitro research suggests that this interaction might occur in some patients. Clinical research, pharmacokinetic data in humans or animals, or in vitro research suggests that this interaction can occur, but is not likely to occur in many patients. Life-threatening or severe impairment is possible. Moderate impairment or significant discomfort is possible.
Unlikely
Severity High
Moderate
Mild
Mild impairment or mild discomfort is possible. Insignificant Drug levels may be affected, but a clinically significant interaction is not likely. Note. Adapted from “About Natural Medicines Comprehensive Database,” by the Natural Medicines Comprehensive Database, n.d.a, retrieved from http://naturaldatabase.therapeuticresearch.com/Content.aspx?cs=&s=ND& page=aboutdbhtml&xsl=generic#ratings Herbal-drug interactions may be generally classified as pharmacodynamic (what the drug does to the human body) or pharmacokinetic (what the human body does to the drug – absorption, distribution, metabolism, and elimination), based on the mechanism of action (Donaldson & Touger- Decker, 2013; Ismail & Bader, 2004; Radler, 2008). Many of these types of interactions may be theoretical. This course is based, however, on a search of evidence-based interactions of greatest clinical concern between medications commonly used by dentists and those herbal supplements most commonly used in the United States. This compilation is most clinically useful for practicing OHCPs and their teams. Table 6 summarizes these findings, which are described in greater detail later in this course. Results were limited to the two highest levels of medical evidence (“A” and “B”), and if the likelihood of occurrence was remote or the severity of the interaction was insignificant, the outcomes were not reported. Table 7 lists the different descriptions of levels of evidence.
Table 6: Herbal-Drug Interactions of Clinical Concern
Interaction Rating by Lexicomp and the Natural Medicines Comprehensive Database
Herbal-Drug Interaction*
Implications for Dentistry
Apple Cider Vinegar - Antiplatelet or anticoagulant agents (aspirin and ibuprofen)
Risk rating = B Level of evidence = B Severity = High Occurrence = Possible Risk rating = B Level of evidence = B Severity = High Occurrence = Possible Risk rating = B Level of evidence = D Severity = High Occurrence = Possible
Capsicum found in apple cider vinegar may increase the risk of bleeding if used with anticoagulant or antiplatelet drugs.
Ashwagandha – antidiabetes drugs
Taking ashwagandha with antidiabetes drugs might increase the risk of hypoglycemia.
Ashwagandha – central nervous system depressants and antianxiety agents
Ashwagandha might increase the sedative effects of benzodiazepines. barbiturates, other sedatives, and anxiolytics.
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