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 Table 6: Herbal-Drug Interactions of Clinical Concern Herbal-Drug Interaction*
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.
Interaction Rating by Lexicomp and the Natural Medicines Comprehensive Database
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 Risk rating = B Level of evidence = B Severity = Moderate Occurrence = Probable Risk rating = B Level of evidence = B Severity = Moderate Occurrence = Possible Risk Rating = D 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 = B Severity = Moderate Occurrence = Probable Risk rating = C Level of evidence = D Severity = High Occurrence = Possible Risk rating = D Level of evidence = B Severity = High Occurrence = Possible Risk rating = B Level of evidence = B Severity = Mild Occurrence = Probable Risk rating = A Level of evidence = A Severity = High Occurrence = Possible Risk rating = B Level of evidence = B Severity = Moderate 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.
Black cohosh – CYP2D6 substrates (codeine and hydrocodone)
Black cohosh can modestly inhibit CYP2D6 and increase levels of drugs metabolized by this enzyme.
Echinacea – CYP1A2 substrates (acetaminophen and diazepam)
Echinacea can increase levels of drugs metabolized by CYP1A2, such as acetaminophen and diazepam.
Echinacea – Glucocorticoids (dexamethasone, prednisone, and methylprednisolone) Elderberry – Glucocorticoids (dexamethasone, prednisone, and methylprednisolone)
Echinacea might interfere with immunosuppressant therapy because of its immunostimulating activity.
Elderberry might interfere with immunosuppressant therapy because of its immunostimulating activity.
Fenugreek – Glucose
Fenugreek may lower blood glucose levels; be aware of use in patients with diabetes.
Fenugreek – Antiplatelet or anticoagulant agents (aspirin and ibuprofen)
Fenugreek can increase the risk of bleeding when used with anticoagulant or antiplatelet drugs.
Ginger – Antiplatelet or anticoagulant agents (aspirin and ibuprofen)
Ginger can increase the risk of bleeding when used with anticoagulant or antiplatelet drugs.
Gingko – alprazolam
Ginkgo might decrease the levels and clinical effects of alprazolam.
Gingko – Antiplatelet or anticoagulant agents (ASA, ibuprofen and warfarin)
Ginkgo has been shown to increase the risk of bleeding in some people when taken with warfarin. Theoretically, ginkgo might increase the risk of bleeding if used with other anticoagulant or antiplatelet drugs. Ginkgo can increase levels of drugs metabolized by CYP1A2 such as local anesthetics.
Gingko – CYP1A2 substrates (local anesthetics except articaine)
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