pureheart

Potential Drug Interactions and Adverse Effects of Commonly Used
Herbal Remedies and Alternative Medications


Capsaicin Chamomile* Echinacea * Ephedra * Feverfew* * Garlic* *
Ginger* Ginkgo* * Ginseng* * Gossypol Glucosamine & Chondroitin
Hawthorne Kava Kava* * Kelp Licorice Melatonin Phytoestrogens Saw
Palmetto St.John's Wort * Valerian *

* ANTICOAGULATION CONCERNS
* PREOPERATIVE SURGICAL CONCERNS

CAPSAICIN General Info Capsaicin is the active ingredient in the
extract of hot peppers. It is most concentrated in the rib or
membrane, less in the seeds, least in the flesh. Capsaicin for
medicinal use comes from Capsi*** fructescens, a species of the
cayenne pepper.

Mechanism of Action Capsaicin depletes substance P in afferent type C
sensory nerve fibers and affects only proprioception. Unlike other
treatments for neuropathy, such as local anesthetics, opiates,
anti-seizure medications or tricyclic antidepressants, capsaicin
specifically treats pain without impairing other aspects of the
nervous system. In incomplete depletion of substance P from suboptimal
use, it may cause parodoxical increase of pain.

Uses Post-herpetic neuralgia, post-mastectomy pain,
hemodialysis-associated pruritus, psoriatic itching and pain, painful
neuropathies, especially diabetic neuropathy, and other superficial
neuropathies.

Doses Creams of varying potency from 0.01% and 0.075% applied 4-5
times daily for at least four weeks. Because of local side effects, it
is advisable to start with low potency creams and increasing in
potency as tolerated. Less frequent application, such as once or twice
daily, can actually lead to increased pain. Older patients, especially
those with long-standing post-herpetic neuralgia, may require several
years of therapy and may even need lifelong treatment.Capsaicin is
also available as fresh and dried peppers, capsules, tablets, and
tinctures.

Precautions Because of potential respiratory toxicity, avoid
concentrations greater than 0.1%. Higher concentrations are also more
likely to cause local chemical irritation. Wear gloves during
applications, avoiding contact with eyes and mucous membranes; do not
use on open abrasions and open wounds.

Formulation Approved for external application, capsaicin is also
available as tablets, capsules and tinctures.

Capsaicin and Dyspepsia In a small trial in Italy (Dr. Mauro
Bortolotti et al, University of Bologna), 30 patients with functional
dyspepsia were randomized on daily capsules of 2.5 g of red pepper or
placebo. The capsaicin content
(trans-8-methyl-N-vanillyl-6-nonenamide) was 0.7 mg/g of red pepper
power. After 3 weeks, upper gastrointestinal symptoms of epigastric
pain, fullness, nausea and early satiety were all significantly
reduced in the capsaicin group and not in the placebo group. The
mechanism of action is believed to be the desensitization of gastric
nociceptive C fibers, which carry pain sensations to the central
nervous system. (NEJM.346[12]:947-48,2002) Clinical Capsules. Internal
Medicine News. May15,2002


CHAMOMILE Matricaria recutita Uses
(1) As a sedative, antispasmodic, and antiseptic. (2) For peptic
ulcers; mucous membrane and anogenital inflammation. (3) To promote
wound healing.

Caution Use with caution in patients taking other sedating medications
because of possible excessive excessive sedation, drowsiness, loss of
coordination, and trouble driving or operating machinery. An active
ingredient in chamomile is coumarin.

* ANTICOAGULATION CONCERNS It is unknown whether chamomile affects
coagulation and if there is significant interaction between chamomile
and warfarin. Monitor chamomile use in patients also taking warfarin.


ECHINACEA Echinacea purpurea General Info A perennial American
wildflower belonging to the daisy family, found in the Plains states.
Different parts of the plant contain different chemicals; e.g.,
isobutylamides are in the roots of augustifolia and purpurea; cichoric
acid is in the above-ground parts of purpurea.

Mechanism of Action Stimulation of phagocytosis by macrophages;
inhibition of hyaluronidase; increase fibroblast number and properdin
levels and possible increase of interferon production.

Uses An immunostimulant used to prevent or treat the common cold and
flu. Topically for stings, bites, wounds, burns. In Europe, available
for parenteral use.

Dose
900 mg (180 drops) of an ethanolic extract of E. Purpurea roots
significantly reduced the severity and duration of symptoms of
flu-like infections. 450 mg (90 drops) were no more effective than
placebo.

Caution Possible reactions in those with a history of allergy to the
daisy family. No do***ented drug interactions. Patients receiving
immunosuppressives (cyclosporine) should be monitored for decreased
effectiveness when used with echinacea. Also, long-term use of
Ecchinacea may cause immunosuppression. Should not be used in patients
with autoimmune diseases or progressive systemic diseases as: SLE, TB
or MS. German Commission E monograph states that "the metabolic
condition in diabetes can decline upon parenteral application." Some
products may be adulterated with another similar herb, Parthenium
intergrifolium L, which has no pharmacologic activity.

* PREOPERATIVE SURGICAL CONCERNS Use for more than 8 weeks raises
concerns for postoperative immunosuppression which may theoretically
cause postsurgical complications, including impaired wound healing and
opportunistic infections. There is also concern for hepatotoxicity.

EPHEDRA Ephedra sinica, Ephedra intermedia, Ephedra equisetina,
Ephedra distachya General Info A naturally occurring substance in the
Chinese herbal Ma-Huang. Ephedrine constitutes 30 to 90 percent of the
alkaloids of Ephedra species. Ephedrine alkaloids are amphetamine-like
compounds with powerful stimulant effects on the heart and nervous
system, increasing the heart rate and blood pressure, decreasing the
appetite and providing an sense of energy-boosting.

Uses Ephedra (Ma-Huang) is found in many herbal weight-loss products
and has been called the "hebal fen-phen," promoted in some weight loss
clinics as the alternative to fenfluramine (Pondimin) and
dexfenfluramine (Redux), prescription anorexiants recently removed
from the U.S. market.

Ephedrine containing products are also marketed as decongestants,
bronchodilators, stimulants and energy-boosters. As a stimulant, it
has been marketed as an ergogenic drug for enhancement of athletic
performance and body building efforts. It has also been available as
"herbal ecstasy" with its ability to induce euphoria, heighten
awareness and ***ual sensations.

Caution Available evidence show a significant and unreasonable risk
of illness and injury from dietary supplements containing ephedra.
Adverse reactions are insomnia, nervousness, tremor, headaches,
hypertension, seizures, arrhythmias, heart attack, stroke and death.
Should not be used with MAOIs (monoamine oxidase inhibitors, ie,
phenelzine, tranylcypromine), cardiac glycosides, and antiarrhythmic
agents. FDA warnings have been issued because of its causative
relationship with hypertension, seizures, and death. It should not be
used in patients with a history of hypertension, heart disease,
arrhythmias, glaucoma or stroke. Although dosage limit has been
suggested at 8 mg every 6 hours
(24 mg per day) for ephedra alkaloids, serious side effects may occur
at much lower doses (4-20 mg per day).

An NIH report concluded that ephedra is associated with higher risks
of mild-to-moderate side effects such as heart palpitations,
psychiatric and upper gastrointestinal effects and symptoms of
autonomic hyperactivity (tremors and insomnia).

While ephedra-products make up less than 1% of all dietary supplement
sales, these products account for 64% of adverse events associated
with dietary supplements.

* PREOPERATIVE SURGICAL CONCERNS Patients on ephedra who are later on
halothane anesthesia may be a higher risk for ventricular arrhythmias.
There is also concern for hypersensitivity myocarditis. Ephedra should
be discontinued at 24 - 48 hours before surgery.


FEVERFEW Tanacetum parthenium Uses Treatment of migraine headaches,
fever, and menstrual problems. It is thought to work by decreasing the
production of prostaglandins through a mechanism different from
NSAIDs. Caution Unknown interaction with aspirin or NSAIDs.

* ANTICOAGULATION CONCERNS It appears to inhibit platelet activity
and should be used with caution by patients receiving anticoagulant
therapy (eg. warfarin, dicoumarol, heparin).


GARLIC Allium sativum Uses Lowers total cholesterol, LDL, triglyceride
levels, and blood pressure, and raises HDL cholesterol levels. It is
reported to have antibacterial, antifungal, antithrombotic,
hypoglycemic, antiinflammatory, and anticancer activity.

Cautions When garlic is used in combination with other lipid-lowering
agents (eg, atorvastatin [Lipitor], fluvastatin [Lescol], pravastatin
[Pravachol], simvastatin [Zocor], gemfibrozil [Lopid], fenofibrate
[Tricor], niacin [Niaspan], hypoglycemic agents (eg, insulin,
glyburide, glipizide, troglitazone [Rezulin], glimeripide [Amaryl],
chlorpropamide [Diabenese], tolbutamide [Orinase], or antihypertensive
agents, their effects may be increased.

* ANTICOAGULATION CONCERNS Garlic can also be used to decrease
platelet aggregation; thus, combined use with anticoagulants may
increase the risk of bleeding. Isolated reports have suggested that
garlic may increase international normalized rations (INRs). However,
none of these potential drug interactions has been adequately
do***ented.

* PREOPERATIVE SURGICAL CONCERNS The potential for irreversible
inhibition of platelet aggregration warrants stopping its use at least
7 daqys prior to surgery, especially if postoperative bleeding is of
particular concern or if other platelet inhibitors are used.


GINGER Zingiber officinale Uses Used mostly for motion sickness as an
antiemetic / antinauseant. Also used as an antispasmodic and
antiinflammatory agent. In a controlled trial in the U.S. with college
students as the subjects, compared with placebo and diphenhydramine,
ginger was most effective for reducing experimentally induced motion
sickness (students were spun in a chair). Fifty percent of the
subjects who ingested ginger remained in the chair for 6 minutes, but
none treated with either placebo or diphenhydramine was able to do so.
In Germany, ginger was approved for use in motion sickness and as a
digestive aid.

Caution
* ANTICOAGULATION CONCERNS Ginger may decrease thromboxane production
and cause prolong bleeding time and platelet inhibition. Therefore,
should be used with caution by patients receiving anticoagulant
therapy.


GINKGO BILOBA General Info

Active Ingredients Flavone glycosides have antioxidant properties:
terpenoids (ginkgolides) improve circulation; bilobalides have
neuroprotective properties. It alters vasoregulation, modulates
neurotransmitter and receptor activity and inhibits PAF (platelet
activating factor).

Uses Ginkgo is promoted to treat Alzheimer's disease and dementia,
improve memory and cognitive function, cerebral and peripheral blood
flow (claudication), tinnitus and vertigo.

Caution Some Ginkgo products may contain a neurotoxin (Ginkgo toxin)
that might increase the risk of seizures. Caution is advised in
patients requiring anticonvulsant therapy (eg, carbamazepine,
phenytoin, phenobarbital) or agents that might lower the seizure
threshold (eg, amitriptyline, imipramine, molindone [Moban],
promethazine [Phenergan], tramadol [Ultram], maprotiline [Ludiomil],
bupropion [Wellbutrin, Zyban]).

* ANTICOAGULATION CONCERNS Ginkgo therapy has been associated with
decreased platelet aggregation and spontaneous bleeding, and should be
used with caution by patients receiving anticoagulants, vitamin E,
aspirin, NSAIDs and other drugs or herbal medicinals with antiplatelet
or anticoagulant effects. A case of spontaneous bilateral subdural
hematoma has been attributed to ginkgo us.

* PREOPERATIVE SURGICAL CONCERNS The effect on PAF and platelet
aggregation may contribute to perioperative bleeding. Ginkgo use
should be discontinued at least 16 hours before surgery.


GINSENG Uses The most controversial of herbs, it has claimed benefit
for just about every human ailment with little scientific evidence to
support its myriad of claims. It has touted as an "adaptogen" (to
build up vitality and resistance to stress) and as an aphrodisiac.
There are claims on lowering total and LDL cholesterol levels. Some
ingredients raise blood pressure, and some lower it. Unfortunately, as
in many herbals claiming medicinal benefits, there is no quality
control and many preparations contain little or no ginseng. One study
looked at 10 'ginseng' products and found 7 contained no ginseng at
all. A study ****yzed 54 ginseng products; 60% contained less than the
the****utically effective levels, and an astounding 20% contained no
active ingredient. In another study, on 18 quality of life measures,
ginseng was equivalent to placebo; four quality of lilfe measures
improved, but clinical relevance was nonexistent.

Caution Nervousness and excitation can occur in the first few days of
intake. Overuse can cause headache, epistaxis, insomnia, and
palpitations. Because of ginseng's unpredictable effect on BP,
hypertensive patients should be cautioned of its use. Estrogenic
effects can cause ******l bleeding and mastalgia; patients on hormonal
therapy should avoid its use. Ginseng can also adversely interact with
monoamine oxidase inhibitor phenelzine. In general, patients should be
discouraged from using ginseng for longer than 3 months.

* ANTICOAGULATION CONCERNS Probably has an interaction with warfarin.
Patients on warfarin and dietary supplements containing this herb
should be closely monitored for a possible interaction.

* PREOPERATIVE SURGICAL CONCERNS May have an irreversible effect on
platelets and should be discontinued at least 7 days before surgery.


GOSSYPOL It is associated with renal loss of potassium, resulting in
hypokalemia. Avoid intercurrent use of gossypol with
hydrochlorothiazide or furosemide or digoxin.

GLUCOSAMINE and CHONDROITIN Uses Both components of the cartilage
matrix, have been touted as pain relievers as well as agents that
might actually slow the progression of osteoarthritis.

Studies show glucosamine stimulates the cartilage cells to synthesize
glycosaminoglycans and proteoglycan ground substance. For the past
three decades, it has been thought to be beneficial for
osteoarthritis. However studies to support this were lacking - until
recently. Studies using glucosamine sulfate, 1500 mg day, suggest a
beneficial effect on arthritis of the knee, hip, and back. A study
showed a slight but significant increase in joint space and less
progression of OA of the knees, with improvement in scores of pain and
physical function. Glucosamine sulfate seems to be more effective,
faster acting and provides far more impressive results and greater
overall benefit than chondroitin. Recent studies have shown that
glucosamine does not adversely affect blood sugar control.

Dose Glucosamine: 1500 mg daily in 3 divided doses; chondroitin
sulfate, 800 to 1,600 mg daily, the lower dosing given to patients
under 120 pounds.

Caution Glucosamine is derived from oysters and the chitin of crab
shells and chondroitin is derived from shark cartilage and bovine
trachea. Because of the nature of these sources, allergic reactions
are possible.


HAWTHORNE Crataegus laevigata, Crataegus monogyna, Crataegus
pinnatifida Uses Hawthorne is used to treat heart disease, angina,
hypertension, and sleep disorders. High doses of hawthorne can cause
depression of the CNS and hypotension.

Caution Should be used with caution in patients receiving
antihypertensive medications and other drugs reported to cause
depression of the CNS (eg, antihistamines, tricyclic antidepressants,
anticonvulsants, benzodiazepines, antipsychotics).


KAVA Piper methysti*** Uses Kava kava is used to treat sleep
disorders, anxiety, and menopausal symptoms. In the U.S., the anxious
and the insomniacs spent more than $50 million on variety of kava
products: drinks and teas, capsules and candies.

Caution When used with other sedative agents (eg, benzodiazepines,
antihistamines, anticonvulsants, tricyclic antidepressants,
antipsychotics), it may cause excessive sedation, drowsiness, loss of
coordination, and trouble driving or operating machinery. Kava
dermopathy has been reported with the use of kava as a traditional
South Pacific beverage.

An alert has been issued because of recent increasing reports of
severe liver damage in kava users with one patient needing a liver
transplant. Patients who have liver disease or who consume moderate
amounts of alcohol should avoid use of kava. Users should avoid daily
use of more than four weeks. The recommended dose is 60 to 120 mg of
the active ingredient, kavalactone.

* ANTICOAGULATION CONCERNS A specific kavalactone, kawain, appears to
decrease thromboxane 2 production and inhibit cyclo-oxygenase,
indicating that kava may have significant inhibitory effect on
platelet aggregation.

* PREOPERATIVE SURGICAL CONCERNS It has hypnotic and sedating effects
and should be discontinued at least 24 hours before surgery.

KELP Its prolonged use is associated with hyperthyroidism; should be
considered a possible etiology of atrial fibrillation with patients
with apparent lone AF. Discourage use of kelp with amiodarone.


LIQUORICE Glycyrrhiza glabra, Glycyrrhiza uralensis Uses Liquorice is
used as an antiinflammatory agent and for the treatment of peptic
ulcers. This liquorice is not, however, found in most candy that is
labeled as "licorice."

Caution Liquorice has mineralocorticoid properties and may cause
pseudoaldosteronism with sodium and water retention and hypokalemia.
Therefore, liquorice may decrease the effectiveness of
antihypertensive agents and diuretics. In addition, it may increase
the risk of hypokalemia when used with non-potassium sparing diuretics
(eg, chlorothiazide [Diuril], furosemide [Lasix], bumetanide [Bumex],
torsemide [Demadex], metolazone [Zaroxolyn]). The effects of digoxin
(Lanoxin) and other digitalis glycosides can be increased if the
liquorice does cause hypokalemia. With low potassium, digitoxicity may
occur with the****utic digoxin levels.


MELATONIN Mel, Melatonex General Info Pineal gland hormone whose
synthesis / secretion is controlled by the prevailing light-dark
environment, via the hypothalamic suprachiasmatic nuclei (SCN). It is
synthesized from serotonin. Nocturnal secretion of melatonin and its
main metabolite 6-sulphatoxy melatonin (6-hydroxy melatonin sulfate)
is highest in young children and falls with age.

In the US, synthetic melatonin is sold over-the-counter as a "food
supplement" because it is naturally found in small amounts in some
foods (e.g., bananas and rice). Like other supplements sold in the US
market before October 15, 1994, melatonin was exempted from federal
drug laws and was considered as a food supplement by the Dietary
Supplement Health and Education Act of 1994. There are no natural
extract versions of melatonin currently available. The US retail
market for melatonin is estimated at $200-350 million annually.

Some studies have suggested melatonin may enhance immune response by
increasing IL production by T-helper cells and free radical
scavenging.

Uses Although melatonin has been studied for cyclic mood disorders,
***ual maturation and reproduction, its main use is for "jet lag" and
as a sleep aid. Studies supports the use of melatonin for short-term
treatment of jet lag. Caution must be exercised since melatonin is a
recombinant human hormone, and the safety of long-term use has not
been evaluated. A recommended jet lag protocol is: 0.3 mg synthetic
melatonin tablets: (1) For eastward travel, take preflight melatonin
in the late afternoon of departure and take post-flight melatonin for
four days after arrival at local bedtime. (2) For westward flights,
take melatonin at local bedtime for four days after arriving with a
second smaller dose if there is early morning awakening. It should not
be taken for more than one month at a time and not more than 0.5 mg
per day, as long-term studies are not yet available. ·

Adverse Effects Sleepiness, impaired libido, mild depression at
greater doses. Nausea, headache, nightmares. Possible decreased
alertness and reproductive effects

Drug interactions with beta-blockers, CNS depressants, androgens and
estrogens, SSRIs and MAOIs.

RECOMMENDATIONS Use only synthetic melatonin and start with the
lowest possible dose (available as 0.3, 1.5, 3.5, 10 mg) 1-2 hours
before bedtime.

CAUTION Do not use during pregnancy, lactation, in children, or if
trying to conceive. Do not use if a patient has immune-system cancers.
Do not use if a patient is on any drug that may interact with
melatonin.

PHYTOESTROGENS General info Phytoestrogens are nonsteroidal plant
compounds resembling estradiol (E2), with both estrogenic and
anti-estrogenic activities. They are found in many fruits, vegetables
and grains, but leguminous seeds are especially rich in these
compounds.

There are 3 main classes of phytoestrogens: flavanoids, coumestans,
and resorcyclic acid lactones. Isoflavones have the most potent
hormonal-like activity and an extensive range of biological activities
in the body. More than 1,100 isoflavanoids are known, exclusively
found in leguminous seeds such as soybeans, chickpeas, lentils and
beans. The most important isoflavones are genistein, daidzein,
glycetin, formonetin, and biochanin. Soybeans, besides being an
excellent sourse of isoflavones, is also rich in daidzein and
genistein.

Ipriflavone (7-isopropoxyisoflavone) is a synthetic isoflavone
derivative used in several countries in Europe, in particular Italy,
and in Japan, for prevention and treatment of osteoporosis. In the US,
ipriflavone (IP) is available as a dietary supplement.

Uses Phytoestrogens are used to treat the symptoms of menopause.
Phytoestrogens (eg, coumestrol, genistein, daidzein, biochanin A,
formononetin) can be found in foods such as soy, lentils, broad beans,
chick-peas, and red clover, as well as nonprescription products (eg,
Promensil).

Doses Isoflavone consumption in Eastern countries is in the order of
20-150 mg/d (average 40 mg/d), as compared with 2-5 mg/d in Western
countries. In adults consuming 50 mg/d total isoflavones (such as
found in traditional Japanese diet) a plasma isoflavone concentration
of 50-800 ng/ml may be achieved, far exceeding normal plasma estradiol
concentrations (40-80 pg/ml).

Persons with risk factors for osteoporosis should consume about 14
servings of soy protein per week. This would provide an average of
approximately 16-20 g of soy protein/d with 32-40 mg of isoflavones/d.
Persons with osteoporosis should consume 21 servings of soy protein
per week, which would yield about 24-30 g of soy protein and 48-60 mg
of isoflavones daily.

The average dose recommendation of isoflavone dietary supplements is
40 mg/d of aglycone isoflavones. Doses of 40-160 mg/d have been used
in humans with a favorable side effect profile. The usual dose of IP
(ipriflavone) is 200 mg tid.

CAUTION Some of the phytoestrogens do have significant activity at the
estrogen receptors. When phytoestrogens are used in combination with
estrogen-containing products, the risk of estrogen-related side
effects (eg, nausea, bloating, breast fullness or tenderness) may be
increased. Isoflavone dietary supplements should be avoided in
pregnancy and lactation.There are concerns with the use of high doses
of isoflavones by patients with hormone-sensitive cancers. Until use
in cancer patients is more carefully evaluated, concentrated
supplements should be taken with caution. It is unknown if
phytoestrogens will decrease the effectiveness of tamoxifen (Nolvadex)
or raloxifene (Evista).


SAW PALMETTO Serenoa repens USES Saw palmetto is used for the
treatment of benign prostatic hypertrophy and as a diuretic and
urinary antiseptic. It appears to inhibit both dihydrotestosterone
binding at the androgen receptors and 5-alpha-reductase activity on
testosterone. CAUTION Whether saw palmetto can increase or decrease
the effectiveness of doxazosin (Cardura), terazosin (Hytrin), and
finasteride (Proscar) is unknown.


ST. JOHN'S WORT Hyperi*** perforatum Uses The mechanism of action of
St. John's wort has not been fully established but likely is involved
with inhibition of serotonin, norepinephrine and dopamine reuptake.
St. John's wort also utilizes the cytochrome P450 system which affects
the metabolism of more than 50% of all drugs. It also inhibits GI
absorption, including the P-glycoprotein enzyme system with
wide-reaching effects. It is used for the treatment of anxiety,
depression, and sleep disorders.

Caution It is commonly stated to be a MAOI and a selective serotonin
reuptake inhibitor. If the MAOI properties were significant, we should
have seen reports of elevated blood pressure in patients concomitantly
receiving decongestants, Ma Huang, and other sympathomimetic products.
However, caution should be used if the patient is taking St. John's
wort and a sympathomimetic agent or other MAOIs (eg, phenelzine
[Nardil], selegiline [Carbex, Eldepryl], furazolidine [Furoxone]),
especially in patients with hypertension or arrhythmias.

The risk of serotonin syndrome may be increased when St. John's wort
is used in combination with other serotonergic agents: tricyclic
antidepressants, SSRIs (Prozac, Paxil, Zoloft), lithium,
dextrometorphan. The serotonin syndrome is a hyperserotinergic
condition that can have very dangerous side effects. Signs and
symptoms of serotonin syndrome may include euphoria, drowsiness,
sustained rapid muscle contraction and relaxation in the ankle,
causing abnormal movements of the foot; clumsiness, restlessness;
dizziness; sweating, muscle twitching, rigidity, high body
temperature; mental status changes, including confusion and hypomania;
shivering, diarrhea, and loss of consciousness.

St. John's wort has had do***ented interactions with cyclosporine,
amitriptyline, digoxin, indinavir (49 % to 99% reduction in serum drug
levels), warfarin, phenprocoumon, theophylline, oral contraceptives,
SSRIs, and loperamide. In addition, St. John's wort may increase the
risk of photosensitivity reactions when used with other
photosensitizing agents (eg, tetracycline, doxycycline,
fluoroquinolones, interferons, felbamate [Felbatol], griseofulvin,
isoretinoin [Accutane], porfimer [Photofrin]).

* PREOPERATIVE SURGICAL CONCERNS May increase the metabolism of drugs
utilized in perioperative care, including cyclosporine, midazolam,
lidocaine, and calcium channel blockers. Use should be discontinued at
least 5 days before surgery.


VALERIAN Valeriana officinalis

General Info A traditional herbal sleep remedy. Chemical constituents
are sesquiterpenes of the volatile oil (valerenic acid), iridoids
(valepotriates), furanofuran lignans, free amino acids, and alkaloids.
The sesquiterpine components are believed to be responsible for its
biologic effects. Studies have suggested direct sedative effects
(valepotriattes, valeric acid) and interaction with neurotransmitters
such as GABA.

As a food supplement, it is not subjected to regulatory control beyond
labeling requirements. FDA classifies valerian as GRAS.

Has the characteristic odor of dirty socks.

Uses Anxiolytic, sedative, and tranquilizer. It appears to be a safe
sedative/hypnotic choice for mild to moderate insomniacs wihtout the
hangover-sleepiness of benzodiazepines. It is also used for mild
anxiety; however supporting data is limited.

Although with poorly defined effects on GABA neurotransmission, it may
attenuate benzodiazepine withdrawal symptoms.

Side Effects The adverse effect profile and tolerability of valerian
are excellent. However, long-term safety studies are lacking.

According to Commission E, there are no contraindications to valerian.

Adverse effects are rare and mild: gastrointestinal (nausea) and
headaches (migraine). A report of an overdose of valerian with 40-50
capsules (20 times the recommended dose) resulted in mydriasis,
fatigue, abdominal cramping, chest tightness, lightheadedness, and
foot-hand tremor that resolved in 24 hours. Lab tests, including liver
funtion tests, were normal.

Doses and Recommendations Use 300-600 mg one hour before bedtime for
insomnia, bid for anxiety. Must contain 0.5% essential oil (valerenic
acid).

For use as dried herbal valerain root, 2 to 3 g is soaked in one cup
of hot water for 10-15 minutes and ingested 1/2 to 2 hours before
bedtime.

Caution No significant herbal/drug interactions with valerian have
been reported. It may potentiate the sedative effects of barbiturates,
anesthetics and CNS depressants. Although not synergistic with
alcohol, concomitant use is not recommended. Withdrawal may occur with
sudden ceasation after high-dosage long-term use. Use in pregnancy is
not recommended.

* PREOPERATIVE SURGICAL CONCERNS Valerian produces dose-dependent
sedation and hypnosis and can potentiate the sedative effects of
anesthetics and adjuvants such as midazolam. Taper use over several
weeks before surgery as sudden discontinuation may result in a
benzodiazepine-like withdrawal.


SOURCES Eight Herbal Agents To Stop Before Surgery: Mitchel Zoler.
Internal Medicine News. May 1, 2003 New Report may signal end of
ephedra products: Jeremy Moore. Today in Cardiology. May 2003
Valerian. Susan Hadley MD, Judith Petry MD. American Family Physician.
April 15,2003. Vol 67, No 3. Herb-drug Interactions, Robert Bonakdar
MD, Patient Care/January 2003 (http://www.patientcareonline.com) Potential
Drug Interactions with Common Herbal Remediesaniel E. Baker, PharmD.
Capsaicin (Hot Pepper Extract for Neuropathic Pain) David
Schiedermayer, MD, FACP Glucosamine: Hope or Hype? Patient Care. July
15, 1999 Q&A with Roland Moskowitz, MD. Consultant. June 2000
Melatonin for Jet Lag. Joshua Ofman, MD & Jay Udani, MD Phytoestrogens
: Use in Osteoporosis; Nicole Nisly, MD and Teresa Klepser, PharmD.
Alternative Medicine Alert. Dec 1999 Herbal Remedies: Adverse Effects
and Drug Reactions; Melanie Cupp, Pharm.D.American Family Physician /
Mar 1, 1999

http://www.stuartxchange.org/DrugInteractions.html