More MS news articles for July 2000

Herbs and prescriptions can make a risky mixture

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By Josh Fischman

The pages of doctors' journals are filling with tales of medical mayhem. Patients on blood thinners bleed from the eyes, epileptics suffer seizures in spite of their prescriptions, diabetics have wild blood-sugar swings. Just a few weeks ago, in the Archives of Internal Medicine, doctors announced they weren't able to measure safe levels of a tried and true heart drug in a patient. The cause? Plants.

Herbs like licorice, Siberian ginseng, and ginkgo biloba are being shaped into pills and sold in neighborhood supermarkets as well as through national fitness magazines. Fifteen million Americans on prescription drugs also take herbal pills or teas, trying to goose their memories, boost energy, aid sleep, and ease digestion. Yet most of them don't tell their doctors what they're using-herbs are natural and seem so benign.

Not always. Some herbals may indeed be gentle remedies. But using them with prescription drugs can be a dangerous mix. They can block drugs' actions, letting illnesses run rampant. Or they can add to the drug effects, producing an overdose.

Eleanor Willis-Camara found out just how nasty such mixtures can be after she was rushed to a hospital, semiconscious and bleeding internally. "Perhaps it was the ginkgo I was taking to make my brain work better, along with my other drugs," says the 50-year-old telecommunications company worker from Washington, D.C. Kim Bullock, an emergency department physician who helped treat Willis-Camara at Washington's Providence Hospital at the end of last year, says that along with the ginkgo, Willis-Camara was taking a migraine medicine that contains aspirin. "That's a blood thinner, and ginkgo keeps blood from clotting quickly," says Bullock. "We'll probably never know exactly what happened, but she'd been bleeding for three weeks and was covered with bruises, which means bleeding under the skin. She was taking a lot of the migraine pills, and with the ginkgo this could have easily prolonged her bleeding."

No more ginkgo. The bleeding certainly prolonged Willis-Camara's stay in the intensive care unit, which lasted a full week. Her discharge instructions: no more ginkgo. "I didn't want to do that, because I thought the ginkgo was helping me," she says. "But the whole experience was so terrifying that I've left it alone."

What worries doctors is that patients don't like talking about what they're taking. "You can't just ask, 'Are you taking herbal medications?' because the answer will be 'No,' " Bullock says. "People don't consider these real drugs, or they're embarrassed to admit they're using them. You have to break it down: 'Are you taking any plants? Any teas?' "

It's also hard for doctors and patients to get scientific information. Congress and the courts say that herbs, as long as they don't claim to treat a specific disease, are not prescription drugs. So the Food and Drug Administration can't require elaborate safety and effectiveness trials that often reveal hazardous drug interactions. "Clinical studies just haven't been done, so what we're left with is what might happen, based on the chemistry," says Lucinda Miller, editor of the Journal of Herbal Pharmacotherapy.

Despite that, herbal drug makers argue that demands for more extensive tests are, well, unnatural. "Plants are safer than synthetic drugs made in a chemist's vat" because medicinal herbs have been used reliably by people for centuries, says Joseph Betz, vice president for scientific and technical affairs of the American Herbal Products Association, which promotes the use of herbal medicines. Doctors have found that saw palmetto, for example, seems as good as the standard treatment for an enlarged prostate (one without cancer) and may have fewer side effects.

But even doctors who think herbals have benefits would like to understand more about their effects and interactions. "I really want to know what happens in a patient," says Bruce Barrett, a physician who teaches family medicine at the University of Wisconsin-Madison.

No dosage control. The biggest trouble with herbals, he adds, "is that manufacturers don't have to show how much of the active chemical is in a pill." A bigger dose can mean a dangerous interaction while a smaller dose works out just fine, but you don't know what you're getting. The American Journal of Health-System Pharmacy is about to publish a study of 20 herbal products that are supposed to contain ephedra, a stimulant. The actual contents varied enormously, ranging from 0 to over 154 percent of what was claimed on the label. That kind of error, in a prescription drug, would lead to a recall.

Other countries have done a better job of labeling and testing herbals. Germany's Commission E, a government agency, has the most complete information. The American Botanical Council in Austin, Texas (www.herbalgram.org; 512-926-4900), publishes a translation of the German work for a pricey $165; a shorter and more reader-friendly version costs $50. The FDA's Office of Special Nutritionals has a Web site that lists herbal side effects (vm.cfsan.fda.gov). But reports on the site can be submitted by anyone, and there's no fact-checking of the reported effects.

Patients' best bet for avoiding herb-drug snafus is to talk to doctors about the herbs they are taking, just as they would talk about using anticholesterol drugs or Maalox. "This is getting harder as more people take more herbs," Bullock says. "From womb to tomb, this is a real problem." But a frank conversation might keep the tomb end of things to a minimum.
 

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Eight popular herbal remedies, medical experts say, may produce nasty combos.

LICORICE

KARELA KAVA MA HUANG MATE AND GUARANA SHANKAPULSHPI SIBERIAN GINSENG ST. JOHN'S WORT Sources: Archives of Internal Medicine, Nov. 9, 1998; Lancet, Jan. 8, 2000