International Journal of Human and Health Sciences Vol. 02 No.

04 October’18

Review Article
Herbal Products and Conventional Drugs – an Uneasy Alliance
Glynn J1, Bhikha R2
Abstract
This review examines the interaction between herbal remedies and conventional (orthodox)
drugs. There has been a substantial increase in the consumption of herbal remedies in
recent times for various reasons. They are often combined with one another, and are often
used simultaneously with conventional drugs that are taken for a wide range of disorders,
both acute and chronic. The probability of a real and substantial interaction between the
therapeutic agents originating from different medical paradigms is likewise expanding.
Whilst most of the herb-drug interactions are undoubtedly minor, benign, and harmless,
there are reports of more serious interactions. Possible reasons for specific herb-drug
interactions are examined, particularly from the pharmacokinetic and pharmacodynamics
perspectives.
Keywords: herbals; pharmaceuticals; interaction; pharmacokinetics; pharmacodynamics.

International Journal of Human and Health Sciences Vol. 02 No. 04 October’18 Page : 193-198
DOI: http://dx.doi.org/10.31344/ijhhs.v2i4.55
Introduction in action. Herbs are increasingly being used
There has been a major resurgence of interest in these days as therapeutic agents, or combined
herbalism in the last 30 or 40 years.1 This interest with minerals and vitamins in health enhancing
may be directed towards herbalism itself or to it as supplements, or in invigorating tonics and teas.
a popular component of complementary medical Although the benefits of herbal medicine are vast,
practice.2 This trend has been given impetus by real it is essential to understand the basics of herbal
misgivings about the negative aspects of numerous medicine and to accept that some herbal medicines
conventional drugs. There is growing concern can have negative impacts on health, especially if
about the short term downside to drugs, especially conventional drugs are being consumed at the same
the newer ones, regarding the impact of adverse time. One of these relates to herb-drug interaction.
drug reactions, and suspicions about the real extent Background
to which they occur.3 It reflects the urge towards a Herbal medicine, like many natural or traditional
more natural lifestyle, and a new-found respect for therapies, has been around for many hundreds of
natural or holistic healing. Herbal medicine deals years. Virtually every society or culture has adopted
with the underlying disharmony which manifests it in one form or another. Even today, in spite of
during the onset of a chronic or recurring disease.4 the massive inroads achieved by conventional
This ‘whole picture’ approach differs from that medicine and synthetic drug usage, around 80% of
of conventional medicine, which is concerned the world’s population uses it to a greater or lesser
primarily with alleviating the patient’s symptoms extent.5,6 It may be stand-alone therapy, especially
and normalizing signs such as laboratory for the minor complaints affecting us all, or it may
parameters. Unlike with conventional medicine, be part of a more comprehensive complementary
the administration of herbal products, alone or healing system, where it is combined with traditional
as part of a broader complementary or traditional systems such as Tibb or Ayurveda for chronic
medical strategy, is a good example of holism and recurring disorders.7 Until well into the latter

1. John Glynn, IbnSina Institute of Tibb, 1137 Anvil Road, Robertville, Roodepoort, Johannesburg,
South Africa (Researcher)
2. Rashid Bhikha, IbnSina Institute of Tibb, 1137 Anvil Road, Robertville, Roodepoort,
Johannesburg, South Africa, (Chairperson)

Correspondence to: Rashid Bhikha, IbnSina Institute of Tibb, 1137 Anvil Road, Robertville,
Roodepoort, Johannesburg, South Africa, Email: [email protected]; Phone: 0119917323.

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part of the 20th century, complementary medicine the patient’s innate self-healing processes and so
in general and herbal medicine in particular helping restore normal harmony and rhythm.10
took a ‘back seat’, especially in the developed Herbal remedies do not subscribe to the ‘quick
world, and was perceived as the poor cousin to fix’ philosophy of conventional medicine. By
conventional, orthodox or western medicine. The adopting herbal medicine integrated with lifestyle
increasingly sophisticated but destructive practice modification, the chronic malady is not only
of many alternative practitioners – “quacks” more likely to be ameliorated, but the chances of
– who systematically sullied the herbalists’ recurrence greatly reduced.10
reputation, encouraged, understandably, a fierce Overview of conventional drugs
backlash against complementary medicine which By conventional drugs we mean either (a)
accelerated its decline in usage. There were pharmacological single entities which have been
also numerous other obstacles in the way of the derived by chemical synthesis – the so-called new-
widespread use of herbal products.1 They included to-nature drugs; or (b) single chemical derivatives
reliability and variation of pharmacological action, of naturally occurring pharmacologically active
lack of credibility, possible toxicity, and doubts substances detected in, and isolated from,
about the authenticity of the product. Even so, a members of the plant, fungus, bacterial, or animal
number of herbs have now established themselves world.11,12 The first category includes laboratory
in the therapeutic mainstream as both effective and originated drugs such as the ACE inhibitors,
safe for defined clinical disorders.5 This has led beta blockers, proton pump inhibitors, and non-
to many people combining herbal medicines with steroidal anti-inflammatories. The second category
conventional drugs in a healing practice known includes morphine, theophylline, colchicine, and
as Integrative Medicine, resulting in increased other drugs derived from plant alkaloids; immune
frequency of herb-drug interactions.8 Most of these suppressants such as cyclosporine from soil
are minor, often barely noticeable. However, some fungus, most antibiotics, and human hormones
interactions can not only affect clinical response, and cytokines, such as insulin and interferon. They
but also lead to troubling adverse reactions or side may be used singly, or, more often, they may be
effects. This review examines the nature of these administered combined with other conventional
interactions, and how they manifest. drugs. This is done either to enhance the desired
Herbal medicines clinical effect, or to ameliorate the negative side
A herb, as described in the Concise English effects of the principal drug.
Dictionary, is any non-woody, seed-bearing plant Generally speaking, the prime objective of
which dies down to the ground after flowering, conventional drug therapy is to alleviate the
whose leaves, seeds, flowers, or other parts can patient’s troubling symptoms.13 The relief of
be used to improve health, combat disease, for pain, depression, digestive disorders, movement
food and its flavoring, and improve environmental problems, for example, is paramount. The
quality with scents. secondary objective is to restore the presenting
Herbal medicines are finished, labelled medicines signs to normal. These days this usually refers
containing pharmacologically active parts of a to one or more of the battery of laboratory
plant or plants, either in crude form or physically parameters detected in the patient’s body fluids,
modified during processing. They are usually soft tissues and organs, and skeleton. There is,
administered orally or topically to deal with however, no real or urgent imperative to deal with
chronic or acute clinical disorders and are available the underlying causes of the disorder, whether
as fresh or dried plants, or as tablets, capsules, lifestyle, environmental, or behavioral in origin.
powders, teas, or extracts.9 This contrasts markedly with the objectives of
They are based on certain parts of the medicinal herbal therapy. This accepts the need for the relief
plant – flower, leaf, stem, bark, or root. However, of the patient’s symptoms, but equally accepts the
they are not single substances extracted by chemical need to rectify the underlying disharmony in the
techniques from the plant and subsequently patient which has encouraged the development of
purified or even structurally altered. The use of the disorder in the first place. This may be humoral
herbal remedy is ideally combined with lifestyle in nature, or biochemical, temperamental, or due to
advice – changes to food consumption, rest, a dysfunctional self-healing apparatus.
exercise, for example. This enhances the potency Herb – drug interactions
of the herbal medicine by supporting and boosting As there is a significant and increasing number
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of people taking herbal remedies simultaneously drug interactions.19,20 It has been linked to a whole
with conventional drugs, there is a distinct and range of drug interactions: certain anxiolytics,
real possibility of herb-drug interaction, analogous lipid lowering agents, immune-suppressants, anti-
to the drug-drug interaction that is now well retroviral, anti-diabetic agents, oral contraceptives,
established and documented. and others.21 Over the last few years a number
It is generally accepted that drugs can interact of popular herbs – garlic, ginkgo, and ginseng,
with food. MAO- inhibitors are potentiated by for example – have been shown to interact with
some cheeses; antibiotic absorption is inhibited by specific drugs. Some of the interactions are of
milk; and warfarin action is diminished by green minor significance, whereas others do carry
vegetables.14 The original indication that a herbal important, serious cautions. The drugs that seem
agent could interact significantly with the action of to be most involved in interactions are blood
a conventional drug was the observation, more than thinners such as warfarin22, antibiotics, and certain
20 years ago, that the consumption of grapefruit antidepressants21.
juice could markedly reduce the metabolism of The interaction of herbs with drugs appears to
the immunosuppressant cyclosporine in patients be highly specific. That is, an interaction will
following transplantation.15 We now know that the only become significant or clinically important
metabolic enzymes (comprising the cytochrome if a critical aspect of the drug’s pharmacological
P450 system) of the patient’s liver were being action is interfered with. For example, if a herb
inhibited, so higher levels of the active drug were affects a drug’s absorption rate, it will only be a
being maintained for a longer period of time. As a cause for concern if it is important for the drug
result, a lower dose of the (very expensive) drug to be absorbed quickly (as with analgesics), or
could be employed without compromising clinical totally (as with antibiotics). If the absorption rate
efficacy or outcome. The cost-effectiveness is not a critical factor (as with antidepressants or
implications are substantial. anxiolytics) then the interaction is likely to be of
If grapefruit has such an important effect – why minor importance.
not herbs? For most herb-drug interactions Garlic is known to decrease absorption of the
the actual mechanisms involved are not fully antiretroviral agent saquinovir, and is implicated
understood. What we do know is that the drug in the onset of hypoglycemia in diabetic patients
does not combine with a herb component to form taking chlopropamide. In its turn, ginkgo increases
a toxic intermediary.8 In most cases changes to clotting time in patients taking aspirin or warfarin,
the absorption of a drug, or its metabolism within and is implicated in increasing blood pressure in
the body, is most likely the basis for interaction. hypertensive patients taking a thiazide diuretic.
We know that several herbs can induce or inhibit Ginseng, another very popular herb, also interferes
enzymes, resident in the liver or intestinal tract with warfarin activity, digoxin levels, and certain
walls, which are responsible for drug metabolism. antidepressants.23
These enzymes, which are mainly of the The implications of the herb-drug interaction are
cytochrome P450 type, are made less effective, so determined by the degree of interaction, the extent
the level of unmetabolised drug rises within the of the interaction in people using the two, and the
systemic blood circulation, and clearance of the seriousness of the adverse effect. For instance,
unchanged drug and its metabolites is affected.16 hypericum is now linked to breakthrough bleeding
Numerous clinical trials, case studies, and and unwanted pregnancies in women taking
anecdotal case reports have emerged which attest certain oral contraceptives. In this situation, the
to the unequivocal interaction of herbs with use of the herbal product should only be taken for
drugs.17,18 This is only to be expected; if a herb good reason, and with alternative contraception
actually triggers a pharmacological response, adopted. This constraint would also apply to
then it could conceivably interfere, to a greater or Parkinson’s disease patients being treated with
lesser extent, with a conventional drug’s activity. L-dopa, where kava increases the ‘off’ periods of
This has important ramifications for drug therapy: treatment benefit.24
many people are taking not one, but several, potent Not all herb-drug interactions are unwelcome or
drugs. The potential for herb-drug interaction is deleterious.25,26. Piperine (an active ingredient
therefore immense when the number of herbal of peppers) increases the bio-availability of the
products coming into popular use is considered. anti-epileptic drug phenytoin, the beta blocker
St John’s wort is arguably the ‘poster child’ of herb- propanolol, and the bronchodilator theophylline.
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In patients with pulmonary tuberculosis, ginseng to conventional drugs, which generally affect the
increases rifampicin blood levels. Regarding drug workings of one receptor site, or the action of one
toxicity, huangqinis effective in ameliorating the enzyme. What herbs do is mimic the body’s natural
digestive problems associated with irinotecan in intrinsic healing processes. This dilemma has
patients with cancer. long been recognized by conventional healthcare
Modes of action of herbs vs drugs practitioners, and an attempt to resolve it by
Identifying the pharmaceutical mechanisms of resorting to drug combinations, or poly-pharmacy.
herbal products activity poses numerous challenges Cocktails of potent drugs are now almost standard
not faced by those studying conventional drugs. in treating cancer, tuberculosis, HIV &Aids, heart
For example, herbal products contain many disease, and others.
active substances which can act in combination Mechanisms of drug-herb interaction
or synergistically, whereas conventional drugs The mechanisms by which a herbal product
are generally studied in isolation as single agents. interferes with a drug, or vice versa, are not fully
Another difference is that a single conventional understood in many cases. There are, however,
drug may only have one major direct action a number of possible activities which explain the
on a particular receptor site. Indeed, the more interaction; these are divided into pharmacokinetic
specific for one type of receptor is the preferred and pharmacodynamics interactions.
outcome of research for new pharmaceutical Pharmacokinetic interaction
agents. Conversely, herbal products probably Inhibition of absorption. The herb or drug acts
have several different pharmacological actions, on the other active agent to reduce or minimize
and the one that predominates depends on the its absorption. A number of agents have been
dosage employed, the part of plant selected, and identified:
the presence of other actives. Moreover, the herbal • Pectins, resins, tannins may bind to certain
product may contain a particular active agent, but antibiotics, preventing unimpeded absorption
it may not be present in sufficient quantity to elicit of the drug.
a pharmacological action. Yet another difference • Garlic (Allium sativum) interacts with several
is that pharmacological synergy may operate with drugs. It also reduces plasma concentrations
a multi-component herbal product – that is, the of chlorzoxazone.
net pharmacological response will be different • Ginkgo decreases the plasma concentrations
when compared to one active agent alone, as the of many drugs.
dominant mechanism may be potentiated by a [In practice this interaction can best be avoided by
separate mechanism. separate timing of drug and herb administration]
If a disorder is complex in origin, as with many Enhancement of absorption. This is usually the
chronic or recurring ailments, a simple approach result of increased gastric emptying or shorter gut
such as drug treatment is unlikely to be more transit time.
than marginally effective. Such disorders do not • Laxatives can increase these processes.
usually arise from a single biochemical, systemic, • Certain saponins can increase gastric emptying,
or organic defect, because the body’s inner healing so enhancing the rate of gastric emptying.
power is quite capable of dealing with this. Clinical [In practice this interaction can best be avoided
disorders are the result of a complex disturbance by reducing laxative usage, or selecting alternate
of homeostasis, involving numerous cellular and times, or by dividing doses between morning and
organic networks. Most disorders are the body’s evening]
natural response to several factors, some small, Drug metabolism increased. The herbal product
but others sometimes large, which work together promotes an increase in metabolic enzymes in the
to overcome the body’s inner healing capacity. liver, so boosting the breakdown or elimination of
There may be trigger factors; environmental drugs.
causes, genetic susceptibility and interplay, dietary • St John’s wort reduces the plasma
factors, emotional considerations, lifestyle issues, concentrations and increases clearance of a
all conspiring together. wide range of drugs.
In order to modify and negate the disease process, • Echinacea affects the metabolic clearance of
effective therapy depends on addressing more caffeine and certain anti-anxiety drugs.
than one form of disharmony. Herbal remedies • Ginkgo decreases the plasma concentrations
usually offer a multi-target approach, in contrast of many drugs.
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• Grapefruit juice decreases metabolism of and ephedrine, or similar, may increase nerve
cyclosporine and other drugs, due in induction stimulant drug action.
of liver metabolic CYT P450 enzyme. • St John’s wort may enhance the nervous
[In practice this interaction can best be avoided system effects of certain antidepressant drugs.
by monitoring plasma drug levels, and adjusting [If both drug and herb are being used for the same
dosage appropriately] therapeutic objective, a decision has to be made
Binding of drug by a herb component. Some preferring one active agent based on cost, ADRs,
antibiotics are chemically bound to certain long term effects].
botanical substances. This prevents or inhibits Summary
absorption through the intestinal wall, as the drug- There are thousands of herbs with a wide range
herb complex is either too big to absorb, or too of different uses, many of which are used in
poorly soluble in the intestinal fluid. conventional medicine as well as for natural
[In practice this interaction can best be avoided by remedies. Herbal medicine is one of the oldest
separating the timing of dosing of the drug and the forms of medicine used for the treatment of
herbal product] physical as well as psychological maladies and
Pharmacodynamics interaction in the search for optimum health. It has played a
Electrolyte depletion. Laxatives and diuretic drugs major part in medicine for millennia. As the use of
can reduce sodium and potassium levels in the herbal medicine is on the increase, the possibility
body, and so lead to adverse cardiac effects. of interaction with conventional drugs is real, and
[In practice this interaction can best be avoided by can pose a threat to successful treatment. Herbal
separating the timing of dosing of the drug and the medicines possess significant pharmacological
herbal product]. activity, so can interact markedly with many
The pharmacological effect is intensified. Certain conventional drugs if these are being taken
herbs have specific pharmacological effects. If simultaneously. Many conventional drugs are used
a drug is being co-administered, an additive or in the general population, especially in the elderly,
perhaps synergistic effect can arise. and these people often resort to herbal medicine
• Several herbal products and certain drugs for improved success in treating chronic disorders
may have the same effect on blood clotting in particular. It is therefore important to assess
mechanisms. whether a particular herbal remedy interferes with
• Hypoglycemic drugs and herbal products used the expected effect of a conventional drug (and
to treat diabetes may act together. vice-versa), and if this can lead to unexpected and
• Herbs which contain the alkaloids caffeine unwanted adverse effects.

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