Herbal Medicine for Medical Students: An Introduction

Herbal Medicine for
Medical Students:
An Introduction
MacGerald V. Cueto
Department of Pharmacology & Therapeutics
Manila Theological College-College of
Medicine
Medical Case
A 53-year-old woman with a history of knee
osteoarthritis, high cholesterol, type 2 diabetes, and
hypertension presents with new onset of hot flashes and a
question about a dietary supplement. She is obese (body mass
index [BMI] 33), does not exercise, and spends a good portion
of her work day in a seated position. She eats a low-sugar diet
and regularly eats packaged frozen meals for dinner because
she doesn’t have time to cook regularly. Her most recent
laboratory values include a low-density lipoprotein (LDL)
cholesterol that is above goal at 160 mg/dL (goal < 100 mg/dL)
and a hemoglobin A1c that is well controlled at 6%. Her blood
pressure is high at 160/100 mm Hg.
Medical Case
Her prescription medications include
simvastatin, metformin, and benazepril. She also
takes over-the-counter ibuprofen for occasional knee
pain and a multivitamin supplement once daily. She
has heard good things about natural products and
asks you if taking a garlic supplement daily could help
to bring her blood pressure and cholesterol under
control. She’s also very interested in St. John’s wort
after a friend told her that it helped alleviate her hot
flashes and could also help improve mood. How
should you advise her? Are there any supplements
that could increase bleeding risk if taken with
ibuprofen?
Introduction
• In recent decades, spectrum of disease has shifted and
the complex chronic diseases have become prevalent.
The effect of Western medicine treatment is not
satisfactory and problems of the adverse drug reaction
are also very prominent.
• About 80% of people worldwide rely on herbal
medicines for some aspects of their primary health care
• It has been estimated that 25% of modern medicines
are made from plants first used traditionally, such as
aspirin, artemisinin, ephedrine, and paclitaxel.
• there is limited scientific evidence to establish the
safety and efficacy of most herbal products.
Introduction
• The medical use of plants in their natural and unprocessed
form undoubtedly began when the first intelligent animals
noticed that certain food plants altered particular body
functions.
• While there is a great deal of historical information about
the use of plant-based supplements, there is also much
unreliable information as a result of unknown or poor-
quality natural product formulations, poorly designed
clinical studies that do not account for randomization errors,
confounders, and—most importantly—a placebo effect that
can contribute 30–50% of the observed response.
• Since the literature surrounding dietary supplements is
evolving, reputable evidence-based resources should be
used to evaluate claims and guide treatment decisions.
“If Its all Natural, it is safe for
everyday use?”
• Many consumers have embraced the use of dietary
supplements as a “natural” approach to their health
care. Unfortunately, misconceptions regarding safety
and efficacy of the agents are common, and the fact
that a substance can be called “natural” does not of
course guarantee its safety.
• In fact, botanicals may be inherently inert or toxic at
high doses. If a manufacturer does not follow GMP, this
can also result in intentional or unintentional plant
species substitutions (eg, misidentification),
adulteration with pharmaceuticals, or contamination
Safety Issues of Herbal
Medicines
Safety Issues of Herbal Medicine
1. Herbal Medicine Is Drug, Not Food.
• Herbal medicine originated from nature and belongs to
“green” therapy and has no toxin or adverse effect and
people can take it in the long term or as often as one
wishes.
• Herbal medicinal products are widely considered to be of
lower risk compared with synthetic drugs but are not
completely free from the possibility of toxicity or adverse
effects.
• Exaggerated propaganda and giving up using synthetic
medicines for adverse events are prejudice against herbal
medicine
• To ensure the safety use of herbal medicinal products,
herbal medicine should be managed as drug
2. The Relative Property of Herbal Medicine Safety.
• As the Chinese proverb says “all medicines have
their own side effects”; that is, medicine is a
double-edge sword: it can cure disease or maintain
health, while it may also cause damage to human
body.
• Herbal medicine should be adopted by appropriate
dosage and course of treatment and for adapted
syndrome, rather than unrestricted abusing.
• Overdosage and course of treatment are bound to
safety problems
• Toxic dose of Radix Bupleuri Chinensis (192 g/60 kg)
versus clinical common dose (9 g/60 kg). However, high-
dose and long-term use may also cause adverse events
3. The Complexity of Safety of Herbal
Medicine. (direct and indirect causes)
• Intrinsic Toxicity. Direct reason is the intrinsic
toxicity of some herb at normal therapeutic
dosage or in overdose.
• Ephedra, Aristolochia, and Aconitum are
considered to be toxic and are given in
controlled doses in TCM Herbology.
4. External Toxicity. Adverse effects associated
with herbal medicines may result from
contamination of products with toxic metals,
adulteration, misidentification or substitution of
herbal ingredients, or improperly processed or
prepared products
• For example, Caulis Akebiae replaced by Caulis
Aristolochiae Manshuriensis and Stephania
tetrandra replaced by Aristolochia fangchi have
led to the serious problem of “aristolochic acid
nephropathy” in the elderly in Japan.
5. Wrong Indication.
• Inappropriate use of herbal medicines can cause
negative or dangerous effects
• For instance, the herb “Ma Huang” (Ephedra) is
traditionally used in China to treat respiratory
congestion, while it was marketed as dietary
supplements formulated for weight reduction in
US.
• Over dosage use led to at least a dozen deaths,
heart attacks, and strokes
6. Herb-Drug Interaction.
• All herbal medicines are complex mixtures of
more than one active ingredient. Multitude of
active ingredients will increase the possibilities
of interactions between herbal medicines and
conventional drugs.
• Many users of medicinal herbs are usually
suffering from chronic conditions for which they
are likely to take prescribed drugs
concomitantly. This, in turn, further increases
the potential of herb-drug interaction
7. Weak Basic Research in Safety of Herbal Medicine.
• The toxicity classification is lack of scientific standard
and objective experimental data.
• Chinese Pharmacopoeia 2010, there are 83 types of
Chinese materia medica officially recorded and defined
as toxic and they were classified into three categories:
high toxicity, medium toxicity, and low toxicity. Efficacy
and toxicity of the majority of them are mostly based on
traditional knowledge and clinical experience
• There is no adequate data about toxic herbs, toxic
target organs, safe dose range, safety window of
effective dose, and minimum toxic dose
Current researches of Herbal Medicines.
• Based on the current situation, worldwide
research on herbal medicine safety is still not
broad or deep enough.
• Although, there are a limited number of
published scientific papers, the contents are
extensive, covering the safety evaluation
method, herb-drug interaction, safety
evaluation of skin-applied herbal medicine,
and the influence of herbal ingredients to
cytochrome P450 system
Next Steps
• Researches needed on the toxicity and
the herb-drug interaction of commonly
used herb medicines
• For clinical safety monitoring,
spontaneous reporting system or active
pharmacovigilance is effective in
identifying therapeutically relevant
safety issues.
• World Health Organization, WHO Traditional
Medicine Strategy 2014-2023
• devotes more attention than its predecessor to
prioritizing health services and systems,
including traditional and complementary
medicine products, practices and practitioners.
• proposes global unified planning, which includes
global management standards and quality
standards, radical source of herbs, seed and
seedling breeding, planting, harvesting and
storage, rational proceeding, manufacture, and
quality standards.
• A regulatory framework for herbal
medicines can provide greater
assurance to consumers.
• Herbal medicines managed as food
supplement, functional food, health
products, or drugs, caused differential
standards and chaotic market
• Establishment of a Safety guarantee
system comprised rational clinical
practice and risk monitoring
Botanical Substance with
Preliminary Clinical
Efficacy and Safety Data
ECHINACEA (ECHINACEA
PURPUREA)
• The three most widely used species of
Echinacea are Echinacea purpurea, E
pallida, and E angustifolia.
• Flavonoids, lipophilic constituents (eg,
alkamides, polyacetylenes), water-
soluble polysaccharides, and water-
soluble caffeoyl conjugates (eg,
echinacoside, cichoric acid, caffeic acid).
ECHINACEA (ECHINACEA PURPUREA)
• Immune modulation—increased phagocytosis, total circulating
monocytes, neutrophils, and natural killer cells, indicative of general
immune modulation. inhibited the rise in pro-inflammatory cytokines
and interleukins-6 and -8, and also inhibited mucin secretion caused by
exposure to rhinovirus type 1A in a 3D tissue model of human airway
epithelium
• Anti-inflammatory effects—Inhibition of cyclooxygenase, 5-
lipoxygenase, and hyaluronidase
• Antibacterial, antifungal, antiviral, and antioxidant effects—
demonstrated virucidal activity (MIC100 < 1 mcg/mL) against influenza
and herpes simplex viruses and bactericidal activity against
Streptococcus pyogenes, Haemophilus influenzae, and Legionella
pneumophila in human bronchial cells. In vitro, Echinaforce inactivated
both avian influenza virus (H5N1, H7N7) and swine-origin influenza
virus (H1N1) at doses consistent with recommended oral consumption.
• The extract blocked key steps (ie, viral hemagglutination activity and
neuraminidase activity in vitro) involved in early virus replication and
cellular entry. It was less effective against intracellular virus. Newer
ECHINACEA (ECHINACEA PURPUREA)
• Clinical Uses
• enhance immune function in individuals who have colds
and other respiratory tract infections as prophylaxis and
treatment.
• Preliminary studies were conducted to enhance
hematologic recovery following chemotherapy
• as an adjunct in the treatment of urinary tract and
vaginal fungal infections.
• Adverse effects with oral commercial formulations
are minimal and most often include unpleasant
taste, gastrointestinal upset, or allergic reactions (eg,
rash). No adverse pregnancy outcomes
GARLIC (ALLIUM SATIVUM)
• The pharmacologic activity of garlic
involves a variety of organosulfur
compounds
• Allicin is responsible for the
characteristic odor of garlic, and alliin is
its chemical precursor
• Cardiovascular effects—In vitro, allicin and related
compounds inhibit HMG-CoA reductase, which is
involved in cholesterol biosynthesis , and exhibit
antioxidant properties. Antiplatelet effects through
inhibition of thromboxane synthesis or stimulation
of nitric oxide synthesis and enhancement of
fibrinolytic activity
• Antimicrobial effects—Allicin has been reported to
have in vitro activity against some gram-positive
and gram-negative bacteria as well as fungi
(Candida albicans), and protozoa (Entamoeba
histolytica) via inhibition of thiol-containing
enzymes.
• Antineoplastic effects— in Animal Studies, garlic
inhibits procarcinogens for colon, esophageal, lung,
breast, and stomach cancer, possibly by
detoxification of carcinogens and reduced
carcinogen activation. Several epidemiologic case-
control studies demonstrate a reduced incidence of
stomach, esophageal, and colorectal cancers in
persons with high dietary garlic consumption.
• Endocrine effects—The effect of garlic on glucose
homeostasis does not appear to be significant in
persons with diabetes
• Adverse effects
• nausea (6%), hypotension (1.3%), allergy
(1.1%), and bleeding (rare).
• Herb-Drug Interaction
• warfarin, aspirin, ibuprofen, reduce the
bioavailability of saquinavir
GINKGO (GINKGO BILOBA)
•Active constituents in ginkgo are
flavone glycosides and terpenoids
including ginkgolides A, B, C, and J,
and bilobalide
• Cardiovascular effects—In animal models and some human
studies, ginkgo has been shown to increase blood flow,
reduce blood viscosity, and promote vasodilation, thus
enhancing tissue perfusion. Enhancement of endogenous
nitric oxide effects and antagonism of platelet-activating
factor have been observed in animal models.
• Metabolic effects—Antioxidant and radical-scavenging
properties have been observed for the flavonoid fraction of
ginkgo as well as some of the terpene constituents.
superoxide dismutase-like activity and superoxide anion-
and hydroxyl radical-scavenging properties. antiapoptotic
properties
• CNS Receptor densities increased for muscarinic, α2, and 5-
HT1a receptors, and decreased for β adrenoceptors.
Increased serum levels of acetylcholine and norepinephrine
and enhanced synaptosomal reuptake of serotonin and
dopamine, inhibition of amyloid-beta fibril formation and
protective effects of Egb761 on hippocampal neurons
against cell death induced by beta-amyloid.
• Clinically used to treat cerebral insufficiency and dementia
of the Alzheimer type
• Promising results studied for its effects in schizophrenia,
tardive dyskinesia, allergic and asthmatic
bronchoconstriction, short-term memory in healthy,
nondemented adults, erectile dysfunction, tinnitus and
hearing loss, and macular degeneration
• Adverse effects
• nausea, headache, stomach upset, diarrhea,
allergy, anxiety, and insomnia. Noted bleeding
complications in the patients also using either
aspirin or warfarin.
• Herb Drug Interaction
• Efavirenz, (virologic falilure) ,trazodone
(sedation), Risperidone (priapism), valproic
acid and phenytoin ( Seizures).
• Uncooked ginkgo seeds are epileptogenic due to
the presence of ginkgotoxin
GINSENG
• Panax ginseng (Chinese or Korean
Variety) Panax quinquefolium,
Eleutherococcus senticosus (Siberian
ginseng) and Pfaffia paniculata
(Brazilian ginseng)
• The active principles are triterpenoid
saponin glycosides called ginsenosides
or panaxosides and eleutherosides
(Siberian ginseng)
GINSENG
• Modulation of immune function (induced mRNA expression
for interleukins-2 and -1α, interferon-γ, and granulocyte
macrophage colony-stimulating factor; activated B and T
cells, natural killer cells, and macrophages).
• Central nervous system effects included increased
proliferating ability of neural progenitors and increased
central levels of acetylcholine, serotonin, norepinephrine,
and dopamine in the cerebral cortex.
• Antioxidant activity; anti-inflammatory effects (inhibited
tumor necrosis factor-α, interleukin-1β, and vascular and
intracellular cell adhesion molecules)
GINSENG
• Anti-stress activity (ie, stimulated pituitary-adrenocortical
system, agonist at glucocorticoid receptor);
• analgesia (inhibited substance P); vasoregulatory effects
(increased endothelial nitric oxide, inhibited prostacyclin
production);
• cardioprotective activity (reduced ventricular remodeling
and cardiac hypertrophy in animal models of myocardial
ischemia); antiplatelet activity;
• improved glucose homeostasis (reduced cell death in
pancreatic beta cells; increased insulin release, number of
insulin receptors, and insulin sensitivity);
• anticancer properties (reduced tumor angiogenesis,
increased tumor cell apoptosis).
Ginseng
• Adverse Effects
• Vaginal bleeding and mastalgia (possible
estrogenic effects) Central nervous system
stimulation (eg, insomnia, nervousness) and
hypertension.
• Methylxanthines found in the ginseng plant
may contribute to this effect.
• Vasoregulatory effects have not been found to
be clinically significant
GINSENG
• Phenelzine, lithium, neuroleptics (Irritability,
sleeplessness, and manic behavior) .
• Caution in patients taking any psychiatric,
estrogenic, or hypoglycemic medications. Ginseng
has antiplatelet properties
• Should not be used in combination with warfarin.
• Caution with Immunocompromised individuals
and autoimmune disorders due to Cytokine
stimulation and natural killer cell activity
MILK THISTLE (SILYBUM
MARIANUM)
• Contain a lipophilic mixture of
flavonolignans known as silymarin.
• Three isomers: silybin (also known as
silybinin or silibinin; most potent),
silychristin (silichristin), and silydianin
(silidianin).
MILK THISTLE (SILYBUM MARIANUM)
• Liver disease—In animal models, milk thistle purportedly
limits hepatic injury associated with a variety of toxins,
including Amanita mushrooms, galactosamine, carbon
tetrachloride, acetaminophen, radiation, cold ischemia, and
ethanol.
• Noncompetitively inhibits lipoxygenase activity and reduces
leukotriene formation. Inhibition of leukocyte migration.
• Inhibits nuclear factor kappa B (NF-κB). increase in RNA
polymerase I activity in nonmalignant hepatocytes but not
in hepatoma or other malignant cell lines.
• It reduced collagen accumulation, and in an in vitro model it
reduced expression of the fibrogenic cytokine transforming
growth factor-β. Dose-dependent stimulatory effect on bile
flow that could be beneficial in cases of cholestasis
MARIANUM)
• Chemotherapeutic effects— In vitro and animals studies.
skin cancer, reduce tumor initiation and promotion.
• Induction of apoptosis in melanoma, prostate, colon,
leukemia cells, bladder transitional-cell papilloma cells,
cervical and hepatoma cells.
• Inhibition of cell growth and proliferation by inducing a G1
cell cycle arrest in cultured human breast and prostate
cancer
• Lactation—Historically, milk thistle has been used by
herbalists and midwives to induce lactation in pregnant or
postpartum Women for it increases prolactin production
MARIANUM)
• Adverse Events
• At high doses (>1500 mg), it can have a
laxative effect caused by stimulation of
bile flow and secretion
• Herb-Drug interaction
• posing no risk for drug interactions in
humans.
ST. JOHN’S WORT (HYPERICUM
PERFORATUM)
• Antidepressant action—The hypericin fraction was
initially reported to have MAO-A and -B inhibitor
properties.
• Inhibition of nerve terminal reuptake of serotonin,
norepinephrine, and dopamine.
• Significantly downregulate the expression of cortical
β adrenoceptors and up-regulate the expression of
serotonin receptors (5-HT2).
• Sigma receptor binding using the hypericin fraction
and GABA receptor. Reduced Interleukin-6
production.
ST. JOHN’S WORT (HYPERICUM
PERFORATUM)
• Adverse events
• Photosensitization-Consumers should be instructed to wear
sunscreen and eye protection while using this product when
exposed to the sun
• mild gastrointestinal symptoms, fatigue, sedation, restlessness,
dizziness, headache, and dry mouth. Hypomania, mania, and
autonomic arousal
• risk of serotonin syndrome with antidepressants and
stimulantsrisk of serotonin syndrome
• Subtherapeutic levels of digoxin, birth control drugs (and
subsequent pregnancy), cyclosporine, HIV protease and
nonnucleoside reverse transcriptase inhibitors, warfarin,
irinotecan, theophylline, and anticonvulsants
SAW PALMETTO (SERENOA REPENS
OR
SABAL SERRULATA)
• Phytosterols (eg, β-sitosterol), aliphatic
alcohols, polyprenic compounds, and
flavonoids are all present.
• Saw palmetto is most often promoted
for the treatment of benign prostatic
hyperplasia (BPH).
OR
SABAL SERRULATA)
• Enzymatic conversion of testosterone to
dihydrotestosterone (DHT) by 5α-reductase
is inhibited by saw palmetto in vitro
• Noncompetitive inhibition of isoforms I and II of
5α-reductase enzyme,
• Inhibits the binding of DHT to androgen
receptors.
• inhibition of prostatic growth factors,
blockade of α adrenoceptors, and inhibition
1
of inflammatory mediators produced by the

5-lipoxygenase pathway.
OR
SABAL SERRULATA)
• Adverse events
• abdominal pain, nausea, diarrhea, fatigue,
headache, decreased libido, and rhinitis
• Herb-Drug Interactions
• No drug-drug interactions have been reported
for saw palmetto.
• Because saw palmetto has no effect on the PSA
marker, it will not interfere with prostate cancer
screening using this test.
PURIFIED NUTRITIONAL
SUPPLEMENTS
Coenzyme Q10
• also known as CoQ, CoQ10, and ubiquinone,
is found in the mitochondria of many organs,
including the heart, kidney, liver, and skeletal
muscle
• a potent antioxidant, role in maintaining
healthy muscle function.
• Reduced serum levels have been reported in
Parkinson’s disease.
Coenzyme Q10
• Hypertension—In clinical trials, small but
significant reductions in systolic and diastolic
blood pressure that might be related to the
antioxidant and vasodilating properties
• Heart failure—Low endogenous coenzyme
Q10 levels have been associated with worse
heart failure outcomes, but this association
is likely because low levels are a marker for
more advanced heart failure, rather than a
predictor of disease. Improve ejection
fraction
Coenzyme Q10
• Ischemic heart disease—metabolic
protection of the ischemic myocardium by
reducing proinflammatory markers (including
interleukin-6 and C-reactive protein) that
contribute to oxidative stress. Improvements
have been observed in lipoprotein (a), high-
density lipoprotein cholesterol, exercise
tolerance, and time to development of
ischemic changes on the electrocardiogram
during stress tests
Coenzyme Q10
• Prevention of statin-induced myopathy -
Initiating statin therapy has been shown to
reduce endogenous coenzyme Q10 levels,
which may block steps in muscle cell energy
generation, possibly leading to statin-related
myopathy.
Coenzyme Q10
• Adverse Events
• rarely leading to any adverse effects at
doses as high as 3000 mg/day
• Coenzyme Q10 shares a structural
similarity with vitamin K, supplements
may decrease the effects of warfarin
therapy
GLUCOSAMINE
• a substrate for the production of articular
cartilage, and serves as a cartilage nutrient
• commercially derived from crabs and other
crustaceans.
• Early studies reported significant
improvements in overall mobility, range of
motion, and strength in patients with
osteoarthritis.
GLUCOSAMINE
• Adverse Events
• Oral glucosamine sulfate is very well tolerated
• In clinical trials, mild diarrhea, abdominal
cramping, and nausea were occasionally
reported.
• Cross-allergenicity in people with shellfish
allergies
• may increase the international normalized ratio
(INR) in patients taking warfarin, increasing the
risk for bruising and bleeding.
MELATONIN
• a serotonin derivative produced by the pineal gland
and some other tissues, is believed to be
responsible for regulating sleep-wake cycles.
• melatonin is most often used to prevent jet lag and
to induce sleep
• Clinical studies of melatonin have reported
subjective reduction in daytime fatigue, improved
mood, and a quicker recovery time (return to
normal sleep patterns, energy, and alertness).
• It has been reported to improve sleep onset,
duration, and quality when administered to healthy
volunteers, suggesting a pharmacologic hypnotic
effect. Melatonin has also been shown to increase
rapid eye movement (REM) sleep.
MELATONIN
• Pre- and postoperative anxiety in adults—Melatonin given
as a premedication has been shown to reduce preoperative
anxiety in adults. Melatonin may be as effective as
midazolam in reducing anxiety before a surgical procedure
(measured 50–100 minutes after administration).
• Male reproductive function—sperm motility was increased
and early apoptosis was inhibited
• Female reproductive function—can be used as an
adjunctive therapy in the treatment of infertility during in
vitro fertilization by reducing oxidative stress and thereby
improving the quality of oocytes and embryos during
ovulation induction and egg retrieval
MELATONIN
Adverse Events
• Some next-day drowsiness has been reported as well as
fatigue, dizziness, headache, and irritability. Transient
depressive symptoms and dysphoria. May affect blood
pressure as both increases and decreases in blood pressure
have been observed
• melatonin concentrations are altered by a variety of drugs,
including nonsteroidal anti-inflammatory drugs, warfarin,
nifedipine, fluvoxamine, antidepressants, β-adrenoceptor
agonists and antagonists, scopolamine, and sodium
valproate.
Ten Medicinal Herbs
(Sampung Halamang
Gamot)
Introduction
• As part of primary health care and because
of the increasing cost of drugs, the use of
locally available medicinal plants has been
advocated by the Department of Health.
• Many local plants and herbs in the Philippine
backyard and field have been found to be
effective in the treatment of common
ailments as attested to by the National
Science Development Board, other
government and private agencies/persons
engaged in research.
Lagundi (Vitex
negudo)
• Shrub growing in wild in vacant
lots and waste land.
• It is better to collect the leaves when are in
bloom.
• Uses: cough and fever, dysentery, colds and pain
in any part of the body, skin diseases, headache,
rheumatism, aromatic bath for sick patients
• may decrease the plasma concentration of
paracetamol
Yerba Buena
(Mentha
cordifelia)
• A small multi-branching aromatic herb.
• The leaves are small, elliptical and with toothed
margin.
• Uses: Pain in different parts of the body as
headache, stomachache, rheumatism, arthritis,
cough and cold, tootache, menstrual and gas
pain, nausea and vomiting, insect bites, pruritis
Sambong (Blumea
balsamifera)
• Leaves as poultice for abscesses.
• Decoction of roots and leaves for fevers, kidney stones, and cystitis.
• Decoction of leaves used to induced diuresis for purpose of treating
kidney stones.
• Sitz-bath of boiled leaves, 500 gms to a gallon of water, for
rheumatic pains of waist and back.
• Used in upper and lower respiratory tract affections like sinusitis,
asthmatic bronchitis, influenza.
• Applied while hot over the sinuses. Used for wounds and cuts.
Fresh juice of leaves to wounds and cuts.
• Poultice of leaves applied to the forehead for relief of headache
Tsaang Gubat (Carmona retusa)
• Leaf decoction or infusion for abdominal colic, cough,

diarrhea and dysentery.
• Root decoction used as an antidote for vegetable poisoning.
• For diarrhea: Boil 8 tbsp of chopped leaves in 2 glasses of
water for 15 minutes; strain and cool. Use 1/4 of the
decoction every 2 or 3 hours. Decoction has also been used
as a dental mouthwash.
• Decoction of leaves used as disinfectant wash after
childbirth.
Niyog-niyogan (Quisqualis indica L.)
• Anthelmintic: Dried seeds preferable for deworming.
• Adults: Dried nuts-chew 8 to 10 small- to medium-sized dried nuts
two hours after a meal, as a single dose, followed by a half glass of
water. If fresh nuts are used, chew only 4-5 nuts. Hiccups occur more
frequently with the use of fresh nuts. Children 3-5 years old: 4-5
dried nuts; 6 - 8 years old: 5-6 dried nuts; 9-12 years old: 6-7 dried
nuts.
• Roasted seeds for diarrhea and fever
• Plant used as a cough cure
• Leaves applied to the head to relieve headaches.
• Pounded leaves externally for skin diseases.
• Decoction of boiled leaves used for dysuria.
• Ifugao migrants use it for headache.
• Ripe seeds roasted and used for diarrhea and fever.
Bayabas/Guava (Psidium guajava L.)
• In the Philippines, the astringent, unripe fruit, the
leaves, bark cortex, and roots - though more often
the leaves only - are used in decoction for washing
ulcers and wounds.
• Fresh leaves used for wounds and toothache.
• Decoction or infusion of fresh leaves used for
wound cleaning to prevent infection and to
facilitate healing.
• Warm decoction of leaves for aromatic baths.
• Decoction of bark and leaves used for diarrhea.
• For diarrhea, boil for 15 minutes 4 to 6 tablespoons of
chopped leaves in 18 ounces of water. Strain and cool.
Drink 1/4 of the decoction every 3 - 4 hours.
• Bark used internally for chronic diarrhea of children
and adults - half an ounce of the bark or root bark in
six ounces of water is boiled down to 3 ounces, and
given in teaspoon doses. Also used for prolapsusani of
children.
• Decoction of rootbark also used as mouthwash for
swollen gums.
• Root-bark has been recommended for chronic
diarrhea.
• For toothache, chew 2-3 young leaves and put into the
tooth cavity.
Akapulko (Cassia alata L.)
• The seeds used for intestinal parasitism.
• Tincture from leaves reported to be purgative.
• Decoction of leaves and flowers for cough and
as expectorant in bronchitis and asthma. Also
used as astringent.
• Crushed leaves and juice extract used for
ringworm, scabies, eczema, tinea infections,
itches, insect bites, herpes
Ulasimang Bato (Peperonia pellucida)
• Pansit-pansitan (Tag.)
• Infusion and decoction of leaves and
stems are used for gout and
arthritis.
• Decoction of leaves used for urinary
tract infections.
• Externally, as a facial rinse for
complexion problems.
• Hypotensive effect and cytochrome
P450 inhibitory effect.
Bawang (Allium sativum)
• Uses: hypertension, toothache
• Known to have antiplatelet properties' can
affect anticoagulation therapy.
• Study suggests alteration of Metformin
pharmacokinetics with increased availability.
Ampalaya (Mamordica charantia)
• In the Philippines, juice expressed from the green fruit is
given for chronic colitis: also used for bacillary dysentery.
• Astringent powdered leaves or root decoction can be
applied to hemorrhoids.
• Leaf juice for cough and as a purgative and anthelminthic to
expel intestinal parasites, and for healing wounds.
• Seeds also used to expel worms.
• The vine or the juice of leaves used as mild purgative for
children.
• In large doses, the fresh juice is a drastic purgative.
• Decoction of roots and seeds used for urethral discharges.
• Juice of leaves used for chronic coughs.
Ampalaya (Mamordica charantia)
• Leaves and shoots used as vulnerary.
• Sap of leaves used as parasiticide.
• Fruit macerated in oil used as vulnerary.
• Fruit considered tonic and stomachic; used in rheumatism, gout,
and diseases of the spleen and liver.
• Pounded leaves used for scalds.
• Infusion of leaves or leaf juice used for fevers.
• Used for chronic stomach ulcers.
• Root sometimes used as ingredient in aphrodisiac preparations.
• Decoction of root used as abortifacient.
• Fruit in large doses considered a drastic purgative and abortifacient.)
• Antidiabetic synergism with Metformin and Glibenclamide.
Medical Case Answer
• Garlic has shown significant benefits in lowering total
cholesterol, LDL, and systolic and diastolic blood pressure,
but the effects are moderate and unlikely to be large
enough to lower this patient’s values into the normal range.
While this patient’s diabetes is under control, her
hypertension places her at risk for microvascular
complications of diabetes, thus making it necessary to
reevaluate her current medication adherence, doses of
benazepril for hypertension and simvastatin for
hyperlipidemia, and duration of therapy. She would benefit
from meeting with a nutritionist because packaged frozen
dinners can be high in sodium, and this may be elevating her
blood pressure. Adding exercise to her weekly routine could
also help with weight control and overall cardiovascular
health.
Medical Case Answer
• The data supporting benefits of St. John’s wort in patients
with hot flashes are preliminary but show promise. Good
data support use of the herb to alleviate symptoms of mild
to moderate depression when used for up to 1 year.
However, this patient is not a good candidate for St. John’s
wort (a cytochrome P450 1A2, 2C9, 3A4 inducer) because of
her prescription drug use and the potential for herb-drug
interactions. Several dietary supplements reviewed in this
chapter (garlic, ginkgo, and ginseng) may have antiplatelet
effects that could be additive with ibuprofen. If this patient
were also taking warfarin, additional interactions could
occur with coenzyme Q10 (vitamin K-like structure), St.
John’s wort, and melatonin (in vitro decreased prothrombin
time), leading to a decreased warfarin effect, or with
glucosamine (increased international normalized ratio),
leading to an increased warfarin effect.
Herb to Drug Interaction
(HDI)
Herb-Drug Interactions (HDIs)
HDIs have been attracting increasing attention for
the following reasons:
1. Herbal medicines are frequently used worldwide
(Gardiner et al., 2006);
2. Prescribed and non-prescribed herbal medicines
are commonly used together in hospitalized
(Goldstein et al., 2007) and non-hospitalized
patients (Qato et al., 2008), but patient–physician
communication about the use of herbal medicines
is insufficient (Shelley et al., 2009), and physicians’
knowledge of and personal experiences with
herbal medicines limit their ability to assist their
patients (Xu & Levine, 2008);
Herb-Drug Interactions (HDIs)
1.The likelihood of HDIs is theoretically higher
than the likelihood of DDIs since herbal
medicines contain more than one
compound, with each active compound
having similar or different effects on the
pharmacokinetics of the victim drug (Foti et
al., 2007; Izzo, 2005);
2.HDIs can lead to severe and even fatal ADRs.
(Bilgi et al., 2010) (Chiang et al., 2005;
Kupiec & Raj, 2005)
3.An increasing number of preclinical and
clinical HDIs have been documented
Mechanism of TCM Derived Pharmacokinetic
Herb-Drug Interactions, HDIs
ADME Targets TCM Representative
Absorption Intestinal Cytochromes, Magnolia berry or five-
CYPs flavor-fruit
Intestinal UDP- Gingko biloba
glucuronosyltransferases,
UGTs Rhubarb
Intestinal P-glycoprotein, Chinese Raspberry
P-gps Black atractylodes rhizome
Other intestinal Xiao-Cai-hu-Tang Herbal
Transporters Decoction
Intestinal pH value
Gastric emptying and
intestinal transit time
Distribution Hepatic P-gps Quercetin
Other hepatic transporters Chinese Red Sage
Serum Albumin binding Chinese Red Sage
Metabolism Hepatic CYPs Coptidis Rhizoma
Hepatic UTGs Gingko Biloba
Elimination Renal transporters Rhubarb
Herb-Drug Interaction: General
Prescribing Guidelines
• Exercise great caution when prescribing
herbs for patients taking drugs with narrow
therapeutic window. These drug may
become dangerously toxic or ineffective with
only relatively small changes in their blood
concentrations. Monitor on a frequent and
regular basis
• Digoxin, warfarin, immunosuppressive drugs,
antiretrovirals, theophylline, phenytoin and
phenobarbital
• Exercise great caution when prescribing
herbs for patients taking drugs:
• If heart, liver or kidney is impaired
• In elderly patients
• In pregnant patients
• In those who receive an organ transplant
• In those with genetic disorder that disrupts
normal biochemical functions
• Monitor on a frequent and regular basis
• Care should be exercised with patients who exhibit
long term use of laxative herbs or potassium-losing
diuretics
• Critical drugs should be taken at different times of
the day from herbs (and food) to reduce chemical
or pharmacokinetic interactions. They should be
separated by at least 1 hour, preferably more.
• Stop all herbs approximately 1 week before surgery.
Milk thistle may help reduce the toxic effects of
anesthetic drugs, so it can be taken up to the day
before and then again after surgery
• Carefully monitor the effects of drugs such as
antihypertensives and antidiabetic when
combining with herbal remedies. The herbs
may make them more or less effective. In the
ideal situation the dose of the drug could be
adjusted
• Interactions may be dose related for the
herbs nd the drug, for example, St. John’s
wort and digoxin
Herbal Medicine OBE
Activity
Group 1
• Please search the medical databases for the
pharmacological benefits, and Herb-Drug
interactions of the “Ensaladang Pilipina or KKMUSS
miracle salad” composed of
• Moringa oleifera – Dahon ng Malunggay
• Capsicum fructescens– Dahon ng sili
• Ipomea batatas – Talbos ng Kamote
• Corchorus capsularis - Saluyot
• Amaranthus spinosus – Uray/Kulitis
• Ipomoea aquatica - Kangkong
Group 2
• Please search the medical databases for the pharmacological
benefits, and Herb-Drug interactions of the “pito-pito” tea
composed of
1. Premna Odorata Blanco – Alagaw Leaves
2. Lagestroemia Speciosa - Banaba leaves
3. Psidium Guajava - Bayabas leaves
4. Pandanus Amaryllifolius – Pandan leaves
5. Mangifera Indica – mangga leaves
6. Pimpinella Anisum- anise seeds
7. Coriandum Sativum - Cilantro leaves
Centella asiatica – Goto Kola
Ananas comosus – Pineapple leaves
Chrysophyllum caimito – Kaimito leaves
References
• Bing-Liang Ma & Yue-Ming Ma (2016): Pharmacokinetic herb–drug
interactions with traditional Chinese medicine: progress, causes of
conflicting results and suggestions for future research, Drug Metabolism
Reviews, DOI: 10.3109/03602532.2015.1124888
• Yong Yang, Zaiqi Zhang, Shuping Li, Xiaoli Ye , Xuegang Li & Kai He.
(2014) Synergy effects of herb extracts: Pharmacokinetics and
pharmacodynamic basis. Fitoterapia, 92 (2014) 133-147.
• Qui-Ju Li, Ai-Hua Zhang, Hui Sun & Xi-Jun Wang (2016) Pharmacokinetic
application of Traditional Chinese Medicine. World Journal of Traditional
Chinese Medicine 2016, 2(1) 43-47.
• Miaomiao Zhou, YanLong Hong, Xian Lin, Lan Shen and Y Feng (2017)
Recent pharmaceutical evidence on the compatibility rationality of
traditional chinese medicine. Journal of Ethnopharmacology
• www.mediherb.com.au

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of inflammatory mediators produced by the

• Leaf decoction or infusion for abdominal colic, cough,

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