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[02/15/00]

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But every time the pharmacist starts to explain something, she is interrupted mid-sentence by someone yelling out a question: "Can I mix lithium with an anti-inflammatory?" No, she responds politely, and that means Advil, too. "You say I need to drink a lot of water while on my medication. Can I still go to the steam room twice a week?" Yes, just make sure you replenish your lost water. As each inquiry comes in, she answers it with an almost-perfect textbook recitation of some pharmaceutical manual.

That is, until a woman toward the end of the evening asks, "How about the herbs? Is there an interaction with my medication?"

"Not that I know of."

Her response is unfortunately representative of her field. Many pharmacists, physicians and other health-care professionals aren't trained in herbal medicine, and are, therefore, unfamiliar with the dangerous side effects that can arise when such remedies are combined with prescription drugs.

With the growth of the $12 billion alternative-medicine business, and the prescription drugging of America, a $134 billion empire, the two worlds are meeting or, as one leading researcher says, "colliding." With the same glass of water, herbs, dietary supplements and natural products are being washed down with prescription drugs. And as Adriane Fugh-Berman wrote in a recent editorial in the Lancet, "All ingested substances have the ability to interact."

At the clinic, Annette Brown, sitting about 10 rows back, listens intently. It's her first time at this support group. The mother of two later opens her eyes wide with enthusiasm and speaks quickly when explaining what happened to her only a month earlier. Though she was diagnosed years ago with manic depression, she sought treatment for it only recently. Her doctor prescribed the antidepressant Paxil, which she took for several weeks. "I felt anxiety, shaking inside, tightness in my arms and legs; every muscle tensed up; I would try to relax but it still hurt," she says as she points to the afflicted areas. "I just kept thinking, 'Paxil is messing with me.'" Her doctor then switched her medication.

What Brown didn't tell her doctor was that she was also taking another pill to combat her depression: St. John's wort, also known as hypericum perforatum. Though it's hard to say for sure what happened to Brown, the popular herb is believed to interact with certain antidepressants, also known as selective serotonin reuptake inhibitors (SSRIs), such as Paxil, Zoloft and Prozac. The interaction can cause serotonin syndrome, with symptoms that include restlessness, muscle twitches and shivering. "I didn't tell my doctor because I never considered it a drug," she says. "After all, it's an herb; it's natural."

Two new studies in last Thursday's the Lancet provide further evidence that St. John's wort is not quite the harmless little herbal many people believe it is. The new research (which prompted the Food and Drug Administration to issue a health advisory) shows that St. John's wort can interact with the commonly used HIV protease inhibitor indinavir, and cyclosporine, an immunosuppressant drug used to prevent rejection after organ transplants. "The common misconception is that because it's natural, it's safe," says Stephen Piscitelli of the National Institutes of Health, author of the HIV study. Since so many people with AIDS also suffer from depression, and take meds to combat it, Piscitelli and his colleagues kept hearing anecdotes of an interaction and decided to look into it. His concerns seem to be justified: St. John's wort, he found, reduces the blood plasma concentrations of indinavir, which can lead to not only drug resistance but to treatment failure. "This study clearly shows that there can be dangerous interactions when you get St. John's with other drugs," he says.

According to a 1998 study in the Journal of the American Medical Association, 15 million people are using dietary supplements, and 18 percent are taking them in addition to their prescription medicine. As a result, pharmacists report interactions between synthesized medicine and natural products are increasing; research into the causes is not.

"It's not a new problem; it's a problem that's growing in numbers because far more people are combining natural products with drugs," says Forrest Batz, assistant professor in the department of clinical pharmacy at the University of California at San Francisco and associate editor of the "Natural Medicines Comprehensive Database." The database is kind of the bible of herb/drug interactions, and includes clashes, like the one between Lanoxin (digoxin), which is used to treat heart conditions, and St. John's wort. There have also been cases where gingko biloba, when taken with the blood-thinner Coumadin (warfarin) has caused spontaneous bleeding. Grapefruit juice supplements can increase the blood levels of people taking any of the cholesterol-lowering drugs like Mevacor (lovastatin), Zocor (simvastatin) and Lipitor (atorvastatin); and when combining neuroleptic drugs and betel nut there is an increased risk of extrapyramidal side effects like spasms and tremors.

On the flip side, having a dietary supplement interact with a prescriptive might be something we want. Herbalists point to "positive" cocktails, where the supplement's presence either magnifies the effect of the drug in a good way, or reverses a side effect of a medication. Gingko, for example, is believed to reverse the sexual dysfunction many people on antidepressants experience. And supplements containing lacto bacillus acidophilus may reduce or prevent antibiotic-induced diarrhea.

"While we have to be cautious about it, we shouldn't be afraid of it," says Roy Upton, executive director of American Herbal Pharmacopoeia. "Also, when you look at the data worldwide, it's not a big problem. Most of the information is either theorized or based on animal studies."

Next page | No one is thoroughly tracking these interactions