As prescription and over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) continue to face scrutiny from the media, an increasing number of arthritis patients are now turning to natural supplements for relief. According to a new survey published in the Annals of the Rheumatic Diseases,¹ several of these herbal remedies may interact dangerously with prescription medications, and many patients and physicians are unaware of the potential risks.

In the study of 238 rheumatology outpatients from three centers, 10% of patients were at increased risk of hemorrhagic complications because they were using NSAIDs or corticosteroids in combination with supplements that are thought to have anticoagulant or antiplatelet effects, such as ginkgo biloba, garlic, or devil's claw. Moreover, 4% of patients receiving disease modifying antirheumatic drugs (DMARDs) were also using the potentially hepatoxic supplement echinacea.

Alarmingly, 24 of the 26 patients in danger from potential interactions were unaware of their risk even though 10 of them had sought advice from a health professional before starting supplements, the survey showed.

Almost half (44%) of patients had used herbal or OTC medicines in the past 6 months, and 11% were taking remedies that might interact with prescription drugs. The most commonly used remedies were cod liver oil (35%), glucosamine and/or chondroitin (21%), and evening primrose oil (11%).

 

Responsibility falls to both doctors and patients

"Healthcare workers should remember to be particularly vigilant to ask about herbal remedies when taking a drug history," suggests survey author Wendy Holden, MD, of Nuffield Orthopaedic Centre in Oxford, United Kingdom. "Both patients and prescribers need more education on the risks and potential interactions of these preparations."

"Arthritis patients are more likely to be harmed by herbal supplements and OTC remedies because they tend to be on multiple drugs and, in general, are older and have other illness," says Gilbert Ross, MD, medical and executive director of the American Council on Science and Health in New York City.

The recent news concerning cardiovascular risks and prescription and OTC NSAIDs may "have propelled many patients toward the supplements, but these are unlikely to do good-and may do harm-both on their own and by interacting with other medications," Dr. Ross says. "At the very least, patients considering using these products should discuss it with their doctor."

Physicians play an important role in preventing harmful drug interactions, he says. "The physician has a responsibility to ask about supplement use at each visit, and review prescription medication with patients. Few think it's important enough to ask about nonprescription remedies, and that's a mistake."

"I'm really glad this is finally coming to light," says Jason Theodosakis, MD, of the University of Arizona College of Medicine in Tucson, Arizona, and author of Arthritis Cure and Maximizing the Arthritis Cure. "I think many of these herbal products have gotten a free ride with regard to safety for too long."

Nutritional and herbal supplements are not held to same regulatory standards as prescription medications. Dietary supplements are governed by a 1993 law called the Dietary Supplements Health and Education Act (DSHEA), which does not require companies to prove that their products are safe and effective before selling them.

 

All herbals are not created equal

Dr. Theodosakis says that aside from potential problems with individual herbal products, many companies formulate mixtures, which dramatically compounds safety issues. "We don't even have good safety data on most individual components in herbal products," he says.

"One of the best solutions for this is for the doctor to keep a record, on the front page of the chart, that has a listing for all medications, as well as a place for all dietary supplements and herbal products," Dr. Theodosakis suggests. The components of an herbal mixture should be listed as well, since the doctor will not understand the components based on the proprietary name of a particular supplement," he explains.

The recent appearance of the well-known drug/herb interactions in drug databases "will go a long way toward ensuring safety," he says.

"I think companies that make herbal products-especially herbal mixtures-should be required to show their customers that there are long-term safety data related to their products," Dr. Theodosakis tells CIAOMed. "Customers have to stop assuming that just because something is natural that it can't hurt them."

Reference:

Holden W, Joseph J, Williamson L. Use of herbal remedies and potential drug interactions in rheumatology outpatients. Ann Rheum Dis. 2005;64:790.