Herbals and Dietary Supplements

• What should pharmacists do when discussing supplements during counseling?

  • encourage discussion with health care providers and medication reconciliation
  • discuss health claims/regulations
  • discuss effectiveness
  • look for seal of approval of quality
  • inform drug-supplement interactions and/or contraindications
  • discuss supplement dosing
  • inform of side effects both common and rare
• omega-3 fatty acids


  • products: omega-3 acid ethyl ester (Lovaza), Icosapent ethyl (Vascepa), omega-3-carboxylic acids (Epanova)
  • primary use for hypertriglyceridemia
  • contraindications/interactions: limit ≤3g/day on anticoagulation/antiplatelets
  • side effects: fish burp, possibility to increase LDL, increased bleeding risk
  • food source: fatty fish 2 times a week
• garlic


  • primary use for hypertension, hyperlipidemia, diabetes, reducing inflammation
  • contraindications/interactions: avoid using in patients on antiplatelets/anticoagulants
  • side effects: garlic breath (halitosis), GI effects (nausea, heartburn, reflux)
• red yeast rice(Monascus purpureus)

  • primary use for hyperlipidemia
  • contraindications/interactions: avoid with pregnancy, heavy drinking, statins, liver disease, CYP3A4 inhibitors
  • side effects: dizziness, headache, bloating, muscle pain, rhabdomyolysis (in high doses), increased liver enzyme
• coenzyme Q10 (ubiquinone)

  • primary use: hypertension, heart failure (contradictory), ischemic heart disease, statin-induced myopathy
  • contraindications/interactions: reduce warfarin efficacy
  • side effects: usually well tolerated, GI effects (1% of patients)
• glucosamine (chondroitin)


  • primary usage for osteoarthritis
  • contraindications/interactions: shellfish allergy, avoid with warfarin
  • side effects: GI discomfort, skin reactions
• tumeric (curcurmin)


  • primary usage for osteoarthritis, inflammation
  • contraindications/interactions: increase risk of bleeding, avoid with NSAIDS, anticoagulants, antiplatelets
  • side effects: GI discomfort, nausea, skin rashes
• melatonin


  • primary usage for insomnia, jet lag, shift workers
  • contraindications/interactions: use in adolescence under supervision, avoid in pregnancy
  • side effects: well tolerated, headache, AM sleepiness, tachycardia
• cinnamon extract


  • primary usage for lowering blood sugar in type-2 diabetes
  • contraindications/interactions: statins, hepatitis with excess intake
  • side effects: plasma celk gingivitis, stomatitis, allergies
• echinacea


  • primary usage for common cold, viral infection, is immunostimulant
  • contraindications/interactions: avoid in allergy to Asteraceae family, ragweed allergy, asthma, atopy, allergic rhinitis, caution in immunocompromised, inhibits CYP3A4, CYP2C8
  • side effects: headache, dizziness, nausea, GI upset, rash, anaphylaxis (rare)
• cranberry


  • primary usage for UTI
  • contraindications/interactions: increased INR with warfarin, inhibits enteric CYP3A activity, avoid with kidney stones
  • side effects: GI upset (large doses), decrease urinary pH
• ginkgo(Ginkgo Biloba)

  • primary usage for dementia and memory
  • contraindications/interactions: increase bleeding with anticoagulants, antiplatelets, NSAIDs, inhibits and induces CYP1A2, 2D6, 3A4
  • side effects: hyponatremia, headache, fatigue, malaise, skin reactions (pruritus, macular erythema)
• saw palmetto


  • primary use: symptoms of benign prostatic hyperplasia (BPH); anti-estrogenic and anti-inflammatory
  • contraindications/interactions: found in combination supplements for woman to increase bust size; contraindication in pregnancy; avoid with estrogenic therapies; avoid in history of bleed; antiplatelet/anticoagulants
  • side effects: GI disturbances, diarrhea, fatigue, headache, decreased libido, rhinitis; acute pancreatitis, hepatotoxicity, hematuria, coagulopathy
• St. John's wort (SJW)

  • primary usage for depression, seasonal affective disorder, anxiety
  • contraindications/interactions: avoid with bipolar disorder; a potent CYP3A4 inducer; increases P-glycoprotein transporter activity
  • side effects: photosensitivity, serotonin syndrome, GI symptoms, sleep disturbances, vivid dreams, insomnia
• black cohosh


  • primary usage for postmenopausal symptoms
  • contraindications/interactions: avoid with liver disease, hepatotoxic agents, estrogenic/antiestrogenic agents; may inhibit CYP450 2D6
  • side effects: GI upset, rashes, dizziness, headache, nausea, vomiting, hepatotoxicity, bradycardia
• green tea


  • primary usage for weight loss, cancer prevention, cardiovascular disease, hypertension
  • contraindications/interactions: avoid in pregnancy, breast feeding, peptic ulcer disease
  • side effects: sleep disruption, headache, pruritic swelling and darkening of lower lip
• conventional medicine

  • disease focused
  • treats symptoms using drugs, radiation, surgery
• alternative medicine

  • used in place of conventional medicine
  • treats symptoms using medications that are closer to nature
  • not all treatments are scientifically validated
• complementary medicine

  • modern approach that used both conventional and alternative medicines to diagnose and treat symptoms
• natural medicines

  • most commonly used complementary and alternative therapy
• herbals

  • plant products that may be useful in treating disease or staying healthy
• vitamins/minerals

  • essential subtances that our bodies need to develop and function normally
• Dietary Supplement Health and Education Act (DSHEA) of 1994

  • required by law:
  • good manufacturing practives (GMPs)
  • adverse reporting
  • not required by law
  • proof of effectiveness
  • health claims
  • disease claims are not permitted (eg. treats painful osteoarthritis)
  • structure/function claims are permitted (eg. promotes joint function)
• What is the difference between drugs and supplements?

  • drugs:
  • active ingredient is identified
  • safety and efficacy are proven by manufacturer
  • purity and conents are regulated
  • claims to treat, cure, or prevent disease are made
  • dietary supplements:
  • actie ingredient may not be identified
  • no proof of efficacy is required (FDA must prove it unsafe post-marketing)
  • no standards for quality/purity (must follow GMP)
  • no claims to treat, cure, or prevent specific diseases are made
• What are the three types of claims supplements can make?

  • health claims that describe a relationship between a substance and reduced risk of a disease or health-related condition
  • structure/function claims that describe the role of a nutrient/dietary ingredient intended to affect the normal structure or function of the human body
  • nutrient content claims that characterize the level of a nutrient in a food
• supplement labeling requirements

  • supplement facts label is similar to label required on food products
  • includes ingrediehnts, quantities, serving size, servings per container
  • includes calories, calories from fat, total fat, saturated fat, cholesterol, sodium, carbohydrate, dietary fiber, sugars, protein, vitamin A, vitamin C, calcium and iron
• What does a product with the Seal of Approval look like?

  • look for U.S. Pharmacopoeia (USP), ConsumerLab, or National Sanitation Foundation (NSF) seal of approval
  • have stanards to ensure the product was properly made contains what label lists and is free of contaminants
  • can search USP verified supplement by supplement type, brands, and retailers
• What are the herbal supplements that interact with prescription medicine often?

  • 5 Gs: ginkgo, garlic, ginger, glucosamine, ginseng
  • decreased platelet aggregation
  • increased bleeding risk
  • others: omega-3 fish oil (high doses), vitamin E, willow bark
• What are some things to consider when using herbal supplements?

  • natural does not equal safe
  • respect patient's beliefs with proactive, nonjudgemental approach
  • encourage communication with provider
  • weigh in risks vs benefits
  • when in doubt, recommend against use due to lack of evidence, especially in pregnancy, lactation, elderly, interacting medicines
  • look for seal of approval
• nutritional supplements

  • nonprescription products used to prevent deficiencies and maintain normal stores
  • vitamins and minerals are used for treatment of other medical conditions
  • some vitamins and minerals are toxic in high doses
• What are some risk factors for nutrient deficiencies?

  • young or old age
  • bariatric surgery
  • chronic disease
  • eating/swallowing disorders
  • alcoholism
  • pregnancy or menstruation
  • medication use
  • vegetarian diet
• vitamin names

  • vitamin A (retinol)
  • vitamin B1 (thiamine)
  • vitamin B12 (cobalmin)
  • vitamin B2 (riboflavin)
  • vitamin B3 (niacin)
  • vitamin B6 (pyridoxine)
  • vitamin B9 (folic acid)
  • vitamin C (ascorbic acid)
• water-soluble vitamins

  • vitamin B
  • vitamin C
• fat-soluble vitamins

  • vitamin A, D, E, K
  • found in fats and oils of food
  • absorbed along with fats in the diet
  • transported with fats through lymphatic system in chylomicrons before entering blood
  • stored in body fat tissues and liver
  • can become toxic at large amounts
• dietary reference intake (DRI) values

  • estimated average requirement (EARs)
  • recommended daily allowance (RDAs)
  • adequate intakes (AIs)
  • tolerable upper intake levels (ULs)
• vitamin A (retinol)

  • primary usage: maintenance of cornea; bone and tooth growth; reproduction; mucosa membrane, epithelial cells, skin
  • deficiency: rare; night blindness, corneal drying (xerosis), blindness; imparied bone growth and easily decaying teeth; keratin lumps on skin
  • toxicity: increased activity of bone-dismantling cells resulting in reduced bone density; liver abnormalities; carotinemia; hypervitaminosis
  • interactions: orlistat, mineral oil, cholestyramine (decreased absorption); retinoids for risk of toxicity
• vitamin D

  • primary usage: mineralization of bones and teeth; maintain calcium and phosphorus mineral homeostasis
  • deficiency: common in lack of sunlight; abnormal bone growth resulting in rickets in children and osteomalacia or osteoporosis in adults; malformed teeth
  • toxicity: hypercalcemia, kidney stones, calcification of soft tissue, headache, nausea, weakness
  • sources: plants (D2 ergocalciferol), animals (D3 cholecalciferol)
  • interactions: orlistat, mineral oil, cholestyramine (decreased absorption)
• vitamin E (Tocopherol)

  • primary usage: antioxidant; protects cell membranes, regulates oxidation reactions, protects poly saturated fats; heme biosynthesis; steroid metabolism; collagen formation
  • deficiency: extremely rare; RBC breakage; nerve damage
  • toxicity: augments the effects of anti-clotting medications; increased bleeding risk
  • interactions: orlistat, mineral oil, cholestyramine (decreased absorption); anticoagulants for risk of bleeding
• vitamin K (phytonadione)


  • primary usage: synthesis of blood-clotting proteins and bone proteins
  • deficiency: uncommon; hemorrhage; abnormal bone formation
  • toxicity: opposes the effects of anit-clotting medication (warfarin)
  • interactions: orlistat, mineral oil, cholestyramine (decreased absorption); warfarin
• What disese states limit abosption of fat-soluble vitamins?

  • celiac disease
  • cystic fibrosis
  • obstructive jaundice
  • hepatic cirrhosis
  • bariatric surgery
  • short-bowel syndrome