Home' Australian Pharmacist : Australian Pharmacist March 2016 Contents Australian Pharmacist March 2016 I ©Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
distress or alarm. The National Health
and Medical Research Council (NHMRC)
has developed a useful resource to
assist communication: Talking with your
patients about complementary medicine –
a resource for clinicians.
If possible printed materials or links
to reliable resources may be provided
to assist patients in making informed
decisions. Where relevant referral to
a qualified herbalist or naturopath
(bachelor degree) may be indicated and/
or the patient may need to be referred
back to the prescribing practitioner for
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and attitudes of pharmacy customers on complementary
medicines and pharmacy practice. BMC Complement Altern
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complementary medicines; Canberra: PSA; 2015. At:
3. Xue CC, Zhang AL, Lin V, et al. Complementary and
alternative medicine use in Australia: a national population-
based survey. J Altern Complement Med 2007;13(6):643–50.
4. Bowe S, Adams J, Lui CW, et al. A longitudinal analysis of
self-prescribed complementary and alternative medicine
use by a nationally representative sample of 19,783
Australian women, 2006–2010. Complement Ther Med
5. Liu MZ, Zhang YL, Zeng MZ, et al. Pharmacogenomics and
herb-drug interactions: merge of future and tradition. Evid
Based Complement Alternat Med 2015:321091.
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an overview of systematic reviews. Br J Clin Pharmacol
7. Cho HJ, Yoon IS. Pharmacokinetic interactions of herbs
with cytochrome p450 and p-glycoprotein. Evid Based
Complement Alternat Med 2015:736431.
8. Moses GM, McGuire TM. Drug interactions with
complementary medicines. Aust Prescr 2010;33(6):177–
80. 2010. At: www.australianprescriber.com/
9. Zadoyan G, Fuhr U. Phenotyping studies to assess the effects
of phytopharmaceuticals on in vivo activity of main human
cytochrome p450 enz ymes. Planta Med 2012;78(13):1428–57.
10. Rahimi R, Abdollahi M. An update on the ability of St. John’s
wort to affect the metabolism of other drugs. Expert Opin
Drug Metab Toxicol 2012;8(6):691–708.
11. Hermann R, von Richter O. Clinical evidence of herbal drugs as
perpetrators of pharmacokinetic drug interactions. Planta Med
12. Braun L, Cohen M. Appendix 2: Herb/nutrient-drug
interactions. In: Herbs and natural supplements: an
evidence-based guide. Vol 2, 4th edn. Australia: Elsevier; 2015.
13. Wang XD, Li JL, Su QB, et al. Impact of the haplotypes of the
human pregnane X receptor gene on the basal and St John’s
wort-induced activity of cytochrome P450 3A4 enzyme. Br J
Clin Pharmacol 2009;67(2):255–61.
14. Braun L, Cohen M. Safety of complementary medicines. In:
Herbs and natural supplements: an evidence-based guide.
Vol 1, 4th edn. Australia: Elsevier; 2015. p.100–8 .
15. Nahin RL, Pecha M, Welmerink DB, et al. Concomitant use of
prescription drugs and dietary supplements in ambulatory
elderly people. J Am Geriatr Soc 2009;57(7):1197–205.
16. Braun L, Cohen M. Schisandra. In: Herbs and natural
supplements: an evidence-based guide. Vol 2, 4th edn.
Australia: Elsevier; 2015. p. 887.
17. Russo E, Scicchitano F, Whalley BJ, et al. Hypericum perforatum:
pharmacokinetic, mechanism of action, tolerability, and clinical
drug-drug interactions. Phytother Res 2014;28(5):643–55.
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biloba. Drug Metab Rev 2013;45(3):353–85.
19. Australian Government National Health and Medical
Research Council (NHMRC). Talking with your patients
about complementar y medicine – a resource for clinicians.
Canberra: NHMRC; 2014. At: www.nhmrc.gov.au/_files_nhmrc/
1. In which ONE of the following cases
might an HDI between St John’s wort
and a medicine provide a potential
benefit to the patient?
a) A patient taking a high dose of a
selective serotonin reuptake inhibitor
b) A patient who has failed to respond to
c) A patient taking cyclosporin.
d) A patient who has failed to respond to
2. Based on current evidence, both
clinical and experimental, which
ONE of the following statements is
a) Genetic polymorphisms (affecting
CYP2C19) may influence the likelihood
of an interaction with kava.
b) Goldenseal may induce CYP3A and
c) Schisandra may inhibit CYP3A4 and Pgp.
d) St John’s wort (SJW) may inhibit CYP1A2,
2C9 and 3A4, as well as intestinal Pgp.
3. A patient who is receiving
cyclosporin following an organ
transplant tells you that they have
been taking a herbal medicine
prescribed by a herbalist/naturopath
who they believe to be well
regarded. They ask for your advice on
whether they should continue taking
the herbs or should discontinue
them. Which ONE of the following
courses of action would be the MOST
a) Ask whether the prescribing practitioner
and the herbalist/naturopath are both
aware of everything the patient is
taking and recommend that the patient
asks the practitioners to communicate
with each other, if this has not already
b) Check your quick reference guides to
see if there is a possible HDI.
c) Recommend that the patient
immediately discontinue the herbs.
d) Use at least two reliable resources to
check if there is a possible HDI.
4. Which ONE of the following
statements regarding HDIs is MOST
a) Herbs are natural compounds and
like foods they are safe to take in
conjunction with pharmaceutical
b) Information about potential HDIs is
based on in vitro and/or animal studies
which can reliably predict the likelihood
of a clinically meaningful interaction.
c) Due to the difficulty involved in
accessing reliable information about
HDIs patients should always be advised
to cease any herbs if they are also taking
d) Assessing the potential for an HDI must
be done on a case-by-case basis taking
into consideration the characteristics
and preferences of the patient, as well
as the purpose, mechanism(s) of action
and metabolic pathways of both the
herb and the medicine.
THE COMPLEMENTARY APPROACH
KEY LEARNING POINTS
Amongst CAMs, herbal medicines present a special challenge for evaluating the
risk of drug interactions as they are complex compounds containing many different
biologically active constituents.
Herbs can interact with medicines via pharmacokinetic, pharmacodynamic or
Assessing the possible risk or benefit of a herb–drug interaction (HDI) requires an
understanding of the patient, the medicine and the herb in question.
A variety of resources are available but there is no definitive list of HDIs and it is
sometimes necessary to utilise multiple resources.
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