Clinicians need to review what herbals patients take
Nonjudgmental, receptive approach is best
The discovery of a dangerous herb-drug interaction between St. John’s Wort and indinavir highlights the need for more clinical data on herbal remedies, experts say.
"There are a lot of theoretical discussions about herb-drug interactions, but they have not been validated clinically," says Mary L. Hardy, MD, medical director of the Cedars-Sinai Integrative Medicine Medical Group in Los Angeles.
Clinicians should be aware that HIV patients might be taking other herbs that have the potential to affect their antiretroviral therapy adversely. Patients who have little hope for a cure via mainstream medicine are willing to turn to alternative treatments, says Anna Garrett, PharmD, a clinical pharmacist with High Point (NC) Regional Health System. "The thinking is that if there’s anything out there that could help maintain health, herbal or otherwise, they’re willing to try it," says Garrett, who has worked with HIV populations in the past.
People with HIV want to have some control over their disease, so they’ll look into alternative medicine treatments, notes Michael Cirigliano, MD, an assistant professor of medicine at the University of Pennsylvania Medical Center in Eddystone.
"They feel empowered to research and treat themselves with agents they think might be of benefit, and that includes a lot of alternative, complementary medical treatments," Cirigliano says.
Clinicians at Nova Southeastern University in Ft. Lauderdale, FL, have documented a case of an HIV patient being treated with efavirenz who also was using St. John’s Wort, which may have interacted poorly and contributed to the patient’s feelings of anxiety, depression, and suicidal ideation.
"She said she felt like running down the street and screaming," recalls Jason Villano, PharmD, an infectious disease resident at Nova Southeastern University.
"We asked her if she had been doing anything different, had anything changed, and her answer was No,’" Villano says. "Then we asked her if she was taking anything over the counter, and she said, Yeah, St. John’s Wort.’"
Clinicians asked her to stop taking the herbal, and by the next day the patient reported that she felt better, Villano says.
While this single case does not offer valid proof of an interaction between efavirenz, a non-nucleoside reverse transcriptase inhibitor, and St. John’s Wort, it at least highlights how important it is for clinicians to monitor the herbal remedies their patients are taking, Villano says.
Villano suggests clinicians have patients undergo a sort of wash-out period by stopping the use of all herbs before starting antiretroviral therapy, and continuing it for a number of weeks until the clinician and patient are aware of all of the adverse effects from the antiretroviral drugs.
Then, if the patient still wants to take some herbal remedies, it’s a good idea to have the patient take one at a time, while being monitored for signs of anything going wrong, such as viral load increases or symptoms of anxiety, Villano says.
Questions should be specific, direct
Clinicians need to ask patients specific and direct questions about herbal remedies, because patients rarely volunteer this kind of information, says Marjorie Robinson, PharmD, assistant professor for pharmacy at Nova Southeastern University.
"They don’t think of herbal medications as drugs," Robinson says.
Robinson suggests clinicians use an herbal remedy checklist and ask patients these types of questions:
• Have you changed your diet in any way?
• Have you changed your antiretroviral dosage?
• Are you taking any over-the-counter drugs?
• Are you taking any vitamins, minerals, or herbal supplements, and if so, which ones are you taking?
• Are you drinking any herbal teas, and which ones are they?
Although it may seem redundant to ask patients about over-the-counter drugs and herbal remedies, it’s important to ask both questions, says Klepser.
"Usually, I ask what are their prescription meds, what are their over-the-counter meds, and then I ask the third question of what are their dietary supplements, herbs, and vitamins," Klepser explains. "A lot of times patients will say they are not taking any meds, but then when you ask the third question, they say, Oh yes, I take about 20 of those.’"
After questioning patients, it’s a good idea to pull out the herbal checklist and have them review that. The checklist should include both common names and official names for the herbs, Robinson says. Also, if a clinician’s patient population includes people who do not speak English, the checklist should be translated into the appropriate language. (See sample herbal checklist, p. 51.)
"The whole point to the checklist is [that] it alerts patients to be better historians of what they’re taking, and it makes them realize that herbal products are alternative drugs," Robinson says.
It might seem that the simplest action to take is to advise HIV patients to stay away from all herbal remedies while they are being treated with antiretrovirals. But this isn’t a good policy because patients will find this to be too restrictive and judgmental, and possibly will just go on using the herbal remedies anyway, Klepser says.
"Health care practitioners have the perception that herbs are not as well proven as prescription medications, but if you come across like that, then patients won’t confide in you," she adds.
Hardy recommends that clinicians treat HIV patients like partners, using a nonjudgmental questioning style and remaining open and receptive to what the patients tell them.
"Then if the clinician would like to recommend that a patient not take a particular product or not take a particular combination, the clinician should do so in a real respectful manner," Hardy says. "They should say something like, I know you are really trying to help yourself and with everything you’ve read about St. John’s Wort, of course you think it would be great, but we have new data that shows this.’"
Villano suggests that the best approach is to let patients know that you are seeking information that will help improve their HIV treatment. When patients explain which herbs they have been taking, then the clinician can research how that herb works in the body and therefore determine whether it is advisable to take that herb along with the antiretroviral drugs. (For more herb resources, see box, p. 54.)
For example, Villano treated a woman who was on an antiretroviral regimen and who wanted to take an herb called cat’s claw. Villano found that the herb would not be metabolized in the same way as the HIV drugs and would have a benign effect on her treatment, so he gave her the green light. "Even if what they want to take is a placebo, I don’t like to say no’ to something that might give them a boost in their quality of life," he says.
Villano monitored the woman after she began taking the herb, and she reported no signs or symptoms of changes.
So far, there is little research information available about herbal medications interacting with antiretroviral drugs, or with any drugs for that matter. The American Pharmaceutical Association of Washington, DC, last year published in its Pharmacy Today newsletter a chart listing 17 herbs and their potential adverse effects and/or drug interactions. But there are few studies available on the literally hundreds of herbs that have been used throughout the ages to treat various ailments, including more than 50 that are potentially fatal.
Within the next decade, many more studies of herbs will be conducted, and clinicians will have a great deal more hard data to review before making recommendations to patients.
"Now there is a renaissance of study and science looking at herbal medicine, which has not been done historically," Cirigliano says, referring to a recent influx of federal grant money to fund such research.
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