Black cohosh

Menopausal: hot flashes and mood symptoms

Premenstrual dysphoric disorder

Weight gain, gastrointestinal (GI) upset, headache, dizziness.

Possible life-threatening liver toxicity.

Monitor liver function.

Hepatotoxic herbs/supplements/drugs: may increase liver toxicity.

Hormone-sensitive cancers and conditions: limited data, should avoid use.

Breast cancer: limited data suggesting increased risk for metastasis.

Most studies used doses of 40-80 mg BID, but doses may vary.

DHEA (dehy droepiandrosterone)

Depression

Menopausal symptoms

Schizophrenia

Anti-aging

Masculinization Liver disease Possible exacerbation of metabolic syndrome, including insulin resistance.

Cytochrome P450 3A4 substrates: may increase levels due to enzyme inhibition.

Hormone-sensitive cancers and conditions, including breast and prostate cancers: limited data suggesting increased risk.

Converted into androgens and estrogens and may have adverse effects on pregnancy and nursing infants.

Doses range from 25-100 mg/d.

Ephedra

Banned by FDA due to cardio vascular and cerebrovascular events.

Weight loss agent

Used as a recreational drug “herbal ecstasy”

Serious adverse effects may include hyperadrenergic state (e.g., arrhythmias, tachycardia, hyperthemia), exacerbation of narrow angle glaucoma, psychosis, mania, suicidality, cardiac arrest, seizures, stroke, death.

Synergistic with sympathomimetics, serotonergic agents. Avoid with monoamine oxidase inhibitors (MAOIs).

QTc prolongation: increased risk of serious ventricular arrhythmias.

Decreased effectiveness of anticonvulsants and antidiabetics.

May cause false-positive urine amphetamine or methamphetamine test results.

Ginkgo

Cognitive/memory impairment

Depression

Premenstrual dysphoric disorder

Schizophrenia

Antidepressantinduced sexual dysfunction

Allergic skin reactions, GI upset, dizziness, muscle spasms, headache, possible induction of mania, lowered seizure threshold.

Anticoagulants/antiplatelet drugs: concomitant use may increase risk of bleeding.

Anticonvulsants: reduced effectiveness.

Cytochrome P450 1A2/2D6 substrates: mild inhibitor.

Cytochrome P450 2C19: inducer.

Cytochrome P450 2C9: strong inhibitor.

Trazodone: concomitant use associated with coma.

Doses range from 120-240 mg/d.

Prevailing mechanisms of action are through antioxidants, free radical scavenging properties, improvement of circulation.

Studies report improved cognition in dementia of Alzheimer’s type.

Ginseng

Stress reduction agent

Stimulant for chronic fatigue

Depression

Immune system booster

Ginseng abuse syndrome with insomnia, hypertonia, and edema. Induction of mania.

Antidiabetes drugs: increased glucoselowering effects with resultant hypoglycemia.

Decreased effectiveness of antipsychotic drugs, MAOIs, warfarin.

Potentiation of activity of stimulants.

Women with hormone-sensitive conditions (e.g., breast, uterine, ovarian): limited data, avoid use.

Doses range from 1-3 g/d. Teratogenic effects in animal models: avoid use during pregnancy.

Limited data for use in breast feeding.

Kava Kava

Associated with life-threatening hepatic damage.

Sedative/hypnotic

Anxiolytic

Antispasmodic

Increased risk of suicide with comorbid depression.

GI upset, headache, dizziness, lethargy, sedation, unsteady gait, anticholinergic, extrapyramidal symptoms, impaired cognition.

DO NOT USE before driving or operating heavy machinery.

Potentiation of activity of anxiolytics, alcohol.

Decreased effectiveness of dopamine agonists.

Dose ranges from 60-240 mg of active ingredient daily.

Melatonin

Insomnia

Circadian-based sleep disorders

Benzodiazepine withdrawal

Uncommon, but high doses may worsen depression and cause abdominal cramps, fatigue, headache, dizziness.

Very high doses can exacerbate depression.

May interact with antihypertensive agents.

Dose ranges from 0.3-10 mg/d.

Omega-3 fatty acids Fish oils – EPA, DHA Plant-derived-ALA

Triglyceridelowering agent Coronary artery disease: anti-inflammatory, antithrombotic Bipolar disorder/depression Dementia of Alzheimer’s type

GI side effects, including fishy aftertaste, halitosis, nausea, diarrhea. Sedation.

Induction of mania.

Anticoagulant/ antiplatelets: increased risk of bleed.

Potentiation of antihypertensive drugs.

Implantable defibrillators: increased risk of ventricular arrhythmias.

Dose ranges from 3000-9000 mg/d. Fatty/fish oils may contain significant amounts of toxins (e.g., mercury, PCBs) that can be carcinogenic, teratogenic, immunosuppressive, or lead to central nervous system (CNS) disturbances.

SAMe

Depression

Fibromyalgia

GI upset, dry mouth, headache, sweating, dizziness.

Additive serotonergic/ MAOI effects with increased risk of serotonin syndrome.

Dose ranges from 400-2400 mg/d.

St. John’s wort

Depression Anxiety Somatization disorder

Anxiety.

Induction of mania.

Activation, GI upset, dizziness, headache, neuropathy, insomnia, photodermatitis, photosensitivity, withdrawal syndrome.

Induction of mania, psychosis.

Contraindicated in pregnancy, lactation, cardiovascular disease, and pheochromocytoma.

Levodopa: reduced effectiveness.

Oral contraceptives: increased/abnormal intermenstrual, menstrual bleeding.

Non-nucleoside reverse transcriptase inhibitors(NNRTIs)and protease inhibitors: decreased serum levels.

Cytochrome P450 1A2/ 2C9/3A3/3A4: inducer.

Doses range from 300-1800 mg/d.

Stop using at least 3 d before starting an agent with serotonegic properties.

Limited data regarding teratogenic effects: avoid use during pregnancy.

Avoid use during breastfeeding due to reports of colic and lethargy.

Valerian

Anxiety Insomnia Benzodiazepine withdrawal

Headache, GI upset, activation, daytime sedation, drowsiness with resultant cognitive impairment.

Cardiac dysfunction and hepatotoxicity with long-term use.

Hepatotoxicity. DO NOT USE before driving or operating heavy machinery.

Avoid concomitant use with alcohol, benzodiazepines, CNS depressants due to additive therapeutic and adverse effects.

Cytochrome P450 CYP 3A4: inhibitor.

Doses range from 400-900 mg of valerian extract daily.

Vitamin E Alpha-tocopherol

Dementia of Alzheimer’s type

Uncommon but can cause GI upset, fatigue, headache, blurred vision, rash.

Anticoagulant/antiplatelet potential, particularly in combination with warfarin and/or antagonism of vitamin K-dependent clotting factors: increased risk of bleeding.

Cytochrome P450 3A4: inducer.

Dose ranges from 400-2000 IU daily.

Other dementias such as vascular, mixed, Huntington’s Premenstrual dysphoric disorder Tardive dyskinesia

Retrospective data indicating concurrent use with Aricept may help slow cognitive decline in dementia of Alzheimer’s type. Therapeutic effects attributed to antioxidant properties.

Some data included in this table are derived from single case reports and anecdotal evidence; solid clinical evidence is lacking, doses may vary depending upon formulation and are intended to be a guideline.