By WES ALLISON

© St. Petersburg Times, published June 7, 2000

Pamela Seefeld picked simple props to make clear a complex problem: a sketch of the human liver, a few bottles of popular herbal supplements and a big, red lapel button emblazoned with, "Ask me about dangerous drug interactions."

Seefeld, the night pharmacist at Morton Plant Hospital in Clearwater, recently lectured about 50 curious people, most senior citizens, on how St. John's wort, ginseng, ginkgo biloba and other popular supplements can affect the way the body breaks down other medicines.

Mixing prescription drugs and herbals can be dangerous, and Seefeld repeatedly told the crowd what physicians and pharmacists too often don't: Make sure your doctor knows about any herbs or other supplements you're taking, no matter how benign they seem to you.

"You need to be cautious with these things," said Seefeld, who also owns Botanical Resource, a natural therapy store in Clearwater. "You can't take things at face value."

People often turn to herbals because they want the effects of pharmaceuticals -- better sleep, vim and vigor, lower cholesterol -- from a "natural" product. And annual sales of herbs and botanicals are expected to hit $4.8-billion this year, the American Botanical Council reports. Sales of all supplements could approach $16-billion.

As the popularity of herbs and vitamins grows, some doctors and pharmacists who have long ignored them are realizing they no longer can. But many of their colleagues and patients don't recognize the importance of checking for interactions with prescription and over-the-counter drugs, they said.

"Pharmacists and physicians in general aren't tuned into herbal meds," said Mike Magee, director of pharmacy for St. Joseph's Hospital in Tampa. "As a pharmacist, I've had to force myself to actively read up on this and understand these better.

"From a scientific perspective, (the benefit of herbals) is kind of questionable still. But the fact of the matter is these things are being used at an exponential rate in the community, and we need to be attuned to that."

Some health care centers have begun trying to bridge this gap, holding lectures, like Seefeld's, that urge patients to talk with their doctors about herbs, and vice versa. And some bay area hospitals recently began asking patients if they're taking supplements.

Major medical publications, including the Archives of Internal Medicine and the Lancet, increasingly are investigating herbal treatments and attitudes toward them.

But such efforts haven't gotten much help from the U.S. Food and Drug Administration, which has minimal requirements regarding herbal products, or the companies that make them. Consider this:

Herbal supplements are not required to carry warnings of potential or even likely drug interactions. Even well-known problems, such as the potentially hazardous effect that St. John's wort can have on anti-depressants and a common AIDS drug, do not have to be published in the packaging.

Retail pharmacies generally do not check for potential interactions with herbals when they fill a prescription. That means a patient who wasn't warned by her doctor won't get any information from the pharmacy, either.

Active ingredients and dosing may vary by brand, or even from pill to pill taken from the same bottle. "You get one capsule and test it, and another capsule and test it, and you can find a 20-fold difference," Magee said.

Mary Beth Corcoran, clinical pharmacist for the senior adult oncology program at the H. Lee Moffitt Cancer Center in Tampa, said that makes it difficult to determine what effect herbs are having on prescription drugs or patients' health.

"When you really don't know how much you're using, one day it may be okay, and the other day it might not be, because it's not controlled," she said.

Recent surveys suggest 20 to 40 percent of Americans use supplements, depending where they live and their age. But some patients, especially senior citizens, often are reluctant to mention them, in part because they think doctors don't put much credence in alternative or natural medicine.

"They don't want to disappoint their physician by telling him they're taking something . . . that they read about in Parade magazine," Magee said.

The American Herbal Products Association, which represents manufacturers, can order its members to include warnings about drug interactions other potential problems, but it has issued just four.

It says people should limit dosing of kava kava, a root taken to ease anxiety, and ephedra, a weight-loss aid. Saw palmetto, which may shrink the prostate, soon will carry a warning advising men over 50 to get checked for prostate cancer rather than trying to treat urinary problems with the herb.

The group also is updating its warning for St. John's wort, a popular mood enhancer. The exact wording has not been determined, but it is expected to advise people who take prescription drugs to tell their doctor if they're also taking St. John's wort, said Dr. Joseph Betz, vice president of scientific and technological affairs for the association.

The association and many manufacturers warn that St. John's wort can make fair-skinned people more sensitive to the sun. It decided to expand the warning after research showed the herb may hurt the effectiveness of Indinivir, a common AIDS medication, and immuno-suppressants that transplant patients take.

"As soon as we get new scientific information, we react as rapidly as we can," said Betz, who previously studied herbal compounds for the FDA. "There are different studies that show different things out there, and the science is by no means clear."

But other herbs have interactions, too, that neither the association nor the FDA have addressed.

The dangers typically aren't the sort that will make you drop dead, although ephedra has been linked to sudden heart failure. Rather, some herbs may increase or decrease the power of drugs, setting the stage for cardiovascular trouble, internal bleeding, brain hemorrhage or other problems later on.

St. John's wort, for instance, can boost the effects of prescription anti-depressants, such as Prozac, and change the way the liver metabolizes ulcer medications, asthma medications and other drugs, pharmacists said. Even ginkgo, garlic and ginseng -- generally considered safe -- work as anti-coagulants, which can cause excess bleeding for people who take blood thinners such as Coumadin. So can ginger.

"Herbs aren't just safe old things you can take no matter what," said Dr. Steven Masley, a family practitioner for Morton Plant Mease Health Care who writes and lectures on herbal medications.

"Herbs are pharmacologically active agents, and that's where many of our medications come from."

Several of those who attended Seefeld's lecture at Morton Plant's health education center at Countryside Mall recently hadn't considered that. Bernita Ventsias of Seminole said she asked her doctor about herbal products, but he shrugged her questions off.

So she has been using several regularly, unconcerned with how they might react with prescription drugs she's taking. Until she heard Seefeld.

"I'm going to ask him about them now," Ventsias said.

Several hospitals, including St. Joseph's, Oak Hill Hospital in Hernando County and Regional Medical Center Bayonet Point in Hudson, have begun asking new patients if they take herbals. Tampa General Hospital is revising its questionnaire to include herbals because of their popularity, a spokeswoman said.

Corcoran also has seen a jump in the number of senior cancer patients at Moffitt who use herbals with chemotherapy and medication, but many don't consider how the herbs may affect their treatment.

"I'm not trying to dissuade them from using herbal products," Corcoran said. "They need to make a well-rounded decision, instead of just hearing one side of the story."

Getting both sides seems to be getting easier, if you know where to dig.

Medical Economics Co., which publishes the venerable Physicians Desk Reference, last year published a version for herbal medicines that contains the uses, scientific evidence, side effects and potential drug interactions of more than 400 products.

The American Botanical Council, an independent, non-profit education and research group based in Austin, and the Texas Medical Association this fall expect to publish a guide to herbs that will include drug interactions.

But one problem doctors and pharmacologists likely always will face is the unstable nature of herbal supplements: Unlike pharmaceuticals, which are crafted in a laboratory, herbs' chemical makeup can vary from farm to farm or crop to crop.

And it's not always possible to identify active ingredients, which can make it difficult to determine how they will react with other things. Wayne Silverman, chief administrative officer of the American Botanical Council, said herbs often draw their benefits from the way several compounds work together.

"The whole concept of wanting every pill to be exactly the same, that's a drug mentality," Silverman said. "The complex nature of herbal medicine, and the synergistic compounds that make it up, just a demand a different mind-set."

Internet resources

Want more information about herbal and dietary supplements? Talk with your pharmacist or check out these resources:

• The Natural Pharmacist
• American Botanical Council
• Office of Dietary Supplements, National Institutes of Health
• Integrative Medical Arts
  www.InteractionReport.org
• American Herbal Products Association
• ConsumerLab.com (tests popular products)

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