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Table 1 Herb-drug interactions (HDIs) of some herbs with possible mechanism, outcome and level of HDIs

From: Current perspectives in herbal and conventional drug interactions based on clinical manifestations

Herb Drug Possible mechanism HDI outcome Level of HDIS References
Danshen Warfarin Additive effect Potentiated anticoagulant effect +++ [19,20,21]
Midazolam CYP3A4 induction Decreased F of midazolam ++ [22]
Echinacea Caffeine CYP1A2 inhibition Decreased CL/F of caffeine ++ [24, 25]
Midazolam CYP3A4 induction Increased CL and decreased F of midazolam + [24, 25]
Tolbutamide CYP2C9 inhibition (weakly) Reduces CL/F of tolbutamide + [24, 25]
Garlic Saquinavir P-gp induction Increased CL and decreased F of saquinavir +++ [27, 28]
Warfarin Additive effect Increased anticoagulant effect ++ [29, 30]
Chlorzoxazone CYP2E1 inhibition Decreased serum 6-hydroxychlorzoxazone/chlorzoxazone ratio ++ [31, 32]
Fluindione P450 inhibition Decreased INR level ++ [33]
Ginkgo biloba Tolbutamide CYP2C9 inhibition Decreased AUC of tolbutamide + [35]
Midazolam CYP3A inhibition Decreased AUC and Cmax of midazolam ++ [36]
Nifedipine CYP3A inhibition Cmax of nifedipine was doubled +++ [37]
Omeprazole CYP2C19 induction Decreased Cmax of omeprazole and increased Cmax of 5-hydroxyomeprazole + [38]
Talinolol P-glycoprotein inhibition Increased Cmax and AUC of talinolol ++ [39]
Fexofenadine P-gp-mediated efflux inhibition Increased AUC and Cmax of fexofenadine +++ [40]
Ibuprofen Additive effects Increase anticoagulant effect +++ [96]
Diuretic (thiazide) Agonism Increased blood pressure +++ [41]
Valproic acid CYP2C19 induction Fatal seizure ++ [42]
Antipsychotic drug (risperidone) CYP2D6 and CYP3A4 inhibition Increased Cmax of risperidone and causes priapism ++ [43]
Efavirenz CYP3A4 and P-gp induction Virologic failure associated with decreased efavirenz blood concentration ++ [44]
Trazodone CYP3A4 induction Enhancement of GABAergic activity leading to coma ++ [45]
Goldenseal Debrisoquine CYP2D6 inhibition Decreased debrisoquine urinary recovery ratios (DURR) +++ [48, 49]
Midazolam CYP3A4/5 inhibition Increased AUC and Cmax of midazolam +++ [48, 50]
Cyclosporin A CYP3A4 inhibition Increased blood concentration of cyclosporin A ++ [48, 51]
Green tea Folic acid Carrier-mediated absorption inhibition Decreased F of folic acid +++ [53, 54]
Simvastatin CYP3A4 inhibition Increased AUC and Cmax of simvastatin +++ [55, 56]
Warfarin Antagonism effect Decreased anticoagulant effect ++ [57, 58]
Kava Benzodiazepine (Alprazolam) Additive effect on GABA receptors Increased benzodiazepine effect +++ [60,61,62]
Chlorzoxazone CYP2E1 inhibition Decreased 6-hydroxychlorzoxazone/chlorzoxazone serum ratios +++ [48]
Dopamine Dopamine antagonism Reduced dopamine efficacy ++ [63]
Liquorice Omeprazole CYP3A4 induction Decreased plasma concentrations of omeprazole ++ [65]
Midazolam (benzodiazepines) CYP3A4 induction Decreased plasma concentrations of midazolam ++ [66]
Milk thistle Metronidazole P-gp & CYP3A4 induction Decreased blood concentration of metronidazole ++ [68]
Losartan CYP2C9 inhibition Increased AUC of losartan. ++ [69]
Talinolol P-gp inhibition Increased AUC and Cmax, and decreased CL/F of talinolol ++ [70]
St. John’s wort Amitriptyline CYP3A4 and P-gp induction Decreased blood concentration of amitriptyline ++ [72,73,74,75,76,77]
Atorvastatin CYP3A4 and P-gp induction Reduced efficacy of atorvastatin + [72, 73, 78]
Cyclosporine CYP3A4 and P-gp induction Cyclosporine exhibits a relatively small therapeutic window ++ [72, 73, 79,80,81,82]
Digoxin CYP3A4 and P-gp induction Decreased blood concentration of digoxin ++ [72, 73, 83, 84]
Methadone CYP3A4 and P-gp induction Decreased blood concentration of methadone +++ [72, 73, 85]
Alprazolam CYP3A4 induction Decreased blood concentration of alprazolam +++ [72]
Imatinib CYP3A4 induction Decreased blood concentration of imatinib +++ [72, 86, 87]
Indinavir CYP3A4 induction Decreased blood concentration of indinavir +++ [72, 88]
Irinotecan CYP3A4 induction Decreased blood levels of SN-38 +++ [72, 89]
Nevirapine CYP3A4 induction Decreased blood concentration of nevirapine ++ [72, 90]
Chlorzoxazone CYP2E1 induction Increase in hydroxylchlorzoxazone/chlorzoxazone serum ratio ++ [31, 32]
Bupropion Additive effects Orofacial dystonia +++ [91,92,93,94]
Buspirone Additive effect on 5-HT reuptake Hypomanic episode, serotonin syndrome +++ [94]
  1. P-gp P-glycoprotein, F Bioavailability, AUC area under the plasma drug concentration-time curve, Cmax maximum plasma concentrations, CL total renal clearance, CL/F oral clearance
  2. +Mild HDI
  3. ++Moderate HDI
  4. +++Major HDI