Interactions Between Commonly Used Medications For Lupus and Herbal Supplements

It is estimated that 4 out of 10 people in the United States take herbal medications. Illnesses including lupus and the medications used to treat them can seem complicated and daunting, and many people are attracted to the idea of natural remedies that seem simple and safe. The truth is that, while some herbal medications and supplements may be effective, they are not simple solutions. In some cases, they can in fact have dangerous interactions with prescription and over-the-counter medications.

The following is a review of what to look for when exploring the world of herbals. It highlights what you should know as a consumer concerning drug/herbal interactions, specifically related to medications commonly used to treat lupus. The summary also includes questions to explore with your physician. In every case, it is essential to alert your health care provider of all medications that you are taking, including over-the-counter supplements and herbals.

I. Buying Medications and Supplements: What to look for and what you should know

When a manufacturer makes a medication, there are strict rules and monitoring by the Food and Drug Administration of how the medication is made and the conditions (sanitation, etc.) under which they’re made.

All Over-the-Counters (OTCs) come with Drug Fact labels that are required by federal law. Everything on the label is important information that a consumer should pay attention to and learn to understand. This includes the following:

1. Active ingredients: the therapeutic ingredient or ingredients

2. Uses: the symptoms that are being targeted. If you don’t have any of the symptoms listed, don’t use this particular medication.

3. Warnings: Since these can be general, it is unlikely that anything will be listed specific to lupus. Instead, look for interactions with other medications you may be taking.

4. Directions: all medications should be used as directed in order to ensure effectiveness and to minimize side effects.

5. Inactive Ingredients: an important section to note if you have allergies to things such as colors and dyes.

Prescription medications come with a package insert that contains the same information found on OTC packaging labels.

Shopping safely for herbal medications can be more difficult. There is no governing body that oversees the production of herbal medications and supplements. Their manufacturing processes are not monitored. The purity of content and accuracy of labeling is also not monitored, meaning labeling is not regulated and can be false. For example, 60% of herbal medicines in one study found no active medicine, despite product labeling. When processed, natural products such as garlic or ginger may be so potent that it can be dangerous to take them, even though they are healthy in their natural form. It is also impossible to know which part of the plant was used to create the supplement, nor when it was cultivated, both of which can affect potency.

II. Lupus Medications and How They Interact With Commonly Used Herbal Supplements

There are three classes of drugs commonly used to treat lupus:

1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) NSAIDS are generally used to reduce pain, inflammation, and fever. Specific to lupus, they reduce and prevent redness, pain and stiffness.

2. Corticosteroids

Corticosteroids generally reduce inflammation and suppress the immune system. Specific to lupus, low-dose corticosteroids are used to reduce levels of redness, pain, and stiffness that are uncontrolled by NSAIDS. Higher doses are used to treat major organ involvement.

3. Immunosuppressive Agents

Immunosuppressive Agents are medications that suppress the immune system and are used to prevent organ damage, and they can be used in cases where NSAIDS and Corticosteroids have not been sufficiently effective.

NSAIDS
Varieties of these medications are available both by prescription and over the counter (OTC). Most OTCs are known to consumers by their brand names

OTC NSAIDS:

Generic Name	Brand Name	Generic Name	Brand Name
Ibuprofen	Advil® Motrin®	Magnesium salicylate	Doan’sPills®
Naproxen	Aleve®	Choline salicylate	Arthropan®
Ketoprofen	OrudisKT® Actron®
Aspirin	Ecotrin® AlkaSeltzer®

Many people take these OTC medications for everyday problems such as headaches. Patients with lupus may routinely take a prescription NSAID, and if these patients also take an over the counter NSAID, it will increase the total amount of NSAID medication ingested. It is important to note that if this is the case, their amount of NSAID ingestion would be more than their doctor prescribed.

Prescription NSAIDS

Generic Name	Brand Name	Generic Name	Brand Name
diflusinal	Dolobid®	naproxen	Naprosyn®, Anaprox®
etodolac	Lodine®	oxaprozin	Daypro®
flurbiprofen	Ansaid®	piroxicam	Faldene®
ibuprofen	Rufen®	salsatate	Salfex®, Disalcid®
indomethacin	Indocin®	sulindac	Clinoril®
ketoprofen	Orudis®	tolmetin	Tolectin®
ketorolac	Toradol®	meciofenamate	Meclomen®
nabumetrone	Relafen®	meloxicam	Mobic®
diclofenac	Voltaren®, Cataflam®

NSAIDs can have some potentially serious side effects such as upset stomach, bleeding, and peptic ulcers. Doctors may prescribe antacids to minimize these effects if prolonged use is needed and side effects start to emerge.

Bleeding in particular is most likely to become problematic if a person is taking other substances that have bleeding as a side effect. This is where an understanding of herbal supplements and their side effects really comes into play.

The following is a list of herbals that, while taken alone, will likely have minimal side effects. They will, however, increase the risk of bleeding when taken in conjunction with NSAIDs. If you are currently using or thinking about using one of these herbals, discuss with your doctor the potential benefits and risk, especially while taking NSAIDs. Most people find that they get more of an effect from their medications than from herbals when it comes to treating lupus symptoms. Herbals should not be used as a replacement for prescribed treatment, especially without consulting your doctor. If you find that your doctor isn’t aware of the possible herbal medications you could turn to, some patients recommend bringing your doctor literature on the products so that they can be reviewed and approved.

1. Cat’s claw: often used for arthritis, this herbal reduces inflammation. As an immunostimulant, it can impact the immune system if used over time. This should be of particular concern to patients with lupus.

2. Devil’s claw: similar to cat’s claw -- inflammation is reduced, although there is no indication at this time that it is an immunostimulant.

3. Evening Primrose Oil and Borage (GLA): used to treat PMS, it also has an anti-inflammatory effect.

4. Fish Oil (Omega 3 fatty acids): perhaps the most recommended by physicians, this can be taken safely up to three times a week naturally in the diet (wild salmon, for example). It has been shown to be effective in reducing cholesterol and also has an anti-inflammatory effect. Side effects are minimal, although an increased risk of bleeding still exists.

5. Garlic: used to decrease blood pressure and cholesterol, it thins the blood, which can reduce clotting. More than 500mg can put you at increased bleeding risk. The thinning of the blood can be a problem if you are on other blood thinning medications. It is important to avoid if surgery is planned. Normal amounts of garlic consumed during your regular diet may not make a difference. It’s important that you keep consistency in your diet. If you do consume large amounts of garlic, any effect it has will be seen as normal for you. If you cut it all out suddenly, however, medicines such as coumadin, a blood thinner, may need to be adjusted.

6. Ginger: has been shown to have an anti-inflammatory effect and is often used for nausea and upset stomach

7. Gingko Biloba: although it’s not used to treat inflammation or other lupus related symptoms, it’s a popular herbal medication used to enhance memory and can increase your risk of bleeding.

8. White Willow Bark: known as "the herbal aspirin", it contains a substance that is the precursor to aspirin and is turned into aspirin in the body. It will increase your risk of bleeding, the same as aspirin.

9. Vitamin E: although a supplement and not an herbal product, Vitamin E can increase bleeding risk.

Corticosteroids

Corticosteroids are available as tablets or injections. They are also used as ingredients in topical ointments. They are potent, reduce inflammation, and suppress the immune system after 6-8 weeks. They also tend to have more side effects than NSAIDS. There can be an effect on blood pressure, blood sugar, and cholesterol levels. Other side effects, such as weight gain, osteoporosis, fluid retention, and infection, are usually seen with long term use of corticosteroids.

Generic Name	Brand Name	HowTaken
Betamethasone	Celestone®	Tablet, Injection
Cortisone		Tablet
Dexamethasone	Decadron®	Tablet, Injection
Dexamthasone	Solurex®, Dexasone®	Injection
Hydrocortisone	Cortef®	Tablet
Hydrocortisone	Hydrocortone®, Solu-Cortef®	Injection
Methylprednisolone	Medrol®	Tablet
Methylprednisolone	Depo-Medrol®, Solu-Medrol®	Injection
Prednisolone	Cortolone®, Prelone®	Tablet, Injection
Prednisone	Deltasone®, Prednicot®	Tablet
Triamcinolone	Artistocort®	Tablet
Triamcinolone	Kenalog®	Injection

Herbals that interact with corticosteroids are echinacea, melatonin, and cat’s claw. By stimulating or boosting the immune system, these herbals could trigger a lupus flare.

They could also decrease the immune system suppression of corticosteroids, thus negating their effect. Zinc, a common supplement, also stimulates the immune system, though it’s less potent than the other three.

Immunosuppressive Agents

Examples of immunosuppressive agents include the following:

Immunosuppressive agents help treat lupus that has progressed to major organ involvement by suppressing the immune system. Herbals such as Echinacea and Melatonin that boost the immune system both cancel the effect of the drug and could potentially trigger a flare.

Formulating a treatment plan to effectively manage lupus can be complex. As you and your doctor sort through options for medications and potential supplemental treatments, keep in mind the importance of how these different substances can interact. Always read over the descriptive information that comes with medications and supplements. Before using an herbal or supplement, discuss it and its interactions with your other medications with your doctor and pharmacist.

SLE Support Program at HSS
Learn more about the SLE Support Program, a free support and education group held monthly at Hospital for Special Surgery.