Arginine
Effect: Possible Harmful Interaction
Arginine is an amino acid found in many foods, including
dairy products, meat, poultry, and fish. Supplemental arginine has been proposed
as a treatment for various conditions, including heart problems.
Arginine has been found to stimulate the body’s production of gastrin, a
hormone that increases stomach acid. Because excessive acid can irritate the
stomach, there are concerns that arginine could be harmful for persons taking
drugs that can negatively affect the stomach (such as NSAIDs). It may be best not
to mix arginine with NSAIDs unless approved by a doctor.
Feverfew
Effect: Possible Harmful Interaction
The herb feverfew (Tanacetum parthenium) is
primarily used for the prevention and treatment of migraine
headaches. NSAIDs are also used for migraines, so there is a
chance that some persons might use both the herb and drug at once, a combination
that may present risks.
The biggest concern with NSAIDs is that they can cause stomach ulcers, which
may progress to bleeding or perforation without pain or other warning symptoms.
This stomach damage is caused by drug interference with the body’s protective
prostaglandins. Newer NSAIDs called COX-2
inhibitors may be less likely to produce this side effect.
Feverfew also affects prostaglandins, so combining it with an NSAID might increase
the risk of stomach problems.
Garlic, Ginkgo
Effect: Possible Harmful Interaction
Among many other proposed uses, the herb garlic
(Allium sativum) is taken to lower cholesterol. One of the
possible side effects of garlic is a decreased ability of the blood to clot,
leading to an increased bleeding tendency. Therefore, one should not combine
garlic and aspirin or other NSAIDs except under medical supervision.
Among many other uses, the herb ginkgo is used to treat Alzheimer’s
disease and ordinary age-related memory loss. Some evidence suggests that ginkgo
might also decrease the ability of the blood to clot, probably through effects on
platelets. However, one double-blind study found that ginkgo does not increase the
anticoagulant effects of aspirin; another study found that while it did not
interact with the antiplatelet drug clopidogrel, the herb did interact slightly
with the related drug cilostazol. Taken together, this evidence still suggests
that one should not take ginkgo while using aspirin or other NSAIDs, except under
medical supervision.
Policosanol (Sugarcane Source)
Effect: Possible Harmful Interaction
A sugarcane-derived form of the supplement policosanol
is used to reduce cholesterol levels. It also interferes with platelet clumping,
creating potential benefit and a risk of interactions with blood-thinning
drugs.
A thirty-day, double-blind, placebo-controlled trial of twenty-seven people with high cholesterol levels found that policosanol at 10 milligrams (mg) a day markedly reduced the ability of blood platelets to clump together. Another double-blind, placebo-controlled study of thirty-seven healthy volunteers found evidence that the blood-thinning effect of policosanol increased as the dose was increased: the larger the policosanol dose, the greater the effect.
Another double-blind placebo-controlled study of forty-three healthy volunteers compared the effects of policosanol (20 mg daily), aspirin (100 mg daily), and policosanol and aspirin combined at these same doses. The results again showed that policosanol substantially reduced the ability of blood platelets to stick together, and that the combined therapy exhibited additive effects.
Based on these findings, one should avoid combining aspirin or other NSAIDs with sugarcane policosanol except under medical supervision. Beeswax policosanol, discussed below, is substantially different from sugarcane policosanol.
PC-SPES
Effect: Possible Harmful Interaction
PC-SPES is an herbal combination that has shown promise for
the treatment of prostate cancer. One case report suggests that PC-SPES might
increase risk of bleeding complications if combined with blood-thinning
medications. Subsequent evidence has indicated that PC-SPES contains the strong
prescription blood thinner warfarin, making this interaction
inevitable.
Potassium Citrate
Effect: Possible Harmful Interaction
Potassium citrate and other forms of citrate (such as calcium citrate and
magnesium citrate) may be used to prevent kidney stones. These agents work by
making the urine less acidic. This effect on the urine may lead to decreased blood
levels and therapeutic effects of several drugs, including aspirin and
other salicylates (choline salicylate, magnesium salicylate, salsalate, sodium
salicylate, and sodium thiosalicylate). One should avoid these citrate compounds
during therapy with aspirin or salicylates, except under medical supervision.
Reishi
Effect: Possible Harmful Interaction
One study suggests that reishi impairs platelet clumping. This
creates the potential for an interaction with any blood-thinning medication.
Dong Quai, St. John’s Wort
Effect: Possible Harmful Interaction
The herb dong
quai (Angelica sinensis) is often
recommended for menstrual disorders such as dysmenorrhea, premenstrual syndrome,
and irregular menstruation. St. John’s wort (Hypericum
perforatum) is primarily used to treat mild to moderate
depression.
Certain NSAIDs, including most notably piroxicam, can cause increased sensitivity to the sun, amplifying the risk of sunburn or skin rash. Because St. John’s wort and dong quai may also cause this problem, taking these herbal supplements during NSAID therapy might add to this risk. One should use sunscreen or wear protective clothing during sun exposure if also taking one of these herbs while using an NSAID.
Vinpocetine
Effect: Possible Harmful Interaction
The substance vinpocetine is sold as a dietary supplement for the
treatment of age-related memory loss and impaired mental function. Vinpocetine is
thought to inhibit blood platelets from forming clots. For this reason, it should
not be combined with medications or natural substances that impair the blood’s
ability to clot normally, as this may lead to excessive bleeding. One study found
only a minimal interaction between the blood-thinning drug warfarin and
vinpocetine, but one should use caution anyway.
Vitamin E
Effect: Possible Mixed Interaction
Vitamin
E appears to add to aspirin’s blood-thinning effects. One
study suggests that the combination of aspirin and even relatively small amounts
of vitamin E (50 mg daily) may lead to a significantly increased risk of bleeding.
In another study of 28,519 men, vitamin E supplementation at a low dose of about
50 IU (international units) daily was associated with an increase in fatal
hemorrhagic strokes, the kind of stroke caused by bleeding within the brain.
However, there was a reduced risk of the more common ischemic stroke, caused by
obstruction of a blood vessel in the brain, and the two effects were found
essentially to cancel each other out.
Weak evidence from one animal study hints that vitamin E might reduce stomach inflammation caused by NSAIDs. One should seek medical advice before combining vitamin E and aspirin.
White Willow
Effect: Possible Harmful Interaction
The herb white
willow (Salix alba), also known as willow
bark, is used to treat pain and fever. White willow contains a substance that is
converted by the body into a salicylate similar to aspirin. It is therefore
possible that taking NSAIDs and white willow could lead to increased risk of side
effects, just as would occur if one combined NSAIDs with aspirin.
Herbs and Supplements
Effect: Possible Harmful Interaction
Based on their known effects or constituents, the herbs dong quai, garlic, ginger (Zingiber officinale), horse chestnut (Aesculus hippocastanum), and red clover (Trifolium pratense), and the substances fish oil, mesoglycan, and OPCs (oligomeric proanthocyanidins), might present an increased risk of bleeding if combined with aspirin.
Citrate
Effect: Possible Harmful Interaction
Potassium citrate, sodium citrate, and potassium-magnesium citrate are sometimes used to prevent kidney stones. These supplements reduce urinary acidity and can, therefore, lead to decreased blood levels and decreased effectiveness of NSAIDs.
Cayenne
Effect: Supplementation Possibly Helpful
Cayenne (Capsicum annuum or C.
frutescens) and other hot peppers used in chili and various dishes
contain as their “hot” ingredient capsaicin, a substance that is thought to be
stomach-protective. For years, people have believed that spicy foods were a cause
of stomach ulcers. However, preliminary evidence suggests that cayenne peppers
might actually help protect the stomach against ulcers caused by aspirin and
possibly other NSAIDs.
In a study involving eighteen healthy volunteers, one group received chili powder, water, and aspirin; the control group received only water and aspirin. Chili powder was found to significantly protect the stomach against damage from aspirin, a known stomach irritant. It was suggested that this protective effect might result from capsaicin-induced stimulation of blood flow in the lining of the stomach.
Further support for this theory comes from a study in rats, which found that capsaicin protected the stomach against damage caused by aspirin, ethanol (consumable alcohol), and acid. Increasing the dose of capsaicin brought even greater benefit, as did increasing the time between giving capsaicin and giving the other agents. An earlier study in rats found that capsaicin conferred similar protection against aspirin damage.
Some researchers have used these data to advocate chili or capsaicin as treatment for peptic ulcer disease. However, one should check with a doctor before trying to self-treat this serious condition.
Colostrum
Effect: Supplementation Possibly Helpful
Colostrum is the fluid that women’s breasts produce during
the first day or two after giving birth. The fluid gives newborns a rich mixture
of antibodies and growth factors that help them get a good start on nutrition.
According to one study involving rats, taking colostrum from cows (bovine
colostrum) as a supplement might help protect against the ulcers caused by
NSAIDs.
Folate
Effect: Supplementation Possibly Helpful
Folate (also known as folic acid) is a B vitamin that plays
an important role in many vital aspects of health, including preventing
neural-tube birth defects and possibly reducing the risk of heart disease. Because
inadequate intake of folate is widespread, persons taking any medication that
depletes or impairs folate even slightly may need supplementation.
There is some evidence that NSAIDs might produce this effect. In test-tube studies, many NSAIDs have been found to interfere with folate activity. In addition, a study of twenty-five people with arthritis receiving the drug sulfasalazine found evidence of folate deficiency. In another report, a woman taking 650 mg of aspirin every four hours for three days experienced a significant fall in blood levels of folate. Based on this preliminary evidence, folate supplementation may be warranted for persons taking drugs in the NSAID family.
Licorice
Effect: Supplementation Possibly Helpful
Licorice root (Glycyrrhiza glabra or G. uralensis), a member of the pea family, has been used since ancient times as both food and medicine. Preliminary evidence suggests that a specific form of licorice called DGL (deglycyrrhizinated licorice) might help protect the stomach against damage caused by the use of aspirin and possibly other NSAIDs. (DGL is a modified version of licorice that is safer to use.)
In a double-blind study of nine healthy volunteers, participants were given aspirin alone (325 mg) or aspirin (325 mg) plus DGL (175 mg). Stomach damage (as measured by blood loss) was found to be about 20 percent less when DGL was given with aspirin. As part of the same study, DGL also was found to reduce stomach damage caused by aspirin in rats, though the benefit was small. It is possible that larger doses of DGL might provide greater protection.
Vitamin C
Effect: Supplementation Possibly Helpful
Test-tube studies suggest that aspirin promotes the loss of vitamin C through the urine, which could lead to tissue depletion of the vitamin. In addition, low vitamin C levels have been noted in persons with rheumatoid arthritis, and this has been attributed to aspirin therapy taken for this condition. Vitamin C supplementation may be advisable in persons who regularly take aspirin.
Policosanol (Beeswax Form)
Effect: Possible Helpful Interaction
The supplement policosanol is a mixture of numerous related substances, and
its exact composition varies with its source. Policosanol made from sugar cane
appears to reduce cholesterol levels. Policosanol from beeswax may help protect
the stomach from damage caused by NSAIDs. However, it is not clear if beeswax
policosanol amplifies the “blood thinning” effect of anti-inflammatory drugs in
the same manner as sugarcane policosanol.
Chondroitin
Effect: Possible Harmful Interaction
Based on chondroitin’s chemical similarity to the anticoagulant drug
heparin, it has been suggested that chondroitin
also might have anticoagulant effects. There are no case reports of any problems
related to this, and studies suggest that chondroitin has at most a mild
anticoagulant effect. Nonetheless, chondroitin should not be combined with NSAIDs
except under physician supervision.
Bibliography
Aruna, D., and M. U. Naidu. “Pharmacodynamic Interaction Studies of Ginkgo biloba with Cilostazol and Clopidogrel in Healthy Human Subjects.” British Journal of Clinical Pharmacology 63 (2007): 333-338.
Ernst, Edzard, Max H. Pittler, and Barbara Wider, eds. Complementary Therapies for Pain Management: An Evidence-Based Approach. New York: Mosby/Elsevier, 2007.
Górski, Andrzej, Hubert Krotkiewski, and Michal Zimecki, eds. Inflammation. Boston: Kluwer Academic, 2001.
Wolf, H. R. “Does Ginkgo biloba Special Extract EGb 761 Provide Additional Effects on Coagulation and Bleeding When Added to Acetylsalicylic Acid 500mg Daily?” Drugs in Research and Development 7 (2006): 163-172.
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