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June 10, 2008

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I just started taking Centrum® Performance Multivitamin. I was on the computer when I felt a strong heartbeat that left me feeling funny. I immediately was concerned and took two baby aspirins. I did not know of the Ginko biloba interaction with aspirin. My question is, will doing this one time cause any problems?

Since these two drugs are available over the counter, it is very important for healthcare professional to educate their patients. For example, when patients pick up their prescriptions along with bottles of ginkgo and Aspirin to the counter, it is important for people in the pharmacy to acknowledge it and talk to the patients. Many patients will think, okay, ginkgo will improve my memory and Aspirin is good for my heart.

Wow, Sue, what a scary experience! I thought I would make everyone aware of the other interactions that ginkgo can have on other conditions/medications. Gingko can increase bleeding when taken with the following medications: ibuprofen (Motrin®, Advil®), naproxen (Aleve®), ketoprofen (Orudis®), clopidogrel (Plavix®), ticlopidine (Ticlid®) or warfarin (Coumadin®). Gingko could also interaction with hydroclorothiazide, haloperidol (Haldol®), buspirone (Buspar®), nifedipine (Adalat®). Lastly, using ginkgo with a diagonised seizure disorder could actually induce seizures. That is why you must be extremely careful when taking over-the-counter medications. Make sure to ask your MD and/or pharmacist if you are unsure because there can be some horrible adverse drug reactions!

One study, conducted by Xuemin Jiang et al. in 2005, found that ginkgo has no or little effect on warfarin. Whether or not this is true, I think we need a lot more research. Lots of herbal supplements are made widely available, and people can easily take this stuff thinking they are natural and there is no harm. This includes low dose of aspirin, which are available over the counter. These two can be easily taken together without the approval of doctors or pharmacists. It would be helpful to include a warning section where possible interactions with herbal supplements are mentioned on the label of an aspirin bottle.

Aspirin, ginkgo and warfarin are just a few agents that might increase bleeding risk. Other herbs/supplements with anti-clotting effects include policosanol, garlic, ginger, pycnogenol, turmeric and vitamin E. Any combination of these supplements may potentially interact with aspirin, ginkgo and/or warfarin.

I am going to echo Rachel and say thank you to Sue. That is a GREAT story of the importance of doctors taking thorough patient histories, and if they don't have any background in integrative medicine, they should, at the very least, have access to a resource that can educate them as needed. It is very upsetting to me that all too often in the United States, only the "squeaky wheel gets the grease." Aka, doctors are lazy and often just shake off patients symptoms and attribute them to stress. I understand that doctors are tired, see several patients and may be working in facilities that are understaffed or under-resourced. And yet their vocation as doctors is to heal. And they should not be satisfied until they know that they have taken the patient's symptoms seriously and done everything in their capacity to find the CAUSE of the pain. I know many stories of doctors missing broken bones, brain tumors and cancer because they attributed the pain to stress instead of doing their jobs. I hope and pray that doctors will read stories like Sue's and realize the importance and fragility of their work.

Really important information here, and it really highlights the importance of 1) herb-drug interactions, 2) open communication among the patient and healthcare provider 3) cooperation between all physicians - whether they be "integrative" or "conventional". All too often these issues are short changed - as either the patient does not tell their healthcare provider about the supplements they are taking, and/or their physician has no idea about supplements, and due to that lack of understanding, they suggest to their patients that they do not take a supplement that may be of benefit. More cooperation and awareness is needed here.

Sue -

Thank you for that personal account. It always drives the point home when you hear a "real person" having an experience and not just reading about it theoretically. Thanks for sharing.

Wow, Sue, that is scary. I hope everything is all right. As I’m sure you know, ginkgo has a long list of potential interactions because of its effect on bleeding. Use of ginkgo with drugs that may cause bleeding may further increase the risk of bleeding, based on multiple case reports of spontaneous bleeding in patients using ginkgo alone, with warfarin (Coumadin®) or with aspirin. Examples of drugs that may increase the risk of bleeding include aspirin; anticoagulants ("blood thinners"), such as warfarin (Coumadin®) or heparin; anti-platelet drugs, such as clopidogrel (Plavix®); and non-steroidal anti-inflammatory drugs, such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®). Use of ginkgo with herbs or supplements that may cause bleeding may also increase the risk of bleeding. Several cases of bleeding have been reported with the use of garlic, and two cases with saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases.

This is very important information. My family has used herbs and natural products for many years. We use them very carefully, and I research constantly.

Ginkgo is in a formula that we have used. There has never been any problem at all until my husband strained his knee and needed something for pain. We don't use aspirin or anything chemical, but, we do use proteolytic enzymes, such as Wobenzym or Repair, for pain. He started taking the enzymes, without thinking about the ginkgo he was taking five days a week. After a week, or so, he complained of having a very bad headache. He went to the ER (he doesn't get headaches), and was told it was stress. After another few days, he went back to the ER (under the guidance of my brother who is an ER physician at a neighboring hospital). This time, tests were run and it was discovered that he had a spontaneous subdural hematoma. The neurologist could offer no explanation except that he MUST have had trauma to his head. We insisted he hadn't. After much thought and research, I realized that it had to be the combination of proteolytic enzymes and ginkgo. I discussed it with the neurologist and he had no thoughts. They don't know anything about natural medicine. I told him to keep it in mind, due to the fact that our area was populated with older, natural health-minded people.

Were the same doctors prescribing both ginkgo and aspirin, or was one doctor prescribing aspirin and one herbalist prescribing ginkgo? I thought it was common knowledge that ginkgo increased bleeding time. It would surprise me if some doctors were prescribing both at the same time. It just goes to show you that just because herbs are "natural," they can still have serious interactions with other agents.

Who is prescribing these two therapies? Since they do not require a prescription per se, is it natural medicine practitioners and herbalists or other “conventional” practitioners? Does this indicate that the blood-thinning potential of this combination is not well understood? I also wonder what type of precautions are taken and what type of screening is done to determine who would be an appropriate candidate for this combined therapy. Seems to me that this is going to cause the adverse effect reports associated with ginkgo (as the “new kid on the block”) to soar!

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