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August 27, 2013

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Although gingko biloba is a herbal product, caution should be use when consuming this product. Patient who are currently on NSAIDS and other anticoagulants like heparin and warfarin should avoid taking gingko. The only NSAIDS that have not been reported for bleeding risk is low dose aspirin (81mg/day).

It’s great that Natural Standard offers a CE/CME on Ginkgo because a lot of patients take this as a supplement over the counter. It’s important to realize that ginkgo can have antiplatelet effects and therefore interact with medications such as warfarin. As someone mentioned earlier on this thread, a lot of patients do not realize this potential interaction. In addition, ginkgo can reversibly inhibit MAO A and B and thus there is potential for drug interaction with certain antidepressants. In investigating the mechanism of action of ginkgo, I found that there are two main active constituent groups responsible for action: terpene lactones and ginkgo flavone glycosides. The concentration of the latter can vary greatly depending on the concentrations found in the leaf of the ginkgo trees from which the plant was harvested, and so may be wise to advise patients who are taking ginkgo to obtain a standardized product if possible.

I think its great the amount of CE’s that natural standard has to offer. Many pharmacy school’s tend to downplay the use of herbal medications. This creates a gap in education where there is no real herbal expert in the community. Natural standard helps to fill in that gap with CE’s. It is interesting to learn about the many different uses of ginko. In school they discussed its use in memory, but there are so many other uses that I would not have known. I found this very interesting.

I think it's really awesome that Natural Standard offers CE credits for health care providers. This is definitely something I will utilize as a practicing pharmacist. One thing I found really interesting in the Gingko monograph was that Gingko may be as helpful as acetylcholinesterase inhibitors like Aricept for dementia. I have family members that have suffered from dementia and having this as a potential option for treatment would have been really cool. I would have never thought of trying something such as Gingko, but having the exposure to Natural Standard has made me think I will definitely stop and think of CAM in instances where I wouldn't have. I would love to see more studies comparing Gingko to acetylcholinesterase inhibitors.

The dose and duration of time the patient takes he Gingko Bilboa may play an important role in the development of adverse effects. For dementia and claudication the recommended max dose is 240mg whereas the max dose for tinnitus and vertigo are 150mg. It may be more likely to experience adverse effects with treatment using a higher dose. In any case the risks and benefits of being on long term therapy should be considered in any patient with thyroid or liver problems by their doctor.

I think it's great that ginko, along with other herbals, are being studied for medical uses. In school I was always taught to discourage the use of herbals; however, I think they are definitely worth a second thought. I have seen first-hand the possible effectiveness of herbals in a family member who was told he could not be cured by Western medicine but is now seeing improvement with the use of herbals. I am now much less of a skeptic of herbals and am very interested in learning more about their possible uses.

I have done a lot of anticoagulation/warfarin dosing during my past rotations and realized that although we do ask the patients if they are taking any other herbals/supplements/vitamins while on their anticoagulants, many of them only think and report vitamins. They probably don't think that herbals like Gingko can potentially lead to increased risk of bleeding.

As far as toxicity testing goes, rats are just a traditional model for toxicologists to test median lethal doses. It should be pointed out, however, that there is a difference between rat physiology (and animal physiology overall) compared to humans. As such, animal models can only be so useful in helping us frame dosing for supplements until we are able to craft safe studies in human participants. As an example, chocolate is fairly benign in most people but is toxic to dogs and rats in much lower doses per unit of body weight.

It's a great idea for Natural Standard to offer a large variety of CE's on alternative medicine topics! Formal training on these topics is few and far between at best in health care academia. I know as a future pharamcist, I will make use of Natural Standard's CE database to beef up my knowledge of CAM.

@Joan - That is a very good point. It is imperative that healthcare professionals make themselves aware of the possible interaction between natural products and prescribed medication. Drugs like Warfarin have numerous interactions with natural products that affect the coagulation cascade, so it's important to keep these things in mind when patients ask about integrating these products into their regimen.

Please one of the mods correct me if I'm wrong but the reason that rats get such high doses is because scientists want to make sure they catch any potential for problems even it's only 500,000 to 1.
That's because there are so many billions of people in the world and there is such variance in human anatomy and systems that you have to assume that everyone is going to react differently. It's like liquor. Some people can have a half dozen martinis and not feel a thing. Some get drunk off of a few sips.
It's the same with drugs. What that research is saying is that you can take Ginko for years and be fine, but your next door neighbor could take it for a few months and get thyroid cancer.It's crazy that the NYT writers don't point this out.

According to Ozgoli et al. in their research published in J Attern Complement Med. in 2009, treatment of PMS with ginkgo was significant with a p value less than 0.001. Hence, gingko could also be used to reduce the symptoms of PMS. This research also states that, further investigation regarding the effectiveness and safety of various doses is required.

@Joan, I checked out that article on the Well blog as well as the toxicology study they linked. The lowest doses used in those rats was 100mg/kg which would translate to about 7000mg (7g) in an average adult. One way to think of it is that practically anything, even water, can be a poison at the right dose. In some medications and supplements we see a hormetic effect (http://en.wikipedia.org/wiki/Hormesis).

Hope this helps!

Like one of the comments mentioned above it is important to always ask if someone is taking herbal supplements because you many never know. Ginkgo is used by thousands of people and it is an important fact to be aware of as healthcare professionals. Specifically for pharmacists here may be very serious drug interactions with ginkgo that would not be addressed unless the question is asked.

I agree with JJS...a pharmacist or doctor might not know how many herbal supplements someone is taking. Ginkgo has some great properties and can be very useful, however so many people are taking medications like ASA and anticoagulants that this could potentially be a dangerous mixture.

Regarding the reports in possibly causing cancer, it should be noted that the doses used in the study was beyond doses you would see in normal use for gingko. The rats were fed 62.5mg/kg to 1,000mg/kg of gingko. Most dosing recommendations for adults taking gingko max out around 240mg daily regardless of weight. The take home message from that study should be to use this supplement with caution and treat it like we would other medications. Weigh the risks and benefits and determine what would be the best course of action.

A lot of people just think that taking "natural supplements" like Ginkgo Biloba is "natural" so there's no need to report to the health professional that they're taking such. That's why it's our jobs as health professionals to kind of get it out of the patient that they're taking these extra add ons to fully document their patient chart so that we can do a full run through on interactions, etc.

In April of this year doubts were raised about the safety of Ginkgo -- the NY Times blog (http://well.blogs.nytimes.com/2013/04/29/new-doubts-about-ginkgo-biloba/) reported on a National Toxicology Program Report stating Ginkgo Biloba "caused cancer in lab animals, including an excessive number of liver and thyroid cancers, as well as nasal tumors." The lead scientist in the study was quoted as having said "with the ginkgo studies it was consistent across the sexes and the species. The liver was a target, the thyroid was a target, and the nose."
Would you please clarify the confusion about this supplement that's helpful for so many things?

It's funny but you'd never realize how many people are taking natural products if you don't ask. I know a number of people taking Gingko and they say it has quite and effect. I looked up some information on the Natural Standards website. Gingko is generally well tolerated at recommended doses for up to six months. There are a number of cautions, most notably when used concurrently with anticoagulants and antiplatelets. Case reports have shown an increased risk of bleeding. So any patient must first be advised before starting/adding anything, including a natural product to their therapy regimen.

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