The Pharmacist's Role
Assessment starts with a drug history, which should include inquiry into the use of dietary supplements including herbal medicines. For a patient who has a possible adverse reaction, it is necessary to rule out associations between all drugs including herbals. An herbal product should not be discounted as the source of a recent adverse effect, even if the patient has been taking it for a long time given the significant variations among batches and brands. Counseling, as an empathetic interaction, should improve the patient's knowledge and behavior to promote regimen adherence. A patient who uses herbals must understand that the products may not be proven efficacious and may have unwanted effects. Pharmacists should provide information to minimize patient harm.
Specific to products being taken or considered, the pharmacist should provide information on potential intrinsic effects including interactions, as they would with other agents. Known contraindications should be discussed, which generally means avoidance by women planning to become pregnant, currently pregnant, or lactating, and by children, in the absence of specific safety data. Herbal products should be discontinued 2 weeks before elective surgery, and their use reported to the anesthesiologist before any surgical procedure because of the potential for unexpected effects. Multiple adverse interactions can occur with anti-cancer therapies. Always discuss with your oncologist, as well as your pharmacist.
Until products are identified as meeting USP/NF specifications, only those from reputable manufacturers using Supplement Facts labeling should be selected. The label should identify clearly the common or scientific name and the dosage of the botanical, the part of the plant from which it was made, active and other ingredients, the manufacturer's name and address, lot number, and date of manufacture and expiration. The recommended dosage on the product label should not be exceeded, and duration of dosing should be limited in the absence of specific efficacy data and only for self-limited complaints. Length of use depends on the product but may be 2 weeks (echinacea) or 2 months (St. John's wort).
Herbal products should be stored in a cool, dry place away from children and used within a year, or sooner based on expiration date. A patient who experiences an adverse effect should discontinue use and immediately notify a pharmacist and physician, saving the remaining product and container for identification as necessary. Any unwanted effects should be reported to the pharmacist and subsequently forwarded to the FDA by way of MedWatch.
