Patient Safety: Herbal Products and Potential Organ Dysfunction

After completing this application-based continuing education activity, pharmacists will be able to

List herbal products associated with liver, kidney, and heart damage

Describe potential drug interactions with herbal medications

Discuss the potential for contaminants in herbal products

After completing this application-based continuing education activity, pharmacy technicians will be able to

List herbal products associated with liver, kidney, and heart damage

Recognize the potential for herbal products to be unsafe

Describe certificates of analysis and how to retrieve them from manufacturers

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

As part of complementary and alternative medicine, herbal products are gaining popularity in the United States. Approximately one in five Americans use herbal products. Although people may perceive them as harmless due to their "natural" origin, studies and case reports on herbal toxicity dispute that belief. Injuries to liver, kidney, and heart; herb-drug interactions; and contamination and mislabeling are grave health risk concerns with some herbal products. Although non-prescription, herbal products' ubiquitous presence in all kinds of
shops, pharmacies, and Internet vendors causes many people to consider them important to their overall well-being. Pharmacists and technicians can help patients reduce health risks associated with herbal products. Ample knowledge of popular herbal products will help pharmacy teams identify health risks quickly.

Herbal Products and Health Risks

Pharmacist Post-test

After completing this continuing education activity, pharmacists will be able to
• List herbal products associated with liver, kidney and heart damage
• Describe potential drug interactions with herbal medications
• Discuss the potential for contaminants in herbal products

1. Which of the following agencies reviews and inspects herbal products before coming to market?
A. United States Food and Drug Administration
B. National Center for Complementary and Alternative Medicine
C. International Association of Traditional Chinese Medicine

2. John Goodman, a frequent customer at your pharmacy, comes to the counter to pick up his monthly medications. He asks, “Would it be a bother to have you check out the rest of my items here as well?” Always one to help a customer, you tell him, “Of course, that’s fine!” You notice he has a botanic extract tincture that claims to help with heartburn. The ingredient list includes greater celandine (Chelidonium majus). Mr. Goodman is also picking up his 30-day supply of Questran (cholestyramine). What organ dysfunction could be a concern?
A. Liver injury
B. Kidney injury
C. Heart damage

3. A patient presents to the emergency room suffering from acute kidney injury and liver injury. Lab tests show glutathione depletion, and the physician recommends N-acetylcysteine as a possible antidote. Upon opening the patient’s bag, you notice three natural product supplements: pennyroyal essential oils, germander weight loss tea, and impila fertility boost capsules. Which product may be responsible for BOTH the kidney and liver injury?
A. Pennyroyal essential oils
B. Germander weight loss tea
C. Impila fertility boost capsules

4. Mr. Goodman returns to your pharmacy. He explains he has been trying to live a healthier lifestyle, but has been feeling exceptionally tired after taking his as-needed alprazolam. When asked what over-the-counter products he uses, Mr. Goodman tells you, “Oh, you know the usual stuff: echinacea, garlic, ginger…” You are concerned because an interaction between alprazolam and ______ could be causing the excessive drowsiness.
A. Echinacea
B. Garlic
C. Ginger

5. Johnathan Bravo comes to the counter with a melancholic look on his face. “You know… getting older is not easy, especially when your wife looks so much better than you. I have tried everything: gym, new haircut, self-help books; and nothing seems to work.” He then proceeds to tell you about this supplement used in Southeast Kazakhstan that his gym buddy recommended. “Yeah, he says he’s seen guys lose weight, look better than ever and… well… you know… have a better relationship with their wife.” This sounds too good to be true; you are concerned this product has been _____________.
A. Mishandled
B. Mistaken
C. Mislabeled

6. Which of the following are chemists mainly concerned about when they look for contaminants in herbal products?
A. Metal
B. Glutathione
C. Poisons

7. Which of the following patients is most at risk of a serious adverse event associated with henbane (Hyoscyamus niger)?
A. A 27-year-old female with an irregular menstrual cycle
B. A 48-year-old male with a history of atrial fibrillation
C. A 62-year-old male with new onset major depressive disorder

8. Mrs. Jin is a longtime customer of your pharmacy who is on warfarin therapy for her atrial fibrillation. Her dose has been stable for quite some time, but today, you are surprised to see a change to her warfarin dosing. You call her cardiologist to double check the prescription and she tells you, “Yeah, it’s really crazy; three years no change in INR and out of nowhere a 0.2-point decrease.” Upon picking up her prescription, you ask Mrs. Jin about complementary and alternative medicine use. What herbal supplement might be a possible explanation for Mrs. Jin’s INR decrease?
A. Chamomile
B. Kava kava
C. American ginseng

9. “These kids nowadays takin’ that codeine, and that awful dextromethorphan!” exclaimed Mr. O’Timer. “When I was a kid, and even now, all I ever took was licorice. My mom, bless her soul, would never let any poison enter MY body. To this day that’s all I use when I get a cold.” Trying to move him along before he inevitably tries to talk to you about politics, you stop as he mentions his busy day full of specialist appointments. Which specialist would be MOST LIKELY to know Mr. O’Timer is using licorice for his colds?
A. Dentist
B. Podiatrist
C. Cardiologist

10. Which of the following patients would be at greatest risk if they accidentally took Asian ginseng instead of American ginseng?
A. A 23-year-old female taking fluvoxamine for obsessive compulsive disorder
B. A 40-year-old female taking ondansetron for chemotherapy-induced nausea
C. A 67-year-old male taking clopidogrel after a myocardial infarction

Pharmacy Technician Post-test

After completing this continuing education activity, pharmacy technicians will be able to
• List herbal products associated with liver, kidney and heart damage
• Recognize the potential for herbal products to be unsafe
• Describe certificates of analysis and how to retrieve them from manufacturers

1. Which of the following agencies review and inspect herbal products before coming to market?
A. United States Food and Drug Administration
B. National Center for Complementary and Alternative Medicine
C. International Association of Traditional Chinese Medicine

2. John Goodman, a frequent customer at your pharmacy, comes to the counter to pick up his monthly medications. He asks, “Would it be a bother to have you check out the rest of my items here as well?” Always one to help a customer, you tell him, “Of course, that’s fine!” You notice he has a botanic extract tincture that claims to help with heartburn. The ingredient list includes greater celandine (Chelidonium Majus). What organ dysfunction has been associated with this herb?
A. Liver injury
B. Kidney injury
C. Heart damage

3. A patient brings a brown bag of herbs and supplements for you to list on his profile. Which product may increase this patient’s risk for BOTH kidney and liver injury?
A. Pennyroyal essential oils
B. Germander weight loss tea
C. Impila fertility boost capsules

4. Mr. Goodman returns to your pharmacy. He explains he has been trying to live a healthier lifestyle, but has been feeling exceptionally tired after taking his as-needed alprazolam. Mr. Goodman goes on to tell you he’s added a new herbal supplement to his daily routine. You refer the patient to the pharmacist because you know and interaction between alprazolam and ______ could be causing the excessive drowsiness.
A. Echinacea
B. Garlic
C. Ginger

5. A customer at your pharmacy asks you for help in the herbal supplement aisle. She wants to take echinacea to boost her immune system, but she’d like more information about the manufacturer’s quality testing. You call the manufacturer for a certificate of analysis (CoA) only to be told they do not release them. Which of the following is most appropriate to tell this customer?
A. All herbal manufacturers are held to the same standards, so this brand is safe to use
B. This company likely has no quality assurance process; we should look for a better brand
C. This means the company uses an in-house laboratory for testing, so it is trustworthy

6. Your pharmacy is now selling a new herbal product. Curious about the contents, you decide to search for a certificate of analysis. On the bottle, you are looking for what three pieces of information?
A. product name, lot number, and expiration date
B. product name, manufacturer, and country of production
C. manufacturer, lot number, and date of production

8. Mrs. Jin is a longtime customer of your pharmacy who is on warfarin therapy for her atrial fibrillation. You ask to update her medication list in the system, including prescription, over-the-counter, and herbal supplements. Which of the following herbals would prompt you to refer Mrs. Jin to the pharmacist for counseling?
A. Chamomile
B. Kava kava
C. American ginseng

9. “These kids nowadays takin’ that codeine, and that awful dextromethorphan!” exclaimed Mr. O’Timer, “When I was a kid, and even now, all I ever took was licorice. My mom, bless her soul, would never let any poison enter MY body. To this day that’s all I use when I get a cold.” Trying to move him along before he inevitably tries to talk to you about politics, you stop as he mentions his busy day full of specialist appointments. Which specialist would be MOST LIKELY toned to know Mr. O’Timer is using licorice for his colds?
A. Dentist
B. Podiatrist
C. Cardiologist

Patient Safety: Herbal Products and Potential Organ Dysfunction

Learning Objectives

Accreditation Statements

Disclosure of Discussions of Off-label and Investigational Drug Use

Faculty

Faculty Disclosure

ABSTRACT

CONTENT

Content

Pharmacist Post Test (for viewing only)

Pharmacy Technician Post Test (for viewing only)

References

Full List of References