Natural Sharp Mind Phytosolution by Aboca USA, Inc

POSSIBLY EFFECTIVE

• Genital herpes. Oral eleuthero root extract might help to prevent and reduce the severity of genital herpes outbreaks. Details: One clinical study in patients with recurrent genital herpes infections shows that taking a specific eleuthero root extract (Elagen) 400 mg, standardized to contain eleutheroside 0.3%, daily for at least 3 months reduces the frequency, severity, and duration of outbreaks when compared with placebo (730).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Athletic performance. Small clinical studies suggest that oral eleuthero root is not beneficial for improving athletic performance. Details: One study in trained distance runners shows that a specific eleuthero root liquid extract, standardized to eleutherosides B and E content, taken as 3.4 mL daily for 6 weeks, does not affect endurance, performance, or psychological, cardiac, or respiratory parameters when compared with placebo (7522). Small studies in trained athletes or healthy adults show that taking eleuthero 800-1200 mg daily (Endurox) for 1-6 weeks does not seem to have any effect on cycling performance time, respiration, lactate production, or heart rate recovery during cycling, stair-stepping exercise, treadmill, or cyclic ergometry when compared with placebo (2335,7600,7601,8994). However, there has been some speculation that a longer duration of supplementation is needed for benefit. One study in recreationally trained athletes shows that taking a specific powdered eleuthero root product 400 mg twice daily for 8 weeks increased cycling endurance time by 23% and maximal oxygen consumption by 12% when compared with placebo. This product was standardized to contain eleutheroside B 0.11% and eleutheroside E 0.12% (17186).
• Bipolar disorder. It is unclear if oral eleuthero root is beneficial for bipolar disorder. Details: A small clinical study in Chinese adolescents ages 12-17 years with bipolar disorder shows that taking eleuthero root 750 mg orally three times daily, in conjunction with lithium for 6 weeks, induces similar response rates and remission rates when compared with lithium plus fluoxetine 20 mg (75028). It is not clear how this response rate compares to the use of lithium alone.
• Cardiovascular disease (CVD). It is unclear if oral eleuthero fruit is beneficial for preventing the development of CVD. Details: One small clinical study in healthy adults with at least two cardiovascular risk factors shows that taking an aqueous extract of eleuthero fruit 500 mg daily for 12 weeks seems to modestly reduce systolic blood pressure and arterial stiffness, as measured by brachial-ankle pulse wave velocity, when compared with placebo. It did not affect diastolic blood pressure, flow-mediated dilation, or carotid intima-media thickness. Also, taking a higher 1000 mg dose of the same eleuthero extract daily did not have significant effects on any measured parameters (105025).
• Chronic fatigue syndrome (CFS). It is unclear if oral eleuthero root is beneficial for CFS. Details: One clinical study in adults with CFS shows that taking eleuthero root extract 2 grams daily for 2 months improves fatigue severity and duration when compared with baseline, but not when compared with placebo (11099).
• Cognitive function. It is unclear if oral eleuthero is beneficial for cognitive function. Details: A very small clinical study in middle-aged people shows that taking eleuthero 325 mg twice daily might improve selective memory when compared with placebo (2574). Another very small study in healthy adults shows that taking a combination product containing extracts of eleuthero leaf 203 mg and Drynaria fortunei 20 mg daily for 12 weeks improves figure recall, but not immediate memory or attention, when compared with placebo (102316). It is unclear if this effect is due to eleuthero, Drynaria fortunei, or the combination.
• Common cold. Oral eleuthero has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Some clinical research shows that taking capsules of a specific combination product containing eleuthero plus andrographis (Kan Jang, Swedish Herbal Institute) orally improves symptoms of the common cold when started within 72 hours of symptom onset. Some symptoms can improve after 2 days of treatment; however, it typically takes 4-5 days of treatment for maximal symptom relief (5784,10795,12380). Some research shows the combination of eleuthero and andrographis relieves cold symptoms better than echinacea or placebo in children (12381). It is unclear if this effect is due to eleuthero, andrographis, or the combination.
• Diabetes. It is unclear if oral eleuthero is beneficial for improving glycemic control in type 2 diabetes. Details: One small clinical study in adults with type 2 diabetes shows that taking a specific eleuthero extract, standardized to contain eleutherosides E and B 1.12%, as 480 mg daily for 3 months, decreases fasting glucose by a mean of 36 mg/dL, postprandial blood glucose by a mean of 35 mg/dL, glycated hemoglobin (HbA1c) by a mean of 0.8%, triglycerides by a mean of 106 mg/dL, and total cholesterol by a mean of 21 mg/dL when compared with placebo (91509).
• Diabetic neuropathy. It is unclear if oral eleuthero is beneficial for diabetic neuropathy. Details: One small clinical study in adults with type 2 diabetes shows that taking a specific eleuthero extract, standardized to contain eleutherosides E and B 1.12%, as 480 mg daily for 3 months, modestly improves subjective symptoms of diabetic neuropathy when compared with placebo (91509).
• Familial Mediterranean fever. Oral eleuthero has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: One small clinical study in children ages 3-15 years with familial Mediterranean fever shows that taking a specific combination product (ImmunoGuard, Inspired Nutritionals) containing eleuthero, andrographis, schisandra, and licorice for one month reduces the duration, frequency, and severity of disease recurrence when compared with placebo (12382). It is unclear if this effect is due to eleuthero, other ingredients, or the combination.
• Fibromyalgia. Although there is interest in using oral eleuthero for fibromyalgia, there is insufficient reliable information about the clinical effects of eleuthero for this condition.
• Hangover. It is unclear if oral eleuthero root is beneficial for hangovers. Details: One small clinical study in healthy males shows that consuming one bottle of a powdered polysaccharide-rich extract of eleuthero root before and after consuming alcohol modestly reduces the severity of hangover as measured by the Acute Hangover Scale questionnaire score when compared with placebo (91508). However, the validity of these findings is brought into question due to the incomplete study information provided.
• Influenza. Oral eleuthero has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in adults with influenza shows that taking a specific combination product containing eleuthero 20-30 mg plus andrographis 178-266 mg (Kan Jang, Swedish Herbal Institute) three times daily for 3-5 days relieves symptoms more quickly than amantadine. This combination product also reduced the risk of post-influenza complications, such as sinusitis or bronchitis, when compared with amantadine (10441). It is unclear if these effects are due to eleuthero, andrographis, or the combination.
• Osteoarthritis. Oral eleuthero has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research shows that taking two capsules each containing 400 mg of a combination of eleuthero, Panax pseudoginseng, and rehmannia daily for 6 weeks improves physical function in individuals with knee osteoarthritis when compared with placebo. However, the combination does not seem to reduce pain or stiffness when compared with placebo (74950). It is unclear if this effect is due to eleuthero, other ingredients, or the combination.
• Osteoporosis. Oral eleuthero has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A very small clinical study in postmenopausal patients shows that taking low-dose calcium and vitamin D3 in combination with a 250 mg blend of rehmannia root and eleuthero stem bark extracts twice daily for 12 months attenuates the loss of spine and femur bone mineral density when compared with placebo or high-dose calcium and vitamin D (75036). It is unclear if this effect is due to eleuthero, rehmannia, or the combination.
• Pneumonia. Oral eleuthero has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in adults with acute, nonspecific pneumonia shows that taking a specific combination product (ADAPT-232), containing eleuthero, rhodiola, and schisandra, as 20 mL twice daily for 10-15 days in conjunction with conventional treatment, reduces the duration of antibiotic treatment and improves quality of life when compared with conventional treatment alone (71152).
• Quality of life. It is unclear if oral eleuthero root improves quality of life in older healthy adults. Details: A small clinical study in elderly volunteers shows that taking eleuthero 300 mg daily improves social functioning and mental well-being after 4 weeks of treatment when compared with placebo. However, this improvement was not maintained after 8 weeks of treatment (15586).
• Rheumatoid arthritis (RA). Although there is interest in using oral eleuthero for RA, there is insufficient reliable information about the clinical effects of eleuthero for this condition.
• Stress. It is unclear if oral eleuthero root is beneficial for stress. Details: One clinical study in adults 30-50 years of age with symptoms of stress shows that taking a specific eleuthero root extract (WS 1070) 120 mg daily for 8 weeks does not improve fatigue, exhaustion, cognitive alertness, or measures of stress when taken alone or in conjunction with stress management training (91510). However, another small clinical study in healthy females 20-68 years of age who have experienced stress for a prolonged period of time shows that taking a single, 270 mg dose of a combination agent (ADAPT-232) containing eleuthero, rhodiola, and schisandra improves attention and cognitive speed and accuracy when compared with placebo (19289). It is unclear if these effects are due to eleuthero, other ingredients, or the combination.
• Upper respiratory tract infection (URTI). Oral eleuthero has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research in adults with an uncomplicated URTI shows that taking 30 mL of a combination product (Kan Jang, Swedish Herbal Institute) containing extracts of eleuthero root (eleutherosides B and E 0.03 mg/mL), echinacea root, and malabar nut leaf daily does not reduce the severity or frequency of cough by a clinically meaningful amount after 3-4 days of treatment when compared with bromhexine hydrochloride or placebo (95648). However, a non-blinded clinical study shows that taking 30 mL of this same product three times daily for 6 days improves the severity and frequency of coughing and the degree of nasal congestion when compared with bromohexine. Additionally, patients taking the combination product recovered two days sooner, on average, than those taking bromohexine (48569). The reason for these conflicting findings is unclear but may be due to an inadequate duration of treatment in the first study and/or lack of blinding in the second study. Also, it is unclear if any benefit is due to eleuthero, other ingredients, or the combination. Other research has evaluated a capsule formulation of Kan Jang (Swedish Herbal Institute), with each capsule containing eleuthero root 11.4 mg and andrographis 195 mg. One small clinical study in patients with an uncomplicated URTI shows that taking this product as two capsules three times daily for 5 days reduces the median number of sick leave days to 2 days, compared with 3 days in the placebo group. It also increases the total number of recovered patients on day 3 to 75%, compared with 55% of those taking placebo (107471). More evidence is needed to rate eleuthero for these uses.

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POSSIBLY EFFECTIVE

• Anxiety. Oral ginkgo seems to modestly reduce anxiety symptoms. Details: Clinical research shows that taking a specific ginkgo extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) for 4 weeks can modestly reduce symptoms of anxiety in a greater percentage of adults with generalized anxiety disorder or adjustment disorder with anxious mood when compared with placebo. After 4 weeks of treatment, a reduction in anxiety rating score of at least 50% was seen in 44% of patients treated with 480 mg daily, 39% of patients treated with 240 mg daily, and 22% of patients treated with placebo (15578). It is unclear whether these effects would persist when taken for longer than 4 weeks. This study was also included in a meta-analysis that performed indirect comparisons of multiple herbs for the treatment of anxiety. This analysis suggests that taking ginkgo may reduce anxiety scores modestly more than kava (110711). However, the interpretation of these results is limited by the small amount of data available for ginkgo.
• Dementia. Oral ginkgo 240 mg seems to improve symptoms of various types of dementia, but lower doses are not always effective. Oral ginkgo does not seem to prevent or slow down the progression of dementia. Details: Most evidence shows that higher doses of a specific ginkgo extract (EGb761) modestly improve symptoms of Alzheimer, vascular, or mixed dementias. Meta-analyses of clinical research in patients with dementia show that taking ginkgo, usually 240 mg daily for 24 weeks, modestly improves cognition and activities of daily living when compared with placebo. When analyses pooled studies testing low-dose (120 mg) and high-dose (240 mg) ginkgo together, the benefit was not always present (87855,87819,87851,87866,88006,89713,102183,102185,102186,103572)(111333). Although most clinical trials show benefit, there are some clinical trials with conflicting findings, suggesting inconsistent and unpredictable effects (16637,87726). There has been some debate about whether ginkgo is more effective in dementia patients who have neuropsychiatric symptoms. Most clinical research shows that this is not the case. However, high-dose ginkgo 240 mg daily seems to modestly relieve most neuropsychiatric symptoms other than psychosis (17717,87794,87897,102185,102187). Few clinical studies compare ginkgo leaf extract to conventional drugs such as cholinesterase inhibitors. Some preliminary comparative studies show that taking a specific ginkgo leaf extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) 160-240 mg daily for 22-24 weeks seems to be comparable to donepezil (Aricept) 5-10 mg daily for mild to moderate Alzheimer disease (14499,87826). Similarly, a clinical study in patients with Alzheimer disease or mild cognitive impairment shows that taking ginkgo extract 150 mg three times daily for 6 months seems to be comparable to donepezil 5 mg daily for improvement of cognitive scores (106611). However, indirect comparisons suggest that ginkgo leaf extract might be less effective than the conventional drugs donepezil, tacrine (Cognex), rivastigmine (Exelon), and other cholinesterase inhibitors (6224,6490,11981,89710). Also, some studies show that taking ginkgo in combination with conventional medications for 12-24 weeks does not improve cognitive scores by a clinically meaningful extent when compared with conventional medications alone (95902,106611). However, a meta-analysis of 17 mostly small, low quality clinical studies in patients with Alzheimer disease, that includes some of these studies, shows that taking ginkgo in combination with donepezil for 3-9 months modestly improves cognitive scores when compared with donepezil alone. Adding ginkgo may also improve activities of daily living scores (111332). However, the validity of these findings is limited by the heterogeneity of the included studies, which utilized various doses and forms of ginkgo. Ginkgo does not appear to be beneficial for preventing or slowing the progression of dementia. Epidemiologic research shows that taking ginkgo extract is not associated with a decreased risk of developing dementia in elderly patients with memory impairment (14812). Three large-scale clinical trials also show that taking ginkgo extract 120 mg twice daily does not reduce the risk of developing all-cause dementia or Alzheimer disease in elderly patients with normal cognitive function or in those with mild cognitive impairment (16634,87848,87904). In addition, taking ginkgo extract does not seem to prevent disease progression in Alzheimer patients (89713). Most of the clinical studies on the effectiveness of ginkgo leaf for dementia have used the standardized extracts EGb 761 (Dr. Willmar Schwabe Pharmaceuticals and Ipsen) and LI 1370 (Lichtwer Pharma). These two extracts are similar and prepared to contain approximately 24% to 25% flavone glycosides and 6% terpene lactones. Other products with similar ingredients include Ginkai (Lichtwer Pharma), Ginkgo 5 (Pharmline), Ginkgold and Ginkgo (Nature's Way), and Quanterra Mental Sharpness (Warner-Lambert).
• Hearing loss. Intravenous ginkgo appears to improve hearing loss when used in conjunction with corticosteroids. The effectiveness of oral ginkgo is unclear. Details: A meta-analysis of randomized controlled trials (RCTs) in adults with sudden hearing loss shows that using intravenous ginkgo leaf extract 40-175 mg daily, in addition to corticosteroids, for 5-14 days increases clinical cure rates by 1.3 times that of corticosteroids alone. Ginkgo leaf in combination with corticosteroids also improved hearing sensitivity (107360). Another meta-analysis of 27 mostly low-quality RCTs in patients with sudden hearing loss, that includes some of the same studies as the prior analysis, shows that adding ginkgo extract to usual care for 1-14 days leads to improvement or no further deterioration in 91% of patients when compared with 75% of patients receiving usual care (111339). However, the interpretation of these results is limited by unclear ginkgo dosing and inclusion of studies that administered ginkgo orally, as an injection, or unknown route. In addition, usual care treatments were not described. In addition, one clinical study in patients with short-term idiopathic hearing loss shows that oral ginkgo leaf extract 120 mg twice daily for 8 weeks might improve hearing recovery rates when compared with ginkgo leaf extract 12 mg twice daily (8543). However, there was a high spontaneous recovery rate in both groups, so it is unclear how much benefit, if any, can be attributed to ginkgo leaf extract.
• Premenstrual syndrome (PMS). Oral ginkgo seems to reduce symptoms of PMS. Details: Taking ginkgo leaf extract orally 80 mg twice daily or 40 mg three times daily seems to produce significant relief in breast tenderness and other physical and psychological symptoms associated with PMS when started during the 16th day of the menstrual cycle and continued until the 5th day of the following cycle for up to two cycles (6229,87839). Specific ginkgo leaf extracts that have been assessed for this condition include Ginko T.D. (Tolidaru Pharmaceuticals) and EGb 761, which is an ingredient in several commercial products including Tebonin (Dr. Willmar Schwabe Pharmaceuticals), Tanakan (Ipsen), and Quanterra Mental Sharpness (Warner-Lambert).
• Schizophrenia. Oral ginkgo seems to reduce total and negative symptoms of schizophrenia, and may be beneficial for reducing antipsychotic-associated adverse effects. Details: Taking a standardized ginkgo leaf extract EGb 761 (Yi Kang Ning, Yang Zi Jiang Pharmaceuticals Ltd.), 120-360 mg orally daily in addition to standard antipsychotic medications (such as olanzapine, clozapine, or haloperidol) for 8-16 weeks, can reduce total and negative symptoms of schizophrenia when compared to treatment with antipsychotic medications alone (87844,95901). Guidelines from The World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce state that ginkgo extract at doses of 120-360 mg daily is weakly recommended for adjunctive use in schizophrenia, primarily for negative symptoms (110318). Treatment with ginkgo leaf extract might also reduce anticholinergic side effects such as thirst and constipation and adverse behavioral, cardiovascular, and nerve symptoms associated with antipsychotic treatment (87708,95901). Additional clinical research is needed to determine the role of ginkgo on antipsychotic-associated adverse effects.
• Stroke. Oral and intravenous ginkgo seem to improve recovery from stroke; intravenous ginkgo might be more effective. Details: While some individual studies show conflicting results, meta-analyses of small, low-quality clinical trials in patients recovering from ischemic stroke show that oral or intravenous ginkgo extract along with conventional therapy seems to improve neurologic function and activities of daily living scores, but does not improve quality of life or reduce the risk of recurrent stroke or death, when compared with conventional therapy alone (14435,102883,102884,107452). One meta-analysis shows that intravenous ginkgo extract is associated with greater improvements in these measures than oral ginkgo extract (102884). Ginkgo diterpene lactone meglumine (GDLM) is a derivative of ginkgo composed of active ingredients ginkgolides A, B, and K that has been investigated for the treatment of acute ischemic stroke both as monotherapy and in combination with thrombolysis. A very large clinical trial in adults with moderate acute ischemic stroke shows that an intravenous infusion of GDLM 25 mg initiated within 48 hours of symptom onset for 14 days increases the proportion of patients achieving a favorable outcome, defined as a score of 0 or 1 on the modified Rankin Scale (mRS) on day 90, by 15% when compared with placebo (111693). Additionally, a meta-analysis shows that combination therapy with GDLM and tissue plasminogen activator (rTPA) is associated with greater improvements than conventional treatments alone or other traditional Chinese herbal medicines that contain ginkgo (i.e. ginaton, danhong, xueshuantong, and shuxuening injections). This specific formulation also appears to be more effective than intravenous ginkgolides or ginkgolide B; however, investigators did not provide a statistical comparison of outcomes between groups, limiting the validity of this finding (108610). Another meta-analysis shows that intravenous administration of ginkgo leaf extract plus dipyridamole 10-40 mL daily for 14-30 days along with conventional therapy also improves neurologic function and activities of daily living when compared with conventional therapy alone (102882). In patients not treated with thrombolytics, a small clinical study in adults in China shows that administering ginkgo diterpene lactone meglumine 25 mg intravenously daily for 14 days, starting within 48 hours after an ischemic stroke, in addition to aspirin 100 mg daily for 90 days, led to improvement in scores related to stroke severity or the degree of disability at 90 days in 94% of patients when compared with 83% of patients treated with aspirin alone (111340). However, the patients in this study had minor or moderate strokes; these results may not apply to patients with more severe strokes. In patients with hemorrhagic stroke, preliminary clinical research shows that daily intravenous administration of ginkgo extract (Taiwan Jisheng Chemical Pharmaceutical Co., Ltd.) 17.5 grams for 2 weeks, in conjunction with routine treatment and intravenous oxiracetam 6 grams, reduces cerebral edema and bleeding and modestly improves recovery of neurological and cognitive function and activities of daily living when compared with oxiracetam plus routine care or routine care alone (103573). Higher quality studies are still needed to confirm these results.
• Tardive dyskinesia. Oral ginkgo seems to reduce the severity of tardive dyskinesia in schizophrenic patients being treated with antipsychotic medications. Details: Clinical research shows that taking a specific ginkgo extract called EGb 761 (Yi Kang Ning, Yang Zi Jiang Pharmaceuticals Ltd.) 80 mg three times daily for 12 weeks can reduce the severity of tardive dyskinesia by at least 30% when compared with placebo in schizophrenic patients being treated with antipsychotic medications (87864).
• Vascular dementia. Oral ginkgo extract seems to modestly improve scores related to cognitive function in patients with this condition. Details: A small clinical study in patients with vascular dementia shows that taking a specific extract of ginkgo EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) 240 mg daily for 24 weeks modestly improves scores related to cognitive function, neuropsychiatric symptoms, and activities of daily living when compared with placebo (17191). A preliminary open-label clinical study in patients aged 50 years or older in China shows that taking the same ginkgo extract 240 mg daily for 24 weeks, starting within 7-14 days after an ischemic stroke, modestly improves scores related to cognitive function and mental health, but not neuropsychiatric symptoms, when compared with standard care (111335). However, the patients in this study had minor strokes; these results may not apply to patients with more severe strokes. Ginkgo has also been evaluated in combination with other ingredients to treat vascular dementia. A small clinical study in patients aged 60 years or older with vascular dementia shows that taking a supplement containing extracts of ginkgo, Panax ginseng, and saffron 60 mg three times daily for 16 weeks modestly improves some cognitive function scores, caregiver assessed activities of daily living, and patient-reported quality of life. However, these effects were not maintained after patients stopped taking the supplement (111336).
• Vertigo. Oral ginkgo seems to improve symptoms of vertigo in people with vestibular disorders. It is unclear if it is beneficial for vertigo caused by cerebral arteriosclerosis. Details: Taking ginkgo leaf extract 120-160 mg daily orally seems to improve symptoms of vertigo and equilibrium disorders (5721,6220,6221,107359,108608). There is evidence from two clinical studies that ginkgo leaf extract (EGb 761) for 3 months is significantly more effective than placebo (6220), and possibly as effective as betahistine, for improving vertigo and dizziness caused by vascular vestibular disorders and vestibular disorders of unknown origin (6220,6221). However, adding balance training to treatment with ginkgo leaf extract (EGb 761) orally 80 mg twice daily for 3 months is no better than taking ginkgo leaf extract alone (107359). Ginkgo has also been evaluated in patients with vertigo caused by mild cerebral arteriosclerosis. A clinical study in this population shows that taking oral ginkgo leaf extract (Zhejiang Jiu Xu Pharmaceutical Co, Ltd) 40 mg three times daily for 6 weeks improves scores of traditional Chinese medicine symptom pattern, specifically dizziness, blurry vision, headache, and amnesia, but does not impact Dizziness Handicap Inventory scores, when compared with naoxinqing (NXQ), a standardized herbal product that contains Japanese persimmon leaf extract (108608). The validity of this study is limited due to the lack of comparison to placebo or an accepted conventional treatment.

POSSIBLY INEFFECTIVE

• Age-related cognitive decline. Most research shows that oral ginkgo does not improve symptoms of age-related cognitive impairment. Details: While some preliminary clinical research shows a modest benefit of ginkgo leaf extract on memory and cognitive function in patients with age-related memory or thinking impairment (5717,6216,89712), most clinical research shows that taking ginkgo leaf extract orally does not improve memory or attention in elderly individuals with normal mental function (5718,8586,8587,8588,87848). Clinical research also shows that taking a standardized ginkgo leaf extract (Thorne Research Inc.) 240 mg daily for 3.5 years does not reduce the risk of developing age-related cognitive impairment in elderly patients aged 85 years and older who have normal cognitive function (16635).
• Antidepressant-induced sexual dysfunction. Most research shows that oral ginkgo does not improve symptoms of sexual dysfunction in people using antidepressants. Details: Although some preliminary clinical research shows that taking ginkgo leaf extract orally might help sexual dysfunction caused by antidepressant therapy (3965,3967), subsequent research indicates that it not likely to be beneficial (207,3966,3969,10893,14383).
• Cardiovascular disease (CVD). Oral ginkgo does not seem to prevent CVD. Details: A large-scale randomized trial shows that taking a specific ginkgo leaf extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) 240 mg daily orally for an average of 6.1 years does not reduce the risk of myocardial infarction, angina, stroke, CVD-related hospitalization, or mortality in elderly patients when compared with placebo (17402).
• Chemotherapy-related cognitive impairment. Oral ginkgo does not seem to improve symptoms of cognitive impairment in people using chemotherapy. Details: Clinical research shows that taking a specific ginkgo leaf extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) 60 mg twice daily, starting prior to the second cycle of chemotherapy and continuing until one month after chemotherapy completion, does not prevent chemotherapy-related cognitive dysfunction when compared with placebo in chemotherapy-naïve breast cancer patients (89701).
• Hypertension. Oral ginkgo does not seem to reduce blood pressure in older, hypertensive patients. Details: Clinical research shows that taking a standardized ginkgo leaf extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) 240 mg daily for up to 6 years does not reduce blood pressure when compared with placebo in hypertensive patients aged 75 years or older (87853).
• Multiple sclerosis (MS). Most research shows that oral ginkgo does not improve symptoms of MS. Details: Most clinical research shows that taking ginkgo leaf extract or ginkgolide B, a constituent of ginkgo leaf extract, does not improve cognition or disability in patients with MS (87739,87787,87903,87947). However, a single preliminary clinical study shows that taking a standardized ginkgo leaf extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) may improve processing speed when compared with placebo in patients with multiple sclerosis (89705).
• Tinnitus. Most research shows that oral ginkgo does not improve symptoms of tinnitus. Details: Taking ginkgo leaf extract orally does not seem to improve symptoms of tinnitus. Although some studies have shown benefit, the majority of the clinical evidence indicates that ginkgo leaf extract is not consistently effective for patients with tinnitus (221,910,5721,6218,6219,9871,87754,87901,110093,111337)(111513).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Age-related macular degeneration (AMD). It is unclear if oral ginkgo is beneficial in AMD. Details: Preliminary clinical research suggests that taking a specific ginkgo leaf extract (EGb 761) 60-240 mg orally in divided doses for up to 6 months might improve symptoms of AMD (6227,6228,11797). There is limited evidence that ginkgo leaf extract might significantly improve distance vision in patients with AMD (6227).
• Aging. Although there has been interest in using oral ginkgo for aging, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Allergic rhinitis (hay fever). Topical ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in patients with seasonal allergic conjunctivitis shows that applying two drops of specific eye drops (Trium, SOOFT) containing ginkgo extract 0.05% and hyaluronic acid 0.15%, three times daily for one month can decrease redness by 80%, discharge by 40%, and swelling by 10% when compared to using eye drops with hyaluronic acid alone (87829).
• Altitude sickness. Research on the use of oral ginkgo for altitude sickness is conflicting. Details: Some research shows that taking ginkgo extract 80-120 mg twice daily for 4 days before the ascent to an altitude of 4300-5400 meters significantly reduces the occurrence of symptoms of acute altitude sickness, including headache, fatigue, dyspnea, nausea, and vomiting, when compared with placebo (6230,87827). A standardized ginkgo leaf extract called EGb 761, 160 mg in two divided doses daily, was used in one of these studies (6230). However, a large-scale trial using a different ginkgo extract (GK501, Pharmaton Natural Health Products) 120 mg twice daily for 1-2 days before the climb from an altitude of 4280 meters to 4928 meters, shows that ginkgo extract has no effect on preventing altitude sickness (11766). Also, another small study suggests that taking ginkgo extract 120 mg twice daily for 3 days before an ascent does not reduce altitude sickness when compared with placebo (87827). The conflicting results may be due to differences in starting baseline altitudes before ascent, duration of the pre-treatment period, or the source of the ginkgo product.
• Asthma. Oral ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research shows that a taking two capsules of a specific combination product (AKL1, AKL International Ltd.) containing ginkgo extract 130 mg/capsule, ginger 100 mg/capsule, and Picrorhiza 270 mg/capsule twice daily for 12 weeks does not improve lung function, respiratory symptoms, or quality of life when compared with placebo in adult patients with asthma (87786).
• Attention deficit-hyperactivity disorder (ADHD). It is unclear if oral ginkgo is beneficial in ADHD. Details: One clinical study shows that taking a standardized ginkgo extract (Ginko T.D., Tolidaru Pharmaceuticals) 80-120 mg daily for 6 weeks is less effective than methylphenidate 20-30 mg daily in children aged 6-14 years with newly diagnosed ADHD. Only 8% of children taking ginkgo extract had at least a 40% improvement in a teacher/parent ADHD rating scale, compared with 64% in children taking methylphenidate (17112). Another clinical study in children aged 6-12 years with ADHD shows that taking the same standardized ginkgo extract 80-120 mg daily in combination with methylphenidate 20-40 mg daily for 6 weeks does not improve parent- or teacher-rated ADHD scores by a clinically meaningful amount when compared with methylphenidate alone (95669). However, one preliminary clinical study shows that taking a specific combination product (AD-fX, CV Technologies) containing ginkgo leaf extract 100 mg, in combination with American ginseng extract 400 mg, in two divided doses for 4 weeks might significantly improve ADHD symptoms such as anxiety, hyperactivity, and impulsivity in children aged 3-17 years (8235). Guidelines from The World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce state that ginkgo extract at doses of 80-120 mg daily is not currently recommended for monotherapy or adjunctive use in children with ADHD due to mixed evidence (110318).
• Autism spectrum disorder. It is unclear if oral ginkgo is beneficial in children with autism. Details: A small clinical trial shows that taking a specific ginkgo extract (Ginko T.D., Tolidaru Pharmaceuticals) 80-120 mg daily for 10 weeks along with risperidone 1-3 mg daily does not improve symptoms of autism when compared with risperidone alone in children aged 4-12 years (89708).
• Bronchitis. Although there has been interest in using oral ginkgo for bronchitis, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Chronic fatigue syndrome (CFS). Oral ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in adults with CFS shows that taking ginkgo leaf 120-180 mg in combination with Cistanche tubulosa root 300-450 mg orally daily for 60 days improves fatigue scores by 16% to 19% when compared with placebo. Taking this combination also improved quality of life scores when compared with placebo (107361).
• Chronic kidney disease (CKD). There is limited evidence on the intravenous use of ginkgo leaf extract in adults with hypertensive nephropathy. It has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small meta-analysis in patients with hypertensive nephropathy shows that intravenous administration of 20-30 mL of ginkgo leaf extract and dipyridamole injection once daily for 3-4 weeks along with conventional antihypertensive therapy improves levels of 24-hour urinary total protein, serum creatinine, and blood urea nitrogen by 0.6 grams/dL, 33 mg/dL, and 7 mg/dL, respectively (106610). It is unclear if these effects are due to ginkgo, dipyridamole, or the combination.
• Chronic obstructive pulmonary disease (COPD). Oral ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research shows that taking two capsules of a specific combination product (AKL1, AKL International Ltd.) containing ginkgo extract, ginger, and Picrorhiza twice daily for 8 weeks does not improve respiratory symptoms when compared with placebo in patients with COPD (89702).
• Cocaine dependence. It is unclear if oral ginkgo is beneficial for maintenance of abstinence from cocaine. Details: A small clinical trial shows that taking a standardized ginkgo leaf extract called EGb 761 in a dose of 120 mg twice daily for 10 weeks does not help maintain abstinence from cocaine use when compared with placebo in cocaine-dependent patients (87723).
• Cognitive function. It is unclear if oral ginkgo is beneficial for cognitive function. Details: Clinical research in healthy adults shows that taking ginkgo leaf extract daily for up to 12 weeks might improve some measures of cognitive function, such as working and long term memory, attention based tasks, speed of information processing, executive function, immediate and delayed recall, and recognition (6214,6215,8236,8544,8585,8588,9759,16635,87788,87879,95668). Doses used in these studies include single doses of ginkgo extract 240-600 mg (6215,8236), a standardized ginkgo extract called EGb 761, 120-240 mg taken once daily or in 2-3 divided doses daily for 4-24 weeks (5717,6216,8585,8588,87879,95668), or another specific ginkgo extract called LI 1370 (Lichtwer Pharma), 120-300 mg daily in three divided doses for 2 days (6214). However, other clinical studies and one clinical review show no significant effect of ginkgo on gait ability, attention, memory, or executive function regardless of participant age, dose, or formulation used (87907,5718,8586,8587,8588,87907,95667). Due to the small number of study participants, significant differences in baseline cognitive function between groups, and variability in outcome measures, no definitive conclusions can be drawn. Larger scale studies are needed to determine the effect of ginkgo on cognitive function in healthy individuals. There is also conflicting evidence about the effect of ginkgo on cognitive function when taken in combination with other products. Some research suggests that taking ginkgo in combination with Panax ginseng or codonopsis enhances memory in healthy young or middle-aged adults, and the combinations might be more effective than the individual products (8591,9759,87758). These studies have used a specific combination product (Ginkoba M/E, Pharmaton SA) containing ginkgo extract 100-600 mg and Panax ginseng 60-360 mg, taken as a single dose or once daily for 12 weeks (8591,9759) or two capsules of a product containing ginkgo extract 40 mg/capsule and Codonopsis 75 mg/capsule daily (87758). However, other clinical research shows that taking ginkgo combined with Panax ginseng (Gincosan, Pharmaton Natural Health Products) or bacopa extract (Ginkgo Brahmi, Blackmore's Ltd.) for up to 12 weeks does not improve cognition when compared with placebo in healthy adults (87767,87748). Similarly, a moderate-sized clinical study in healthy adults aged 40-65 years shows that taking a supplement containing ginkgo leaf, bacopa, and B vitamins twice daily for 12 weeks does not improve memory or attention when compared with placebo (111334).
• Cognitive impairment. It is unclear if ginkgo is beneficial for cognitive impairment. Details: A clinical study of 500 patients with mild cognitive impairment that is abnormal for their age shows that taking a specific ginkgo standardized extract (EGb761, Tanakan) 40 mg three times daily for 24 months improves scores for cognitive decline, memory, activities of daily living, and depression when compared with baseline (105530). However, it is not clear if these improvements are clinically significant and the validity of the study is limited by the lack of a control group. Cognitive impairment is common side effect of electroconvulsive therapy (ECT). A small clinical study in patients aged 18-60 years with psychiatric disorders undergoing ECT in Iran shows that taking ginkgo (Vitarmonil Co., France) 200 mg after meals, starting 48 hours before initiation of ECT and continuing until the end of ECT sessions, modestly improves scores related to cognitive impairment and memory when compared with placebo (111338). However, it is unclear if these improvements are clinically significant.
• Colorectal cancer. Intravenous ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research shows that adding intravenous ginkgo extract (EGb 761 ONC), 350 mg over 30 minutes on days 1-6 of every 3-week cycle to treatment with 5-fluorouracil 500 mg/m2 daily on days 2-6 of every 3-week cycle for 4 courses of treatment, might reduce disease progression in some patients with metastatic colorectal cancer (9872). However, since the study did not include a control group, it is unclear if the effects of treatment were greater than the effects of 5-fluorouracil alone.
• Cough. Although there has been interest in using oral ginkgo for cough, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Depression. It is unclear if oral ginkgo is beneficial in depression. Details: Preliminary clinical research in elderly patients shows that taking an unknown dose of a specific ginkgo extract (Harbin HaoBo Pharmaceutical Co., Ltd.) in conjunction with citalopram 20 mg daily for 12 weeks improves depression scores by 75% or more in an additional 3% of patients when compared with taking citalopram alone. Taking ginkgo extract with citalopram also produces a faster onset of action when compared to taking citalopram alone. However, it is not clear if these improvements are clinically significant (98811).
• Diabetes. Research on the use of oral ginkgo in type 2 diabetes is conflicting. Details: In patients with uncontrolled type 2 diabetes taking metformin, preliminary clinical research shows that taking ginkgo extract (EGb 761) 120 mg for 90 days reduces glycated hemoglobin (HbA1c) levels from an average of 8.6% at baseline to an average of 7.7%. Fasting serum glucose and insulin were also reduced, when compared with baseline, by approximately 20% and 28%, respectively (103574). However, a meta-analysis of 7 clinical studies shows that taking ginkgo is associated with an increase in HbA1c levels, with no effect on fasting serum glucose levels. The only beneficial effect identified in this analysis was an increase in high density lipoprotein (HDL) cholesterol levels (105529).
• Diabetic retinopathy. It is unclear if oral ginkgo is beneficial for this condition. Details: Preliminary clinical research shows that taking a specific ginkgo leaf extract called EGb 761 120 mg daily orally for 6 months improves measures of color vision when compared with placebo in patients with early diabetic retinopathy (6175).
• Dry eye. Ginkgo eye drops have only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A nonblinded clinical study in adults undergoing cataract surgery and receiving standard treatment shows that applying a specific, preservative-free eye drop (Trium Free; SOOFT) containing ginkgo extract 0.05% and hyaluronic acid 0.15%, three times daily, beginning the first day after surgery and continued for 4 weeks, reduces dry eye severity and symptoms when compared with standard treatment alone. After 4 weeks, 50% of patients in the standard treatment group reported dry eye symptoms, compared with 16% of patients using ginkgo (108609). The effects of ginkgo in patients with chronic dry eye or dry eye caused by other factors is unclear.
• Dyslexia. It is unclear if oral ginkgo is beneficial for dyslexia in children. Details: Preliminary clinical research shows that taking a standardized ginkgo leaf extract (EGb 761) 80 mg daily for an average of 34 days can help reduce dyslexia when compared to baseline in children aged 5-16 years (87790). The validity of this finding is limited by the lack of a comparator group.
• Fibromyalgia. Oral ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research shows that taking tablets containing ginkgo extract (Bio-Biloba, Pharma Nord) 200 mg daily in conjunction with capsules containing coenzyme Q10 (Bio Quinone Q10, Pharma Nord) 200 mg daily orally for 84 days improves patient-reported quality of life, such as physical fitness levels, emotional feelings, social activities, overall health, and pain, when compared to baseline (17716). The validity of these findings is limited by the lack of a comparator group.
• Gastric cancer. It is unclear if oral ginkgo is beneficial in gastric cancer. Details: Preliminary clinical research shows that taking carbohydrates from the outer layer of ginkgo fruit 250 mg orally twice daily for 30 days may reduce tumor size in patients with gastric cancer when compared with pre-treatment (87742).
• Glaucoma. It is unclear if oral ginkgo is beneficial in glaucoma. Details: A small observational study has found that taking ginkgo leaf extract 80 mg twice daily for up to 12.3 years is associated with reduced progression of visual field damage in patients with normal tension glaucoma (87900). Furthermore, a small clinical study in patients with normal tension glaucoma shows that taking ginkgo leaf extract 40 mg three times daily for up 4 weeks might improve pre-existing damage and reduce the progression of damage to the visual field (10378). However, conflicting evidence exists. Another small study in patients with newly diagnosed normal tension glaucoma shows that taking a specific ginkgo extract (Ginaton, Dr. Willmar Schwabe Pharmaceuticals) 40 mg three times daily for 4 weeks does not improve damage or progression of glaucoma (89707). Reasons for the discrepancies may be due to the formulation of ginkgo leaf extract used or the severity of glaucoma at baseline.
• Hemorrhoids. Oral ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: One small clinical study shows that taking a combination of ginkgo extract, troxerutin, and heptaminol for one week may decrease some symptoms of hemorrhoids, including bleeding, pain, feelings of incomplete defecation, and discharge when compared to baseline (87751). The validity of these findings is limited by the lack of a comparator group. Additionally, it is unclear if these effects are due to ginkgo, other ingredients, or the combination.
• Hypercholesterolemia. Although there has been interest in using oral ginkgo for hypercholesterolemia, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Intestinal parasite infection. Although there has been interest in using oral ginkgo for intestinal parasite infection, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Lyme disease. Although there has been interest in using oral ginkgo for cognitive dysfunction associated with Lyme disease, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Migraine headache. Oral ginkgolide B, a constituent of ginkgo biloba extract, has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research shows that ginkgolide B (BN52021), a constituent of ginkgo extract, along with coenzyme Q10, riboflavin, and magnesium, taken twice daily for 3 months, may help prevent migraines in school-aged children when compared to baseline (44181,87876). Also, a specific product (Migrasoll, Pharmaval Srl) containing ginkgolide B 60 mg, coenzyme Q10 11 mg, and vitamin B2 8.7 mg, taken twice daily for 4 months, may help prevent migraines in females when compared to baseline (44103). The validity of the findings from these studies is limited by the lack of a comparator group.
• Ovarian cancer. It is unclear if oral ginkgo is beneficial in preventing ovarian cancer. Details: Epidemiological evidence found that use of ginkgo extract for 6 months is associated with a decreased risk for developing ovarian cancer (14813).
• Pancreatic cancer. Intravenous ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research shows that adding a specific intravenous ginkgo extract called EGb 761 ONC 350 mg on days 1-6 of every 3-week cycle to treatment with 5-fluorouracil 500 mg/m2 daily on days 2-6 of every 3-week cycle until disease progression might slow the progression of pancreatic cancer in some patients (87699). However, since the study did not include a control group, it is unclear if the effects of treatment were greater than the effects of 5-fluorouracil alone.
• Parkinson disease. It is unclear if oral ginkgo is beneficial for drug-induced Parkinsonism. Details: Preliminary clinical research in patients with psychiatric diagnoses treated with antipsychotic drugs shows that taking dried ginkgo extract, 80 mg three times daily orally for 3 months, reduces resting tremors, rigidity, bradykinesia, and the severity of motor symptoms when compared with placebo (112945).
• Peripheral arterial disease (PAD). It is unclear if oral ginkgo is beneficial in PAD. Details: Some small clinical studies show that taking a specific ginkgo leaf extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals and Ipsen) orally increases pain-free walking distance in patients with Fontaine's IIb peripheral arterial occlusive disease and intermittent claudication and might decrease overall peripheral vascular disease (PVD) event incidence, such as surgery or amputation, in elderly patients (3461,6211,6212,6213,17402). Significant benefit has been found with doses as low as 120-160 mg daily (6211). However, there is some evidence that a higher dose of 240 mg daily might be more beneficial in some patients (3461,6212). Although some research is positive, other research shows that taking a specific ginkgo leaf extract called EGb 761 (Dr. Willmar Schwabe Pharmaceuticals) 300 mg daily for 16 weeks does not significantly improve maximum treadmill walking time when compared with placebo in patients with PAD (16638). A reason for this discrepancy may be due to the duration of treatment. A meta-analysis of clinical research shows that taking ginkgo leaf extract does not improve maximum treadmill walking distance when compared with placebo in patients with Fontaine stage II PVD and intermittent claudication when administered for 6-8 weeks or 12-16 weeks, but does increase maximum treadmill walking distance by about 85 meters when administered for at least 24 weeks (89440).
• Pulmonary hypertension. It is unclear if intravenous ginkgo is beneficial in patients with pulmonary hypertension and cor pulmonale. Details: A meta-analysis of 28 small, low-quality clinical trials, including nearly 2500 Chinese patients with pulmonary hypertension and cor pulmonale, shows that intravenous administration of ginkgo leaf extract plus dipyridamole 15-40 mL daily for 1-4 weeks along with conventional therapy increases the total effective rate by 28% and improves various blood gas measures when compared with conventional therapy alone (102881). It is unclear if these effects are due to ginkgo, dipyridamole, or the combination. Large, high-quality clinical trials are needed to confirm these results.
• Quality of life. Some preliminary clinical studies suggest that oral ginkgo might improve quality of life in elderly individuals. Details: A large survey-based study shows that taking a standardized ginkgo leaf extract called LI 1370 (Lichtwer Pharma) 120 mg daily for 4-10 months may improve quality of life measures such as activities of daily living, mood, sleep, and alertness in elderly individuals when compared with control (87715,87760).
• Radiation exposure. It is unclear if intravenous ginkgo is beneficial in people who have been exposed to radiation. Details: Preliminary clinical research shows that taking a standardized ginkgo leaf extract called EGb 761 (Tanakan, Ipsen) 120 mg daily for 2 months might reduce clastogenic factors in the blood of patients who had previously been irradiated. The reduction in clastogenic factors was observed for at least 7 months after initiation of ginkgo in most patients (17719).
• Radiation dermatitis. Topical ginkgo has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research shows that applying a specific cream product (Radioskin 2, Herbalab di Perazza Massimiliano Company) containing ginkgo extract, Aloe vera, and metal esculetina, along with another specific cream product (Radioskin 1) containing alga atlantica and ethylbisiminomethylguaicolo manganese cloruro, may improve skin hydration and reduce skin toxicity associated with radiation therapy in patients with breast cancer (89727). The creams were applied topically 2-3 times daily at least 3 hours before and after radiation treatment from 15 days prior to radiation until one month after completion. It is unclear if these effects are due to ginkgo, other ingredients, or the combination.
• Raynaud syndrome. Evidence for the use of oral ginkgo for flare reduction is conflicting. Details: Some research shows that taking a standardized ginkgo extract (Seredrin, Health Perception Ltd.) 120 mg orally three times daily for 10 weeks can decrease the number of painful attacks per week in patients with Raynaud syndrome (11363). However, other research shows that ginkgo extract is no different than placebo in decreasing the number of attacks in these patients (87888). Also, another study shows that taking ginkgo extract 120 mg daily is less effective than nifedipine SR 30 mg daily orally in decreasing Raynaud syndrome flares (87818).
• Scabies. Although there has been interest in using topical ginkgo for scabies, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Seasonal affective disorder (SAD). It is unclear if oral ginkgo is beneficial for SAD. Details: One small clinical study shows that taking ginkgo leaf extract orally does not seem to prevent winter depression symptoms in patients with SAD when compared with placebo (8233).
• Sexual dysfunction. It is unclear if oral ginkgo is beneficial for sexual dysfunction in females. Details: Some clinical research shows that taking a ginkgo leaf extract 300 mg daily for 8 weeks does not significantly improve sexual function in females with sexual arousal disorder when compared with placebo (16640). However, other preliminary clinical research shows that taking a specific combination product (ArginMax for Women, Daily Wellness Company) containing ginkgo leaf extract, Panax ginseng root extract, damiana leaf extract, L-arginine, multivitamins, and minerals for 4 weeks can improve sexual satisfaction when compared with placebo in females who self-report sexual dysfunction (46933). It is unclear if these effects are due to ginkgo, other ingredients, or the combination.
• Venous thromboembolism (VTE). Although there has been interest in using oral ginkgo for thrombosis, there is insufficient reliable information about the clinical effects of ginkgo for this condition.
• Vitiligo. It is unclear if oral ginkgo is beneficial for reducing vitiligo progression. Details: Preliminary clinical research shows that taking a specific ginkgo extract (Ginkgo Plus, Seroyal) 120 mg in two divided doses daily for up to 6 months reduces the progression of vitiligo vulgaris and lesion size when compared to baseline (17718,87728). The validity of these findings is limited by the lack of a comparator group.
• Wound healing. Although there has been interest in using topical ginkgo for healing of skin sores or chilblains, there is insufficient reliable information about the clinical effects of ginkgo for these conditions. More evidence is needed to rate ginkgo for these uses.

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POSSIBLY EFFECTIVE

• Cognitive function. Oral sage seems to be beneficial for improving cognitive function in healthy adults. The benefits of sage aromatherapy are unclear. Details: Clinical research shows that taking a specific product providing common sage polyphenols and Spanish sage terpenoids (Cognivia), either as a single dose or daily for 29 days, modestly improves working memory and accuracy when compared with placebo. A single dose of this product contains common sage leaf extract 400 mg and Spanish sage essential oil 200 mg (105337). In addition, preliminary clinical research shows that Spanish sage essential oil 25-50 mcL orally as a single dose seems to dose-dependently enhance some measures of cognitive performance in young adults by a small amount (10811,72609,72616,72660). When used as aromatherapy, essential oils of common sage, but not Spanish sage, seem to improve quality of memory and secondary memory. Neither species improves speed of memory or working memory when used as aromatherapy. In this study, five drops of common sage essential oil and 5 mL water were placed on a warmed stone and allowed to diffuse for 5 minutes prior to exposure (72658).
• Hyperlipidemia. Oral sage seems to be beneficial for reducing low-density lipoprotein (LDL) cholesterol and triglyceride levels. Details: Clinical research in adults with mixed hyperlipidemia types shows that taking common sage leaf extract 500 mg, standardized to quercetin 2.16%, three times daily for 2 months reduces LDL cholesterol and triglyceride levels by about 20% and 23%, respectively, and increases high-density lipoprotein (HDL) cholesterol levels by 20%, when compared with placebo (72662). Also, preliminary clinical research in adults with type 2 diabetes and hypercholesterolemia shows that taking common sage leaf extract 500 mg three times daily for 3 months lowers total cholesterol by 17%, LDL cholesterol by 36%, and triglycerides by 56%, and increases HDL cholesterol by 28%, when compared with placebo (91971).
• Menopausal symptoms. Oral sage seems to be beneficial for reducing menopausal symptoms. Details: Clinical research shows that taking a thujone-free common sage extract (Menosan, A.Vogel AG) 280 mg daily for 4 weeks reduces overall symptoms of menopause by 39% when compared with placebo. About 41% of patients taking common sage had at least a 50% reduction in symptoms, compared with 8% of those taking placebo. Hot flushes, sleep problems, joint and muscle discomfort, irritability, and physical and mental exhaustion were improved, whereas urogenital symptoms such as sexual desire and vaginal dryness were not (105338). Other clinical research shows that taking common sage extract 300 mg daily for 3 months moderately reduces overall symptoms of menopause after about 10 weeks when compared with placebo. However, there was no effect on vaginal dryness, physical and mental exhaustion, or urinary incontinence (103379). Another small clinical study shows that taking a specific thujone-free common sage extract (Sage Menopause, Bioforce AG) 280 mg daily for 56 days reduces daily hot flash frequency by 40% and reduces hot flash intensity when compared with baseline (17177). The validity of these findings is limited by the lack of a comparator group.

POSSIBLY INEFFECTIVE

• Postoperative pain. Using an oral rinse containing common sage does not seem to be beneficial for reducing postoperative pain. Details: A large open-label clinical trial in children and adults shows that using a common sage oral rinse 6 times daily in combination with ibuprofen or diclofenac is less effective than benzydamine hydrochloride, a local anesthetic, for reducing pain following tonsillectomy and/or adenoidectomy. Furthermore, treatment with common sage oral rinse is associated with an increased risk of postoperative infection in adults when compared with benzydamine hydrochloride (72700).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Age-related cognitive decline. It is unclear if a single oral dose of common sage is beneficial for age-related cognitive decline. Details: Clinical research in healthy, older adults shows that taking a single dose of common sage extract 333 mg improves accuracy of attention and some measures of memory when compared with placebo. However, not all doses were effective and some measures of cognitive function were not affected (72642).
• Alzheimer disease. It is unclear if oral sage is beneficial for Alzheimer disease. Details: Preliminary clinical research shows that taking extracts of common sage and Spanish sage orally seems to improve cognitive function in patients with mild to moderate Alzheimer disease when used for up to 4 months (10334,10810). In one study, a fixed dose of common sage hydroalcoholic extract, equivalent to 1 gram of sage per day, was used for 4 months (10810). In the other, an extract of Spanish sage titrated up to 2.5 mg three times daily for 6 weeks was used (10334). These studies are limited by their short duration and small numbers of participants.
• Androgen deprivation therapy (ADT)-associated hot flashes. It is unclear if oral sage is beneficial for ADT-associated hot flashes. Details: Preliminary clinical research in patients with prostate cancer receiving ADT shows that taking common sage extract 150 mg three times daily with meals for 4 weeks reduces hot flash severity by 48% and hot flash frequency by 42% when compared with baseline. These improvements were maintained with an additional 8 weeks of treatment (91970). The validity of these findings is limited by the lack of a comparator group.
• Athletic performance. It is unclear if oral sage is beneficial for improving athletic performance. Details: In young, healthy, physically active adults, taking a specific supplement (Cognivia, Nexira) containing 400 mg common sage leaf extract and 200 mg Spanish sage oil, orally 2 hours prior to a 40-minute stationary cycling session at 80% of maximum aerobic power, lowers perceived exertion scores and improves working memory and reaction times when compared with placebo (108961).
• Chemotherapy-induced nausea and vomiting (CINV). It is unclear if topical sage is beneficial for the treatment or prevention of CINV. Details: A small clinical study in patients undergoing chemotherapy shows that using common sage oil 2 mL topically during 15-minute sessions of Swedish abdominal massage twice daily for 3 days modestly reduces nausea severity scores, but does not affect vomiting frequency, when compared with massage alone (107023).
• Dental plaque. It is unclear if rinsing the mouth with sage is beneficial for reducing plaque. Details: Preliminary clinical research shows that rinsing the mouth with 10-15 mL of a solution containing common sage, twice for 30 seconds four times daily for 4 days, in addition to standard oral care with brushing and use of an oral gel (Biotene), is as effective as normal saline for reducing dental plaque. However, there was no effect on tongue plaque. The rinse was made by steeping 2.5 grams of dried sage leaf in 100 mL boiled water for two minutes (105339).
• Diabetes. It is unclear if oral sage is beneficial for diabetes. Details: A small clinical study in adults with type 2 diabetes shows that taking common sage leaf extract 500 mg three times daily for 3 months lowers fasting blood glucose by 32% and glycated hemoglobin (HbA1c) by 23% when compared with placebo (91971). However, another small clinical study in patients with type 2 diabetes shows that taking common sage extract 150 mg three times daily for 3 months does not lower fasting blood glucose or HbA1c when compared with placebo, although there is a modest reduction in 2-hour postprandial blood glucose levels (105340). A meta-analysis of 3 small studies, including the 2 described above, shows that taking common sage, 150-500 mg three times daily for 2-3 months, modestly reduces fasting blood glucose and 2-hour postprandial blood glucose levels, as well as HbA1c, when compared with placebo (108962). These studies were all conducted in Iran; it is unclear if these findings are generalizable to other geographic locations.
• Dry mouth. It is unclear if rinsing the mouth with common sage is beneficial for dry mouth. Details: Preliminary clinical research in patients receiving palliative cancer care shows that rinsing the mouth with 10-15 mL of a solution containing common sage, twice for 30 seconds four times daily for 4 days, in conjunction with standard care involving brushing and an oral gel (Biotene), is as effective as normal saline for improving overall oral health and modestly more effective than normal saline for improving dry mouth. The rinse was made by steeping 2.5 grams dried sage leaf in 100 mL boiled water for two minutes (105339).
• Gingivitis. Sage has only been evaluated as a mouthwash in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical trial in elderly individuals shows that rinsing the mouth with a mouthwash containing sage, marshmallow, calendula, tormentil, horse chestnut, neem, and myrrh, once daily for 30 seconds for 6 weeks, is no more effective than placebo for improving plaque and gingival bleeding (105341).
• Herpes labialis (cold sores). It is unclear if topical sage is beneficial for herpes labialis. Details: Clinical research shows that topical application of a cream containing either sage alone or sage with rhubarb, starting within 1 day of the first symptoms and continuing for 10-14 days, heals herpes labialis legions in 7.6 days or 6.7 days, respectively, compared to a healing time of 6.3 days with acyclovir cream. The combination of sage and rhubarb also improves the time to healing and reduces pain when compared with sage alone. The cream provided 23 mg sage extract, with or without 23 mg rhubarb extract, per gram and was applied every 2-4 hours while awake (10437).
• Lung cancer. It is unclear if dietary sage is beneficial for lung cancer prevention. Details: Epidemiological research has found that regularly consuming sage is associated with a 54% lower risk of developing lung cancer when compared with those who do not use sage as a spice (72593).
• Oral mucositis. It is unclear if rinsing the mouth with sage is beneficial for oral mucositis. Details: Preliminary clinical research in patients receiving palliative cancer care shows that rinsing the mouth with 10-15 mL of a rinse containing common sage, twice for 30 seconds four times daily for 4 days, in addition to standard oral care with brushing and use of an oral gel (Biotene), does not improve oral mucositis when compared with baseline or normal saline rinse. The rinse was made by steeping 2.5 grams of dried sage leaf in 100 mL boiled water for two minutes (105339).
• Pharyngitis. It is unclear if inhaling a spray containing sage, with or without other ingredients, is beneficial for pharyngitis. Details: Clinical research in patients with acute viral pharyngitis shows that inhaling three puffs (140 mcL) of a specific spray (Valverde Salvia Rachenspray) containing common sage extract 15%, six to nine times daily for 3 days, reduces throat pain intensity over 2 hours when compared with placebo. However, sprays containing common sage extract 5% or 30% do not seem to be more effective than placebo for reducing throat pain (72619). Other preliminary clinical research in patients with sore throat due to acute pharyngitis or tonsillitis shows that applying a combination spray product containing common sage leaf tincture 430 mg/mL, Echinacea flowering aerial parts tincture 863.3 mg/mL, and Echinacea root tincture 45.5 mg/mL, every 2 hours up to 10 times daily for up to 5 consecutive days improves symptoms as effectively as a chlorhexidine-lidocaine spray (20077).
• Polycystic ovary syndrome (PCOS). It is unclear if oral sage is beneficial for PCOS. Details: Clinical research shows that taking common sage extract 330 mg daily for 8 weeks modestly reduces body mass index (BMI), diastolic blood pressure, and fasting blood glucose, and modestly improves measures of insulin resistance, when compared with placebo in individuals with PCOS. However, there was no effect on waist to hip ratio or systolic blood pressure (103380).
• Sunburn. It is unclear if topical sage is beneficial for sunburn prevention. Details: Clinical research shows that a single application of a hydrophilic ointment containing common sage extract 2% to the skin immediately after exposure to ultraviolet light reduces the development of skin redness when compared with placebo (72638).
• Swallowing dysfunction. It is unclear if rinsing the mouth with sage is beneficial for swallowing dysfunction. Details: Preliminary clinical research in patients receiving palliative cancer care shows that rinsing the mouth with 10-15 mL of a solution containing common sage, twice for 30 seconds four times daily for 4 days, in addition to standard oral care with brushing and use of an oral gel (Biotene), does not improve swallowing when compared with baseline or normal saline rinse. The rinse was made by steeping 2.5 grams of dried sage leaf in 100 mL boiled water for two minutes (105339).
• Tonsillitis. Sage has only been evaluated in a spray in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in patients with sore throat due to acute pharyngitis or tonsillitis shows that applying a combination spray product containing common sage leaf tincture 430 mg/mL, Echinacea flowering aerial parts tincture 863.3 mg/mL, and Echinacea root tincture 45.5 mg/mL, every 2 hours up to 10 times daily for up to 5 consecutive days improves symptoms as effectively as a chlorhexidine-lidocaine spray (20077).
• Tonsillopharyngitis. It is unclear if oral sage is beneficial for treating tonsillopharyngitis. Details: A moderate-sized observational study in patients aged 12-75 years old with acute tonsillopharyngitis suggests that taking lozenges containing sage extract 378.5 mg and echinacea extract 5 times daily for 4 days reduces throat pain and tonsillopharyngitis symptoms when compared to baseline, both acutely within 90 minutes and after 4 days of treatment (111530). The validity of these findings is limited by the lack of a comparator group. Also, it is unclear if these effects are due to sage, echinacea, the combination, or natural resolution of the condition. More evidence is needed to rate sage for these uses.

(Read more about SAGE)

LIKELY SAFE ...when used orally and appropriately, short-term. Eleuthero root extract 300-2000 mg has been used safely in clinical trials lasting up to 3 months (730,1427,2574,7522,11099,15586,91509). There is insufficient reliable information available about the safety of eleuthero when used long-term.

CHILDREN: POSSIBLY SAFE
when used orally in adolescents aged 12-17 years, short-term. Eleuthero 750 mg three times daily was used for 6 weeks with apparent safety in one clinical trial (75028). There is insufficient reliable information available about the safety of eleuthero in children or adolescents when used long-term.

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using.

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LIKELY SAFE ...when used orally and appropriately. Standardized ginkgo leaf extracts have been used safely in trials lasting for several weeks up to 6 years (1514,1515,3461,5717,5718,6211,6212,6213,6214,6215)(6216,6222,6223,6224,6225,6490,14383,14499,16634,16635)(16636,16637,17402,17716,17718,87794,87819,87826,87848,87864)(87888,87897,87901,87904,89701,89707,107359,107360). There have been some reports of arrhythmias associated with ginkgo leaf extract. However, it is not yet clear if ginkgo might cause arrhythmia (105253,105254). There is some concern about toxic and carcinogenic effects seen in animals exposed to a ginkgo leaf extract containing 31.2% flavonoids, 15.4% terpenoids, and 10.45 ppm ginkgolic acid, in doses of 100 to 2000 mg/kg five times per week for 2 years (18272). However, the clinical relevance of this data for humans, using typical doses, is unclear. The content of the extract used is not identical to that commonly used in supplement products, and the doses studied are much higher than those typically used by humans. A single dose of 50 mg/kg in rats is estimated to be equivalent to a single dose of about 240 mg in humans (18272).

POSSIBLY SAFE ...when used intravenously, short-term. A standardized ginkgo leaf extract called EGb 761 ONC has been safely administered intravenously for up to 14 days (9871,9872,107360,107452). A Chinese preparation containing ginkgo leaf extract and dipyridamole has been safely administered intravenously for up to 30 days (102881,102882). ...when applied topically, short-term. There was no dermal irritation during a 24-hour patch test using the leaf extract, and no sensitization with repeat applications (112946). When used topically in cosmetics, extracts of ginkgo leaves are reported to be safe, but there is insufficient data to determine the safety of nut and root extracts, and isolated biflavones and terpenoids (112946).

POSSIBLY UNSAFE ...when the roasted seed or crude ginkgo plant is used orally. Consuming more than 10 roasted seeds per day can cause difficulty breathing, weak pulse, seizures, loss of consciousness, and shock (8231,8232). Crude ginkgo plant parts can exceed concentrations of 5 ppm of the toxic ginkgolic acid constituents and can cause severe allergic reactions (5714).

LIKELY UNSAFE ...when the fresh ginkgo seed is used orally. Fresh seeds are toxic and potentially deadly (11296).

PREGNANCY: POSSIBLY UNSAFE
when used orally. There is concern that ginkgo might have labor-inducing and hormonal effects. There is also concern that the antiplatelet effects of ginkgo could prolong bleeding time if taken around the time of labor and delivery (15052). Theoretically, ginkgo might adversely affect pregnancy outcome; avoid using during pregnancy.

LACTATION:
Insufficient reliable information available; avoid using.

CHILDREN: POSSIBLY SAFE
when used orally and appropriately, short-term (87790,89708). A specific ginkgo dried extract (Ginko T.D., Tolidaru Pharmaceuticals), has been safely used in doses of 80-120 mg daily for 6 weeks in children aged 6-14 years (17112,95669). Another specific combination product containing ginkgo leaf extract and American ginseng extract (AD-FX, CV Technologies, Canada) has also been safely used in children aged 3-17 years for up to 4 weeks (8235).

CHILDREN: LIKELY UNSAFE
when ginkgo seed is used orally. The fresh seeds have caused seizures and death in children (8231,11296).

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LIKELY SAFE ...when used orally in amounts commonly found in foods. Sage is approved for use as a food in the United States (4912).

POSSIBLY SAFE ...when used orally in medicinal doses, short-term. Common sage (Salvia officinalis) and Spanish sage (Salvia lavandulaefolia) have been used with apparent safety when taken orally in doses of 280 mg daily for up to 8 weeks (10334,10810,17177,105338). ...when used topically. Common sage (Salvia officinalis) has been used with apparent safety as a single agent or in combination products for up to one week (10437,72619,107023). ...when the essential oil is inhaled as aromatherapy, short-term (72658).

POSSIBLY UNSAFE ...when used orally in high doses or long-term (12,1304). Some species of sage, including common sage (Salvia officinalis), contain a thujone constituent that can be toxic if consumed in large enough quantities (12,1304).

PREGNANCY: LIKELY UNSAFE
when used orally. The constituent thujone can have menstrual stimulant and abortifacient effects (19).

LACTATION: POSSIBLY UNSAFE
when used orally; sage is thought to reduce the supply of mother's milk (19).

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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, eleuthero may have antiplatelet effects and may increase the risk of bleeding if used with anticoagulant or antiplatelet drugs.  Details In vitro and animal research shows that a constituent of eleuthero, dihydroxybenzoic acid, appears to inhibit platelet aggregation (7592,74976). Concomitant use with anticoagulant or antiplatelet drugs might increase the risk of bleeding.

ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Theoretically, eleuthero might have additive effects when used with antidiabetes drugs.  Details Animal research suggests that certain constituents of eleuthero have hypoglycemic activity in both healthy and diabetic animals (7591,73535,74932,74956,74988,74990). A small study in adults with type 2 diabetes also shows that taking eleuthero for 3 months can lower blood glucose levels (91509). However, one very small study in healthy individuals shows that taking powdered eleuthero 3 grams, 40 minutes prior to a 75-gram oral glucose tolerance test, significantly increases postprandial blood glucose levels when compared with placebo (12536). These contradictory findings might be due to patient-specific variability and variability in active ingredient ratios.

CYTOCHROME P450 1A2 (CYP1A2) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, eleuthero might increase levels of drugs metabolized by CYP1A2.  Details In vitro and animal research suggest that standardized extracts of eleuthero inhibit CYP1A2 (7532). This effect has not been reported in humans.

CYTOCHROME P450 2C9 (CYP2C9) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, eleuthero might increase levels of drugs metabolized by CYP2C9.  Details In vitro and animal research suggest that standardized extracts of eleuthero might inhibit CYP2C9 (7532). This effect has not been reported in humans.

CYTOCHROME P450 2D6 (CYP2D6) SUBSTRATES Interaction Rating = Minor Be watchful with this combination. Severity = Moderate •  Occurrence = Unlikely •  Level of Evidence = B Theoretically, eleuthero might increase levels of drugs metabolized by CYP2D6.  Details In vitro and animal research suggest that standardized extracts of eleuthero might inhibit CYP2D6. However, research in healthy human volunteers has found that taking eleuthero 485 mg twice daily for 14 days does not inhibit CYP2D6 drug metabolism (7532,10400).

CYTOCHROME P450 3A4 (CYP3A4) SUBSTRATES Interaction Rating = Minor Be watchful with this combination. Severity = Moderate •  Occurrence = Unlikely •  Level of Evidence = B Theoretically, eleuthero might increase levels of drugs metabolized by CYP3A4.  Details In vitro and animal research suggest that standardized extracts of eleuthero might inhibit CYP3A4. However, research in healthy human volunteers has found that taking eleuthero 485 mg twice daily for 14 days does not inhibit CYP3A4 drug metabolism (7532,10400).

DIGOXIN (Lanoxin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Unlikely •  Level of Evidence = D Eleuthero might increase serum digoxin levels and increase the risk of side effects.  Details In one case report, a 74-year-old male who was stabilized on digoxin presented with an elevated serum digoxin level after starting an eleuthero supplement, without symptoms of toxicity. After stopping the supplement, serum digoxin levels returned to normal (543). It is not clear whether this was due to a pharmacokinetic interaction or to interference with the digoxin assay (15585). Although the product was found to be free of digoxin and digitoxin (543), it was not tested for other contaminants (797).

IMMUNOSUPPRESSANTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, eleuthero might interfere with immunosuppressive drugs because of its immunostimulant activity.  Details Animal and in vitro research shows that eleuthero extracts have immunomodulatory effects, including increasing cellular and humoral activity (74887,74915).

ORGANIC ANION-TRANSPORTING POLYPEPTIDE SUBSTRATES (OATP) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, eleuthero might decrease levels of drugs metabolized by OATP.  Details In vitro research suggests that eleuthero inhibits OATP2B1, which might reduce the bioavailability of oral drugs that are substrates of OATP2B1 (35450). Due to the weak inhibitory effect identified in this study, this interaction is not likely to be clinically significant.

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, eleuthero might increase levels of P-glycoprotein substrates.  Details In vitro research suggests that eleuthero can inhibit the multi-drug transporter protein, P-glycoprotein (22639,91509). However, it is too soon to tell if this is clinically important. This interaction has not been reported in humans.

(Read more about ELEUTHERO)

ALPRAZOLAM (Xanax) Interaction Rating = Moderate Be cautious with this combination. Severity = Mild •  Occurrence = Probable •  Level of Evidence = B Theoretically, ginkgo might decrease the levels and clinical effects of alprazolam.  Details In clinical research, ginkgo extract (Ginkgold) 120 mg twice daily seems to decrease alprazolam levels by about 17%. However, ginkgo does not appear to decrease the elimination half-life of alprazolam. This suggests that ginkgo is more likely to decrease absorption of alprazolam rather than induce hepatic metabolism of alprazolam (11029).

ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = A Ginkgo has been shown to increase the risk of bleeding in some people when taken with warfarin. Theoretically, ginkgo might increase the risk of bleeding if used with other anticoagulant or antiplatelet drugs.  Details Several pharmacodynamic studies suggest that ginkgo inhibits platelet aggregation. It is thought that the ginkgo constituent, ginkgolide B, displaces platelet-activating factor (PAF) from its binding sites, decreasing blood coagulation (6048,9760). Several case reports have documented serious bleeding events in patients taking ginkgo (244,578,579,8581,13002,13135,13179,13194,14456,87868). However, population and clinical studies have produced mixed results. Some evidence shows that short-term use of ginkgo leaf does not significantly reduce platelet aggregation and blood clotting (87732). A study in healthy males who took a specific ginkgo leaf extract (EGb 761) 160 mg twice daily for 7 days found no change in prothrombin time (12114). An analysis of a large medical record database suggests that ginkgo increases the risk of a bleeding adverse event by 38% when taken concurrently with warfarin (91326). It has been suggested that ginkgo has to be taken for at least 2-3 weeks to have a significant effect on platelet aggregation (14811). However, a meta-analysis of 18 studies using standardized ginkgo extracts, 80-480 mg daily for up to 32 weeks, did not find a significant effect on platelet aggregation, fibrinogen concentration, or PT/aPTT (17179). In addition, a single dose of ginkgo plus clopidogrel (14811) or ticlopidine does not seem to significantly increase bleeding time or platelet aggregation (17111,87846). Also, taking ginkgo leaf extract daily for 8 days in conjunction with rivaroxaban does not affect anti-factor Xa activity; however, this study did not evaluate bleeding time (109526).

ANTICONVULSANTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might reduce the effectiveness of anticonvulsants.  Details Ginkgo seeds contain ginkgotoxin. Large amounts of ginkgotoxin can cause neurotoxicity and seizure. Ginkgotoxin is present in much larger amounts in ginkgo seeds than leaves (8232). Ginkgo leaf extract contains trace amounts of ginkgotoxin. The amount of ginkgotoxin in ginkgo leaf and leaf extract seems unlikely to cause toxicity (11296). However, there are anecdotal reports of seizure occurring after use of ginkgo leaf both in patients without a history of seizure disorder and in those with previously well-controlled epilepsy (7030,7090).

ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Theoretically, taking ginkgo with antidiabetes drugs might alter the response to antidiabetes drugs.  Details Ginkgo leaf extract seems to alter insulin secretion and metabolism, and might affect blood glucose levels in people with type 2 diabetes (5719,14448,103574). The effect of ginkgo seems to differ depending on the insulin and treatment status of the patient. In diet-controlled diabetes patients with hyperinsulinemia, taking ginkgo does not seem to significantly affect insulin or blood glucose levels. In patients with hyperinsulinemia who are treated with oral hypoglycemic agents, taking ginkgo seems to decrease insulin levels and increase blood glucose following an oral glucose tolerance test. Researchers speculate that this could be due to ginkgo-enhanced hepatic metabolism of insulin. In patients with pancreatic exhaustion, taking ginkgo seems to stimulate pancreatic beta-cells, resulting in increased insulin and C-peptide levels, but with no significant change in blood glucose levels in response to an oral glucose tolerance test (14448).

ATORVASTATIN (Lipitor) Interaction Rating = Moderate Be cautious with this combination. Severity = Mild •  Occurrence = Probable •  Level of Evidence = B Theoretically, ginkgo might decrease the levels and clinical effects of atorvastatin.  Details In humans, intake of ginkgo extract appears to increase atorvastatin clearance, reducing the area under the curve of atorvastatin by 10% to 14% and the maximum concentration by 29%. However, this interaction does not appear to affect cholesterol synthesis and absorption (89706). Further, a model in rats with hyperlipidemia suggests that administering ginkgo extract does not impact blood levels of atorvastatin and leads to lower total cholesterol, low-density lipoprotein cholesterol, and triglycerides when compared with rats given atorvastatin alone (111331).

CYTOCHROME P450 1A2 (CYP1A2) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Theoretically, ginkgo might increase levels of drugs metabolized by CYP1A2.  Details Laboratory research suggests that ginkgo leaf extract can mildly inhibit CYP1A2 enzymes (1303,6423,6450). However, clinical research suggests ginkgo might not affect CYP1A2 (10847). Until more is known, use ginkgo cautiously in patients taking drugs metabolized by these enzymes.

CYTOCHROME P450 2C19 (CYP2C19) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Theoretically, ginkgo might decrease levels of drugs metabolized by CYP2C19.  Details Some clinical research shows that a specific ginkgo leaf extract (Remembrance, Herbs Product LTD) 140 mg twice daily can induce CYP2C19 enzymes and potentially decrease levels of drugs metabolized by these enzymes (13108). However, other clinical research shows that taking ginkgo 120 mg twice daily for 12 days has no effect on levels of drugs metabolized by CYP2C19 (87824).

CYTOCHROME P450 2C9 (CYP2C9) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might increase levels of drugs metabolized by CYP2C9.  Details In vitro, a specific standardized extract of ginkgo leaf (EGb 761) inhibits CYP2C9 activity (11026,12061,14337). The terpenoid (ginkgolides) and flavonoid (quercetin, kaempferol, etc.) constituents seem to be responsible for this effect. Most ginkgo extracts contain some amount of these constituents. Therefore, other ginkgo leaf extracts might also inhibit the CYP2C9 enzyme. However, clinical research suggests that ginkgo might not have a significant effect on CYP2C9 in humans. Ginkgo does not seem to significantly affect the pharmacokinetics of CYP2C9 substrates diclofenac or tolbutamide.

CYTOCHROME P450 3A4 (CYP3A4) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Theoretically, ginkgo might decrease levels of drugs metabolized by CYP3A4.  Details There is conflicting evidence about whether ginkgo induces or inhibits CYP3A4 (1303,6423,6450,11026,87800,87805,111330). Ginkgo does not appear to affect hepatic CYP3A4 (11029). However, it is not known if ginkgo affects intestinal CYP3A4. Preliminary clinical research suggests that taking ginkgo does not significantly affect levels of donepezil, lopinavir, or ritonavir, which are all CYP3A4 substrates (11027,87800,93578). Other clinical research also suggests ginkgo does not significantly affect CYP3A4 activity (10847). However, there are two case reports of decreased efavirenz concentrations and increased viral load in patients taking ginkgo. It is suspected that terpenoids from the ginkgo extract reduced drug levels by inducing cytochrome P450 3A4 (CYP3A4) (16821,25464).

EFAVIRENZ (Sustiva) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might decrease the levels and clinical effects of efavirenz.  Details There are two case reports of decreased efavirenz concentrations and increased viral load in patients taking ginkgo. In one case, an HIV-positive male experienced over a 50% decrease in efavirenz levels over the course of 14 months while taking ginkgo extract. HIV-1 RNA copies also increased substantially, from less than 50 to more than 1500. It is suspected that terpenoids from the ginkgo extract reduced drug levels by inducing cytochrome P450 3A4 (CYP3A4) (16821). In another case report, a patient stable on antiviral therapy including efavirenz for 10 years, had an increase in viral load from <50 copies/mL to 1350 copies/mL after 2 months of taking a combination of supplements including ginkgo. After stopping ginkgo, the viral load was again controlled with the same antiviral therapy regimen (25464).

IBUPROFEN (Advil, others) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might increase the risk of bleeding when used with ibuprofen.  Details Ginkgo might have antiplatelet effects and has been associated with several case reports of spontaneous bleeding. In one case, a 71-year-old male had taken a specific ginkgo extract (Gingium, Biocur) 40 mg twice daily for 2.5 years. About 4 weeks after starting ibuprofen 600 mg daily he experienced a fatal intracerebral hemorrhage (13179). However, the antiplatelet effects of ginkgo have been questioned. A meta-analysis and other studies have not found a significant antiplatelet effect with standardized ginkgo extracts, 80 mg to 480 mg taken daily for up to 32 weeks (17179).

NIFEDIPINE (Procardia) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = B Theoretically, taking ginkgo with oral, but not intravenous, nifedipine might increase levels and adverse effects of nifedipine.  Details Animal research and some clinical evidence suggests that taking ginkgo leaf extract orally in combination with oral nifedipine might increase nifedipine levels and cause increased side effects, such as headaches, dizziness, and hot flushes (87764,87765). However, taking ginkgo orally does not seem to affect the pharmacokinetics of intravenous nifedipine (87765).

OMEPRAZOLE (Prilosec) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = B Theoretically, taking ginkgo with omeprazole might decrease the levels and clinical effects of omeprazole.  Details Clinical research shows that a specific ginkgo leaf extract (Remembrance, Herbs Product LTD) 140 mg twice daily can induce cytochrome P450 (CYP) 2C19 enzymes and decrease levels of omeprazole by about 27% to 42% (13108).

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, taking ginkgo with P-glycoprotein substrates might increase the levels and adverse effects of these substrates.  Details A small clinical study in healthy volunteers shows that using ginkgo leaf extract 120 mg orally three times daily for 14 days can increase levels of the P-glycoprotein substrate, talinolol, by 36% in healthy male individuals. However, single doses of ginkgo do not have the same effect (87830).

RISPERIDONE (Risperdal) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking ginkgo with risperidone might increase the levels and adverse effects of risperidone.  Details A single case of priapism has been reported for a 26-year-old male with schizophrenia who used risperidone 3 mg daily along with ginkgo extract 160 mg daily (87796). Risperidone is metabolized by cytochrome P450 (CYP) 2D6 and CYP3A4. CYP3A4 activity might be affected by ginkgo. Theoretically, ginkgo may inhibit the metabolism of risperidone and increase the risk of adverse effects.

ROSIGLITAZONE (Avandia) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might decrease the levels and clinical effects of rosiglitazone.  Details Animal research shows that ginkgo leaf extract orally 100 or 200 mg/kg daily for 10 days alters the pharmacodynamics of rosiglitazone in a dose-dependent manner. The 100 mg/kg and 200 mg/kg doses reduce the area under the concentration time curve (AUC) of rosiglitazone by 39% and 52%, respectively, and the half-life by 28% and 39%, respectively. It is hypothesized that these changes may be due to induction of cytochrome P450 2C8 by ginkgo (109525).

SEIZURE THRESHOLD LOWERING DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking ginkgo with drugs that lower the seizure threshold might increase the risk for convulsions.  Details Ginkgo seeds contain ginkgotoxin. Large amounts of ginkgotoxin can cause neurotoxicity and seizure. Ginkgotoxin is present in much larger amounts in ginkgo seeds than leaves (8232). Ginkgo leaf extract contains trace amounts of ginkgotoxin. The amount of ginkgotoxin in ginkgo leaf and leaf extract seems unlikely to cause toxicity (11296). However, there are anecdotal reports of seizure occurring after use of ginkgo leaf both in patients without a history of seizure disorder and in those with previously well-controlled epilepsy (7030,7090,14281).

SIMVASTATIN (Zocor) Interaction Rating = Moderate Be cautious with this combination. Severity = Mild •  Occurrence = Probable •  Level of Evidence = B Theoretically, ginkgo might decrease the levels and clinical effects of simvastatin.  Details Clinical research shows that taking ginkgo extract can reduce the area under the curve and maximum concentration of simvastatin by 32% to 39%. However, ginkgo extract does not seem to affect the cholesterol-lowering ability of simvastatin (89704).

SOFOSBUVIR (Sovaldi) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might increase the levels and clinical effects of sofosbuvir.  Details Animal research in rats shows that giving a ginkgo extract 25 mg/kg orally daily for 14 days increases the area under the concentration time curve (AUC) after a single sofosbuvir dose of 40 mg/kg by 11%, increases the half-life by 60%, and increases the plasma concentration at 4 hours by 38%. This interaction appears to be related to the inhibition of intestinal P-glycoprotein by ginkgo (109524).

TACROLIMUS (Prograf) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might increase the blood levels of tacrolimus.  Details In vitro evidence suggests that certain biflavonoids in ginkgo leaves (i.e. amentoflavone, ginkgetin, bilobetin) may inhibit the metabolism of tacrolimus by up to 50%. This interaction appears to be time-dependent and due to inhibition of cytochrome P450 (CYP) 3A4 by these bioflavonoids. In rats given tacrolimus 1 mg/kg orally, amentoflavone was shown to increase the area under the concentration time curve (AUC) of tacrolimus by 3.8-fold (111330).

TALINOLOL Interaction Rating = Major Do not take this combination. Severity = High •  Occurrence = Probable •  Level of Evidence = B Taking ginkgo with talinolol seems to increase blood levels of talinolol.  Details There is some evidence that using ginkgo leaf extract 120 mg orally three times daily for 14 days can increase levels of talinolol by 36% in healthy male individuals. However, single doses of ginkgo do not seem to affect talinolol pharmacokinetics (87830).

TRAZODONE (Desyrel) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, ginkgo might increase the levels and clinical effects of trazodone.  Details In a case report, an Alzheimer patient taking trazodone 20 mg twice daily and ginkgo leaf extract 80 mg twice daily for four doses became comatose. The coma was reversed by administration of flumazenil (Romazicon). Coma might have been induced by excessive GABA-ergic activity. Ginkgo flavonoids are thought to have GABA-ergic activity and act directly on benzodiazepine receptors. Ginkgo might also increase metabolism of trazodone to active GABA-ergic metabolites, possibly by inducing cytochrome P450 3A4 (CYP3A4) metabolism (6423).

WARFARIN (Coumadin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Ginkgo has been shown to increase the risk of bleeding in some people when taken with warfarin.  Details Several pharmacodynamic studies suggest that ginkgo inhibits platelet aggregation. It is thought that the ginkgo constituent, ginkgolide B, displaces platelet-activating factor (PAF) from its binding sites, decreasing blood coagulation (6048,9760). Several case reports have documented serious bleeding events in patients taking ginkgo (244,576,578,579,8581,13002,13135,13179,13194,14456,87868). Information from a medical database suggests that when taken concurrently with warfarin, ginkgo increases the risk of a bleeding adverse event by 38% (91326). There is also some evidence that ginkgo leaf extract can inhibit cytochrome P450 2C9, an enzyme that metabolizes warfarin. This could result in increased warfarin levels (12061). However, population and clinical research has produced mixed results. Clinical research in healthy people suggests that ginkgo has no effect on INR, or the pharmacokinetics or pharmacodynamics of warfarin (12881,15176,87727,87889). A meta-analysis of 18 studies using standardized ginkgo extracts, 80 mg to 480 mg daily for up to 32 weeks, did not find a significant effect on platelet aggregation, fibrinogen concentration, or PT/aPTT (17179). There is also some preliminary clinical research that suggests ginkgo might not significantly increase the effects of warfarin in patients that have a stable INR (11905).

(Read more about GINKGO)

ANTICHOLINERGIC DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might decrease the clinical effects of anticholinergic drugs.  Details In vitro evidence suggests that common sage (Salvia officinalis) and Spanish sage (Salvia lavandulaefolia) can inhibit acetylcholinesterase and might increase acetylcholine levels (31438,39566,72603,72616).

ANTICONVULSANTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might interfere with the clinical effects of anticonvulsant drugs.  Details Some species of sage can cause convulsions when consumed in large quantities (10812).

ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Theoretically, taking sage with antidiabetes drugs might increase the risk of hypoglycemia.  Details In patients with polycystic ovary syndrome (PCOS) or inadequately controlled type 2 diabetes, common sage (Salvia officinalis) has demonstrated hypoglycemic activity (91971,103380). However, other clinical research in patients with inadequately controlled type 2 diabetes shows that common sage extract does not lower fasting blood glucose levels (105340).

ANTIHYPERTENSIVE DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might increase or decrease the effects of antihypertensive drugs.  Details Animal research suggests that common sage (Salvia officinalis) can cause prolonged blood pressure reduction (4152). However, clinical research suggests that Spanish sage (Salvia lavandulaefolia) can increase blood pressure in some people with hypertension (10334). Until more is known, use with caution.

BENZODIAZEPINES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking sage might increase the sedative and adverse effects of benzodiazepines.  Details In vitro evidence suggests that certain components of common sage (Salvia officinalis) can bind to benzodiazepine receptors (72588). This effect has not been reported in humans.

CHOLINERGIC DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might have additive effects when used with cholinergic drugs.  Details In vitro evidence suggests that common sage (Salvia officinalis) and Spanish sage (Salvia lavandulaefolia) can inhibit acetylcholinesterase and might increase acetylcholine levels (31438,39566,72603,72616).

CNS DEPRESSANTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking sage might increase the sedative and adverse effects of CNS depressants.  Details Some constituents of sage have CNS depressant activity (10334).

CYTOCHROME P450 2C19 (CYP2C19) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might increase the levels and clinical effects of drugs metabolized by CYP2C19.  Details In vitro evidence suggests that aqueous extracts of sage can inhibit CYP2C19 (10848). So far, this interaction has not been reported in humans.

CYTOCHROME P450 2C9 (CYP2C9) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might increase the levels and clinical effects of drugs metabolized by CYP2C9.  Details In vitro evidence suggests that aqueous extracts of sage can inhibit CYP2C9 (10848). So far, this interaction has not been reported in humans.

CYTOCHROME P450 2D6 (CYP2D6) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might increase the levels and clinical effects of drugs metabolized by CYP2D6.  Details In vitro evidence suggests that aqueous extracts of sage can inhibit CYP2D6 (10848,19430). So far, this interaction has not been reported in humans.

CYTOCHROME P450 2E1 (CYP2E1) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might decrease the levels and clinical effects of drugs metabolized by CYP2E1.  Details Animal research suggests that drinking common sage (Salvia officinalis) tea increases the expression of CYP2E1 (72627). So far, this interaction has not been reported in humans.

CYTOCHROME P450 3A4 (CYP3A4) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might increase the levels and clinical effects of drugs metabolized by CYP3A4.  Details In vitro evidence suggests that aqueous extracts of sage can inhibit CYP3A4 (10848,72641). So far, this interaction has not been reported in humans.

ESTROGENS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might interfere with hormone therapy.  Details In vitro evidence suggests that geraniol, a constituent of Spanish sage (Salvia lavandulaefolia), exerts estrogenic activity (39572). The clinical significance of this effect is unclear.

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, sage might increase levels of drugs transported by P-glycoprotein.  Details In vitro research suggests that common sage (Salvia officinalis) can inhibit the multi-drug transporter protein, P-glycoprotein (72641). This effect has not been reported in humans.

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General ...Orally, eleuthero root is generally well tolerated when used short-term.
Most Common Adverse Effects:
Orally: Diarrhea, dyspepsia, gastrointestinal upset, headache, nausea, and urticaria.

Cardiovascular ...Orally, increased blood pressure has been reported in children with hypotension taking eleuthero in one clinical study (74980). Eleuthero has been reported to cause tachycardia, hypertension, and pericardial pain in patients with rheumatic heart disease or atherosclerosis. It is unclear if these effects were caused by eleuthero, or by the cardioglycoside-containing herb, silk vine (Periploca sepium), which is a common adulterant found in eleuthero products (12,797,6500).

Dermatologic ...Orally, eleuthero has been reported to cause rash in some clinical studies (75013,75028).

Gastrointestinal ...Orally, eleuthero has been reported to cause dyspepsia, nausea, diarrhea, and gastrointestinal upset in some patients (74938,75028,91510).

Genitourinary ...Orally, mastalgia and uterine bleeding were reported in 7. 3% of females taking eleuthero 2 grams daily in one clinical study (6500,11099). These adverse effects seem to be more likely with higher doses.

Neurologic/CNS ...Orally, headaches have been reported in 9. 8% of people taking eleuthero in one clinical study (11099).
In one case report, a 53-year-old female developed spontaneous subarachnoid hemorrhage associated with the use of an herbal supplement containing red clover, dong quai, and eleuthero (70419). It is unclear if this event was related to the use of eleuthero, the other ingredients, the combination, or another cause entirely.

Psychiatric ...Orally, nervousness has been reported in 7. 3% of people taking eleuthero in one clinical study (11099). Eleuthero has also been reported to cause slight anxiety, irritability, and melancholy in some patients (6500,11099). These adverse effects seem to be more likely to occur with higher doses.

(Read more about ELEUTHERO)

General ...Orally, ginkgo leaf extract is generally well tolerated when used for up to 6 years. However, the seed and crude plant contain toxic constituents and should be avoided.
Intravenously, ginkgo leaf extract seems to be well tolerated when used for up to 30 days.
Topically, no adverse effects have been reported with ginkgo as a single ingredient. However, a thorough evaluation of safety outcomes has not been conducted.
Most Common Adverse Effects:
Orally: Dizziness, gastrointestinal symptoms, headache.
Serious Adverse Effects (Rare):
Orally: Arrhythmia, bleeding, Stevens-Johnson syndrome.

Cardiovascular ...Cardiac arrhythmias suspected to be related to ginkgo have been reported. Internationally, there are at least 162 reports from 18 countries, with 34% of cases considered serious, involving five deaths and four life-threatening events. Additionally, a report from Canada found that 10 out of 15 cases of arrhythmia were considered serious. Ginkgo was the only suspect ingredient in 57% of all international reports, with symptoms generally presenting within days of initiation. The most common symptoms included palpitations, tachycardia, bradycardia, syncope, and loss of consciousness. Most cases were reported to be related to oral use of ginkgo leaf products; however, some cases were associated with oral use of the seed, and others with intravenous or intramuscular use of the leaf. Documented discontinuation of ginkgo led to recovery in approximately 84% of cases where ginkgo was the sole suspect. Despite these findings, ginkgo cannot be confirmed as the causal agent. It is possible that these reports are confounded by underlying co-morbidities. Of the reported cases, the main reason for ginkgo use was tinnitus, a symptom commonly associated with pre-existing arrhythmias (105253,105254). Despite this large number of reports, only three cases of cardiac arrhythmia have been published in the literature (105253,105254). In one case, frequent nocturnal episodes of paroxysmal atrial fibrillation were reported for a 35-year-old female taking ginkgo extract 240 mg daily orally for 2 months. Arrythmias ceased following discontinuation of ginkgo (87884).
In one clinical trial, the rate of ischemic stroke and transient ischemic attacks was significantly higher in patients taking ginkgo extract orally when compared with placebo (16635). It is unclear if these events were due to ginkgo, other factors, or a combination.

Dermatologic ...Topically, ginkgo fruit pulp can cause contact dermatitis, with intense itching, edema, papules, and pustules which take 7-10 days to resolve after stopping contact (112946).

Gastrointestinal ...Orally, ginkgo extract may cause mild gastrointestinal discomfort or pain (3965,8543,17112,87818,87858), nausea and vomiting (8543,17112,87728,87844,87858), diarrhea (87844), dry mouth (17112), and constipation (5719,87787). However, post-market surveillance suggests that the incidence of these events is relatively low, occurring in less than 2% of patients (88007).
Fresh ginkgo seeds can cause stomach ache, nausea, vomiting, or diarrhea. Ingesting roasted seeds in amounts larger than the normal food amounts of 8-10 seeds per day, or long-term, can also cause these same adverse reactions (8231,8232).

Genitourinary ...Orally, ginkgo extract has been reported to cause blood in the urine in one patient (87858).

Hematologic ...Spontaneous bleeding is one of the most concerning potential side effects associated with ginkgo. There are several published case reports linking ginkgo to episodes of minor to severe bleeding; however, not all case reports clearly establish ginkgo as the cause of bleeding. In most cases, other bleeding risk factors were also present including taking other medications or natural medicines, old age, liver cirrhosis, recent surgery, and other conditions. In most cases, bleeding occurred after several weeks or months of taking ginkgo (13135). Large-scale clinical trials and a meta-analysis evaluating standardized ginkgo leaf extracts show that the incidence of bleeding in patients taking ginkgo is not significantly higher than in those taking placebo (16634,16635,17179,17402).
There are several case reports of intracerebral bleeding. Some of these cases resulted in permanent neurological damage and one case resulted in death (244,578,8581,13135,13179,14456,87868,87977).
There are at least 4 cases of ocular bleeding including spontaneous hyphema (bleeding from the iris into the anterior part of the eye) and retrobulbar hemorrhage associated with ginkgo use (579,10450,13135).
There are also cases of surgical and post-surgical complications in patients using ginkgo. Retrobulbar hemorrhage (bleeding behind the eye) during cataract surgery has been associated with ginkgo use (10450). Excessive postoperative bleeding requiring transfusion has also occurred following laparoscopic surgery in a patient who had been taking ginkgo leaf extract (887). There have also been two cases of excessive bleeding during surgery and post-surgical hematoma in patients undergoing rhytidoplasty and blepharoplasty (13002). In another case, an elderly patient taking ginkgo experienced excessive postoperative bleeding following total hip arthroplasty (13194). In another case, use of ginkgo following liver transplantation surgery was associated with subphrenic hematoma requiring evacuation by laparotomy. The patient also subsequently experienced vitreous hemorrhage (14315). In another case, an elderly patient who had taken ginkgo chronically experienced excessive post-operative bleeding following an ambulatory surgical procedure (14453).
In another case, an elderly man experienced nose bleeds and ecchymosis following use of ginkgo. One case of diffuse alveolar hemorrhage in a female taking ginkgo and ginseng for over one year has been reported (95670). These instances of bleeding stopped when ginkgo was discontinued, and recurred when the patient started taking ginkgo again (13135).
Persistent bleeding has also occurred following dental surgery (87862) and laparoscopic cholecystectomy (88000). Nosebleed has also been reported as an adverse effect in a clinical trial (87813).

Immunologic ...Orally, ginkgo leaf extract can cause allergic skin reactions in some patients (14449,15578,112946). In one case, a patient developed acute generalized exanthematous pustulosis 48 hours after taking a single-ingredient ginkgo product. The rash resolved within 10 days after discontinuing ginkgo (14449). In another case, progressive erythema of the face, neck, trunk, and extremities occurred after two 60 mg oral doses of ginkgo extract (112946). There is also a case of Stevens-Johnson syndrome following a second administration of a preparation containing ginkgo leaf extract, choline, vitamin B6, and vitamin B12 (208). In another case, systemic edema and severe arthralgia was reported after contact with a ginkgo tree nut and manifested as multifocal lymphadenopathy associated with an allergic reaction on PET/CT scan imaging (95672).

Musculoskeletal ...Edema has been reported for three patients treated with ginkgo extract 40 mg orally three times daily (87818).

Neurologic/CNS ...Orally, ginkgo extract may cause headache (6220,8543,87818), dizziness (5719,87818), increased desire to sleep (87839), and sedation (10893) in some patients. In addition, although ginkgo leaf and ginkgo leaf extract contain only small amounts of ginkgotoxin, there are anecdotal reports of seizure occurring after use of ginkgo leaf preparations both in patients without a history of seizure disorder and in those with previously well-controlled epilepsy (7030,7090,11296,14281).

Ocular/Otic ...Orally, ginkgo extract may cause tinnitus is some patients, although the incidence is rare (8543).
Topically, eye drops containing ginkgo extract and hyaluronic acid may cause stinging sensations in some people (87829).

Psychiatric ...Orally, ginkgo has been associated with a single case of mood dysregulation. A 50-year-old female with schizophrenia developed irritability, difficulty controlling anger, and agitation after one week of taking ginkgo 80 mg twice daily. The mood changes resolved within 2-3 days of discontinuation. When ginkgo was re-trialed at a later date, the same symptoms reappeared, and again dissipated after discontinuation of the ginkgo product. The relationship between ginkgo and mood dysregulation was considered to be "probable" based on the Naranjo adverse drug reaction probability scale (96763); however, the exact mechanism by which ginkgo may have affected mood regulation is unknown.

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General ...Orally, topically, and when inhaled, sage seems to be well tolerated.
Most Common Adverse Effects:
Orally: Abdominal pain, agitation, diarrhea, dizziness, nausea, and vomiting.
Topically: Burning, dermatitis, pain.
Serious Adverse Effects (Rare):
Orally: Generalized tonic-clonic seizures associated with the thujone, camphor, and/or cineol constituents.

Cardiovascular ...By inhalation, sage essential oil has been reported to increase the blood pressure of hypertensive patients (10334).

Dermatologic ...Orally, sage extract has been reported to cause acneiform skin eruptions in one patient in a clinical trial (91970).
Topically, sage leaves can cause contact dermatitis (46902,72661,72710). Sage extract can cause burning and pain (10437).

Gastrointestinal ...Orally, sage can cause nausea, vomiting, abdominal pain, and diarrhea (10810,17177).
Topically, sage extract sprayed into the mouth and throat can cause dryness or mild burning of the throat (72619).

Neurologic/CNS ...Orally, sage can cause dizziness or agitation (10810,17177). Thujone, a constituent of common sage (Salvia officinalis), is a neurotoxin and can cause seizures (10812,12868). Camphor and cineol, constituents of common sage and Spanish sage, can also cause neurotoxicity and seizures in high doses (10334,12868). Generalized tonic-clonic seizures have been reported in adults, children, and infants after ingestion of sage oil (12868,72666).

Pulmonary/Respiratory ...Orally, sage can cause wheezing (10810,17177).
Occupational exposure to sage dust can cause reduction in ventilatory capacity and chronic respiratory impairment (72672,72682,72686).

(Read more about SAGE)