Vadik Herbs Sitopladi Churna by Bazaar of India

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Dental caries. It is unclear if brushing the teeth with toothpaste containing bamboo salt can prevent dental carries. Details: A small clinical trial in dental students with good oral hygiene and a lack of dental carries shows that brushing with a specific toothpaste containing bamboo salt (Tiger Herb, LG) twice daily for 4 weeks reduces salivary counts of Streptococcus mutans and Lactobacillus when compared to baseline. These reductions were similar to those reported in students using a conventional toothpaste (Crest Complete) (109458). It is unclear whether this toothpaste is effective for preventing dental carries. More evidence is needed to rate bamboo for this use.

(Read more about BAMBOO)

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Diabetes. Small clinical studies suggest that oral cardamom may slightly reduce glycated hemoglobin (HbA1c) in patients with type 2 diabetes, but it does not appear to improve blood glucose, blood pressure, or cholesterol levels in these patients. Details: A small clinical study in overweight or obese adults with type 2 diabetes who are taking antidiabetes medication shows that taking cardamom 1 gram three times daily for 10 weeks reduces HbA1c by 0.4% and improves insulin and triglyceride levels when compared with a rusk powder placebo (101887). However, other small clinical studies show that taking cardamom 1 gram three times daily does not reduce fasting blood glucose, blood pressure, or total cholesterol levels, or improve anthropometric measures in patients with type 2 diabetes (95597,99436,101887).
• Dyspepsia. Although there has been interest in using oral cardamom for dyspepsia, there is insufficient reliable information about the clinical effects of cardamom for this purpose.
• Epilepsy. Although there has been interest in using oral cardamom essential oil for epilepsy, there is insufficient reliable information about the clinical effects of cardamom for this purpose.
• Hyperlipidemia. Small clinical studies suggest that oral cardamom may modestly reduce triglyceride levels in patients with hyperlipidemia, but it does not seem to improve other lipid levels in these patients. Details: A meta-analysis of mostly small randomized controlled trials shows that taking cardamom 3 grams daily for 8-12 weeks does not improve total, low-density lipoprotein (LDL), or high-density lipoprotein (HDL) cholesterol levels. However, it might modestly reduce triglyceride levels when compared with placebo (101886).
• Hypertension. It is unclear if oral cardamom powder is beneficial in patients with hypertension. Details: A small clinical study in adults with newly-diagnosed, untreated, stage 1 essential hypertension shows that taking cardamom powder 1.5 grams orally twice daily for 12 weeks reduces systolic blood pressure by about 19 mmHg and diastolic blood pressure by about 12 mmHg when compared to baseline (95308). The validity of these findings is limited by the lack of a comparator group.
• Irritable bowel syndrome (IBS). Although there has been interest in using oral cardamom for IBS, there is insufficient reliable information about the clinical effects of cardamom for this purpose.
• Nausea and vomiting. Although there has been interest in using oral cardamom for nausea and vomiting, there is insufficient reliable information about the clinical effects of cardamom for this purpose.
• Nonalcoholic fatty liver disease (NAFLD). It is unclear if oral cardamom is beneficial in patients with NAFLD. Details: A small clinical study in overweight or obese patients with NAFLD shows that taking cardamom 1000 mg three times daily for 3 months improves some measures of cardiovascular and hepatic health when compared with placebo. Fatty liver grade, as measured by sonography, improved in 42% of patients taking cardamom, compared with 4.5% of those taking placebo. High-density lipoprotein (HDL) cholesterol levels, triglyceride levels, and insulin resistance also improved by a moderate amount. However, taking cardamom did not affect fasting blood glucose, body mass index (BMI), or low-density lipoprotein (LDL) cholesterol levels (101885).
• Obesity. It is unclear if oral cardamom is beneficial in patients with diabetes. Details: A small clinical study in overweight adults with diabetes shows that drinking black tea steeped with 3 grams of cardamom powder in three divided doses daily for 8 weeks does not affect weight, waist circumference, or blood pressure when compared with baseline or black tea only (95597).
• Polycystic ovary syndrome (PCOS). It is unclear if oral cardamom powder is beneficial in patients with PCOS. Details:A small clinical study in patients with PCOS shows that taking cardamom powder 1 gram three times daily for 16 weeks while following a low-calorie diet improves cyst size and number, reduces levels of testosterone and luteinizing hormone, increases levels of follicle stimulating hormone, and reduces levels of several inflammatory markers when compared with placebo plus a low-calorie diet (107920).
• Postoperative nausea and vomiting (PONV). Aromatherapy with cardamom essential oil has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: One small clinical study shows that applying a mixture of essential oils from ginger, cardamom, and tarragon topically to the neck at the first sign of PONV can inhibit nausea and/or vomiting for 30 minutes in 50% to 88% of postoperative patients. The treatment effect appears to vary depending on the number of emetic drugs given during anesthesia or postoperatively, and whether the drugs were given during or after the operation (77054). Another small study shows that aromatherapy with a mixture of ginger, spearmint, peppermint, and cardamom, as 3 inhalations from a gauze pad, reduces nausea scores by 43% when compared with placebo. When compared with ginger aromatherapy alone, nausea scores were reduced by 15%. Using the combination aromatherapy also reduced the need for anti-nausea medications by 40% when compared with placebo and by 15% when compared with ginger aromatherapy (95307). It is unclear if these benefits are due to cardamom, other ingredients, or the combination.
• Pregnancy-induced nausea and vomiting. Although there has been interest in using oral cardamom for pregnancy-induced nausea and vomiting, there is insufficient reliable information about the clinical effects of cardamom for this purpose.
• Respiratory tract infections. Although there has been interest in using oral cardamom for various respiratory tract infections, including bronchitis, influenza, and the common cold, there is insufficient reliable information about the clinical effects of cardamom for these conditions. More evidence is needed to rate cardamom for these uses.

(Read more about CARDAMOM)

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Asthma. Although there has been interest in using oral Indian long pepper for asthma, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Bronchitis. Although there has been interest in using oral Indian long pepper for bronchitis, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Cancer. Although there has been interest in using oral Indian long pepper for cancer, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Cardiovascular disease (CVD). Although there has been interest in using oral Indian long pepper for CVD, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Cognitive function. Although there has been interest in using oral Indian long pepper for cognitive function, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Common cold. Although there has been interest in using oral Indian long pepper for the common cold, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Cough. Although there has been interest in using oral Indian long pepper for cough, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Depression. Although there has been interest in using oral Indian long pepper for depression, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Dyspepsia. Although there has been interest in using oral Indian long pepper for dyspepsia, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Epilepsy. Although there has been interest in using oral Indian long pepper for epilepsy, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Gastroesophageal reflux disease (GERD). Although there has been interest in using oral Indian long pepper for GERD, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Hypothyroidism. It is unclear if oral Indian long pepper is beneficial in patients with hypothyroidism. Details: A small, uncontrolled clinical study in adults with subclinical or overt hypothyroidism shows that taking Indian long pepper powder 0.69 grams daily for 19 days or following a dose escalating and deescalating regimen for 19 days improves some symptoms of hypothyroidism, as measured by Zulewski scores, but has little to no effect on thyroid hormone levels when compared to baseline. The dose escalating and deescalating regimen included 0.69 grams of Indian long pepper powder on day 1 which was titrated up to 6.9 grams by day 10 and then deescalated down to 0.69 grams by day 19 (111111). The validity of these findings is limited by the lack of a placebo control group.
• Liver disease. Although there has been interest in using oral Indian long pepper for liver disease, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Muscle soreness. Although there has been interest in using oral Indian long pepper for muscle soreness, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Osteoarthritis. Although there has been interest in using oral Indian long pepper for osteoarthritis, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Psoriasis. Although there has been interest in using oral Indian long pepper for psoriasis, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Rheumatoid arthritis (RA). Although there has been interest in using oral Indian long pepper for RA, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Stress. Although there has been interest in using oral Indian long pepper for stress, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose.
• Tuberculosis. Although there has been interest in using oral Indian long pepper for tuberculosis, there is insufficient reliable information about the clinical effects of Indian long pepper for this purpose. More evidence is needed to rate Indian long pepper for these uses.

(Read more about INDIAN LONG PEPPER)

POSSIBLY EFFECTIVE

• Anxiety. Oral kava seems to improve anxiety when taken for at least 5 weeks. Details: Most clinical research shows that kava extracts 150-400 mg, standardized to 70% kavalactones, daily are superior to placebo for relieving symptoms of non-psychotic anxiety (2094,2095,11372,18315,18316,18317,18320,98980), and are possibly comparable to buspirone 10 mg or low-dose benzodiazepines such as oxazepam 30 mg (18314). However, kava may not be effective for improving subthreshold anxiety. A meta-analysis of 3 small clinical studies in patients with subthreshold anxiety shows that taking kava does not improve anxiety symptoms when compared with placebo (110711). Overall, kava's effects appear to be dose-dependent and duration-dependent. One meta-analysis suggests that taking more than 200 mg kavalactones daily tends to be more beneficial for anxiety than taking less than 200 mg kavalactones daily (98980). Some clinical research also suggests that kava extract must be taken for at least 5 weeks to provide a benefit (2094,15046,18314,98980), while single-dose treatments may not be beneficial for acute anxiety (18319). Most studies have used a specific standardized extract (WS 1490, Dr. Willmar Schwabe Pharmaceuticals) 150-300 mg daily. Another specific kava extract (LI 150, Lichtwer Pharma) 400 mg daily has also been used (18314,98980). Clinical practice guidelines from a joint taskforce of the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) conclude that there is evidence supporting the use of kava for acute or short-term management of general anxiety symptoms but that only products standardized to a sufficient level of kavalactones should be recommended (110318).

POSSIBLY INEFFECTIVE

• Generalized anxiety disorder (GAD). Oral kava doesn't seem to be effective for treating GAD. Details: A meta-analysis of 3 small, low-quality clinical studies in adults with GAD shows that kava extract standardized to 70% kavalactones, providing 140-280 mg kavalactones daily, is no more effective than placebo when used for 4-8 weeks (15130). Additionally, a more recent meta-analysis of 3 moderate-sized clinical trials in patients diagnosed with GAD shows that taking kava does not reduce anxiety when compared with placebo or conventional therapy (110711). While a small clinical trial in adults with GAD shows that taking kava rootstock extract, standardized to provide 120-240 mg of kavalactones daily, for 6 weeks reduces clinician rated anxiety scores when compared with placebo (29663), a large, multi-center clinical trial from the same research group shows that taking kava root extract standardized to 120 mg of kavalactones twice daily for 16 weeks does not reduce anxiety scores when compared with placebo in adults diagnosed with GAD (102086). Clinical practice guidelines from a joint taskforce of the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) recommends against the use of kava rootstock extracts (standardized to 60-250 mg kavalactones) as either monotherapy or adjunctive therapy in patients with GAD (110318). This recommendation against kava for GAD is based on high quality evidence from a meta-analysis and two additional clinical trials, along with a meta-review of two meta-analyses on the use of kava for GAD (110318,112133).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Benzodiazepine withdrawal. It is unclear if oral kava is beneficial for reducing benzodiazepine withdrawal symptoms. Details: One small clinical study in patients with non-psychotic anxiety shows that titrating a specific kava extract (WS1490, Dr. Willmar Schwabe Pharmaceuticals) up to 300 mg daily over one week while tapering the benzodiazepine over 2 weeks is no more effective than placebo for decreasing benzodiazepine withdrawal symptoms (7325).
• Cancer. It is unclear if oral kava is beneficial in patients with cancer. Details: Epidemiological evidence has found that increasing kava consumption is associated with a lower incidence of cancer (8175).
• Epilepsy. Although there is interest in using oral kava for epilepsy, there is insufficient reliable information about the clinical effects of kava for this condition.
• Insomnia. It is unclear if oral kava is beneficial in patients with insomnia. Details: One small clinical study shows that taking a specific kava extract (WS1490, Dr. Willmar Schwabe Pharmaceuticals) 200 mg standardized to 70% kavalactones daily for 4 weeks reduces sleep disturbances associated with non-psychotic anxiety disorders (18321). However, another internet-based clinical trial in patients with self-reported insomnia associated with anxiety suggests that taking kava in a dose equivalent to 100 mg kavalactones three times daily for 4 weeks does not improve sleep when compared with placebo (15046).
• Menopausal symptoms. It is unclear if oral kava is beneficial for menopausal symptoms. Details: One small clinical study shows that taking kava 100-200 mg standardized to contain 55% kavaina daily for 3 months reduces depression, anxiety, and hot flashes when compared to baseline in perimenopausal patients. However, the changes in depression and hot flashes were not better when compared with the control group that took calcium (18318).
• Myalgia. Although there is interest in using oral kava for myalgia, there is insufficient reliable information about the clinical effects of kava for this condition.
• Premenstrual syndrome (PMS). Although there is interest in using oral kava for PMS, there is insufficient reliable information about the clinical effects of kava for this condition.
• Sexual arousal. Although there is interest in using oral kava for sexual arousal, there is insufficient reliable information about the clinical effects of kava for this condition.
• Stress. It is unclear if oral kava reduces reactivity to experimental stress. Details: A small study in healthy volunteers shows that taking a single dose of kava (LI 150, Lichtwer Pharma) 120 mg orally might reduce the physiological changes associated with mentally stressful tasks when compared to baseline (9893). More evidence is needed to rate kava for these uses.

(Read more about KAVA)

LIKELY SAFE ...when properly prepared bamboo shoots are used orally in food amounts (96875).

POSSIBLY SAFE ...when bamboo salt-containing toothpaste is used topically during brushing twice daily for up to 4 weeks (109458). There is insufficient reliable information available about the safety of bamboo when taken by mouth in the amounts found in medicine or when used topically on areas of the body beyond the teeth and gums.

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

(Read more about BAMBOO)

LIKELY SAFE ...when used orally in amounts commonly found in foods. Cardamom has Generally Recognized as Safe (GRAS) status in the US (4912).

POSSIBLY SAFE ...when used orally in medicinal amounts, short-term. Cardamom powder 3 grams daily in 2-3 divided doses has been used with apparent safety for up to 16 weeks (95308,95597,101885,107920). ...when the essential oil is used by inhalation for aromatherapy (77054,95307).

PREGNANCY: LIKELY SAFE
when used orally in amounts commonly found in foods.

PREGNANCY: POSSIBLY UNSAFE
when used orally in medicinal amounts. Cardamom is thought to have abortifacient and emmenagogue effects (19,39884). Avoid using amounts greater than those used in food.

LACTATION: LIKELY SAFE
when used orally in amounts commonly found in foods. There is insufficient reliable information available about the safety of cardamom when used in medicinal amounts. Avoid using amounts greater than those used in food.

(Read more about CARDAMOM)

LIKELY SAFE ...when used orally in food amounts. The fruit is commonly used in foods (101151). There is insufficient reliable information available about the safety of Indian long pepper when used in medicinal amounts.

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

(Read more about INDIAN LONG PEPPER)

POSSIBLY SAFE ...when used orally, short-term. Kava extracts have been used safely in clinical trials under medical supervision for up to 6 months (2093,2094,2095,4032,7325,15046,15130,18314,18316,18318)(18320,29663,29671,98980,102086,112642). Historically, there has been some concern that kava preparations could induce hepatotoxicity and liver failure in patients taking relatively normal doses, short-term. At least 100 cases of liver toxicity following kava use have been reported. Although liver toxicity is more frequently associated with prolonged use of very high doses (6401,57346), in some cases the use of kava for as little as 1-3 months has been associated with the need for liver transplants, and even death (390,7024,7068,7086,7096,17086,57252)(57254,57297). However, some experts question the clinical validity of several of these cases (11369,11371).

PREGNANCY: POSSIBLY UNSAFE
when used orally. There is some concern that pyrone constituents in kava can cause loss of uterine tone (19); avoid using.

LACTATION: POSSIBLY UNSAFE
when used orally. There is concern that the toxic pyrone constituents of kava can pass into breast milk (19); avoid using.

(Read more about KAVA)

ANTITHYROID DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, long-term bamboo use might increase the effects and adverse effects of antithyroid drugs, possibly leading to hypothyroidism.  Details Animal research suggests that long-term consumption of bamboo shoot can decrease thyroid peroxidase activity, as well as levels of thyroxine (T4) and triiodothyronine (T3) (33538). This effect has not yet been reported in humans.

(Read more about BAMBOO)

(Read more about CARDAMOM)

AMOXICILLIN (Amoxil, Trimox) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the effects and adverse effects of amoxicillin.  Details Evidence from animal research shows that piperine, a constituent of Indian long pepper, increases the plasma levels of amoxicillin when taken concomitantly (29269).

ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the risk of bleeding when taken with anticoagulant/antiplatelet drugs.  Details In vitro research shows that Indian long pepper extract inhibits platelet aggregation (101151).

ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the risk of hypoglycemia when taken with antidiabetes drugs.  Details Animal research shows that piperine, a constituent of Indian long pepper, can reduce blood glucose levels (29225). Monitor blood glucose levels closely. Dose adjustments might be necessary.

CARBAMAZEPINE (Tegretol) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = B Theoretically, Indian long pepper might increase blood levels of carbamazepine.  Details A small pharmacokinetic study in patients taking carbamazepine 300 mg or 500 mg twice daily shows that a single 20 mg dose of purified piperine, which is a constituent of Indian long pepper, increases carbamazepine levels. Piperine may increase absorption by increasing blood flow to the GI tract, increasing the surface area of the small intestine, or by cytochrome P450 3A4 (CYP3A4) inhibition in the gut wall. Absorption was significantly increased by 7-10 mcg/mL/hour. The time to eliminate carbamazepine was also increased by 4-8 hours. Although carbamazepine levels were increased, this did not appear to increase side effects (16833).

CEFOTAXIME (Claforan) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the effects and adverse effects of cefotaxime.  Details Animal research shows that piperine, a constituent of Indian long pepper, increases the plasma levels of cefotaxime when taken concomitantly (29269).

CYCLOSPORINE (Neoral, Sandimmune) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the effects and adverse effects of cyclosporine.  Details In vitro research shows that piperine, a constituent of Indian long pepper, increases the bioavailability of cyclosporine (29282).

CYTOCHROME P450 1A1 (CYP1A1) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the effects and adverse effects of CYP1A1 substrates.  Details In vitro research shows that piperine, a constituent of Indian long pepper, inhibits CYP1A1 (29213).

CYTOCHROME P450 2B1 (CYP2B1) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the effects and adverse effects of CYP2B1 substrates.  Details In vitro research shows that piperine, a constituent of Indian long pepper, inhibits CYP2B1 (29332).

CYTOCHROME P450 3A4 (CYP3A4) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the effects and adverse effects of CYP3A4 substrates.  Details In vitro research shows that piperine, a constituent of Indian long pepper, inhibits CYP3A4 (14375).

NEVIRAPINE (Viramune) Interaction Rating = Moderate Be cautious with this combination. Severity = Mild •  Occurrence = Probable •  Level of Evidence = B Theoretically, Indian long pepper might increase blood levels of nevirapine.  Details A small pharmacokinetic study shows that piperine, a constituent of Indian long pepper, increases the plasma concentration and systemic exposure of nevirapine. However, no adverse effects were associated with the elevated plasma levels of nevirapine (29209).

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase levels of P-glycoprotein substrates.  Details In vitro research shows that piperine, a constituent of Indian long pepper, can inhibit P-glycoprotein (14375,29281).

PENTOBARBITAL (Nembutal) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase the sedative effects of pentobarbital.  Details Animal research shows that piperine, a constituent of Indian long pepper, can increase pentobarbitone-induced sleeping time (29214).

PHENYTOIN (Dilantin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, Indian long pepper might increase blood levels of phenytoin.  Details A small pharmacokinetic study shows that piperine, a constituent of Indian long pepper, increases phenytoin serum levels and slows its elimination (537).

PROPRANOLOL (Inderal) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, Indian long pepper might increase blood levels of propranolol.  Details A small pharmacokinetic study shows that piperine, a constituent of Indian long pepper, accelerates absorption and increases serum concentrations of propranolol (538).

RIFAMPIN (Rifadin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, Indian long pepper might increase blood levels of rifampin.  Details Piperine, a constituent of Indian long pepper, seems to increase absorption and serum levels of rifampin (14375,29284).

THEOPHYLLINE Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Indian long pepper might increase blood levels of theophylline.  Details A small pharmacokinetic study shows that piperine, a constituent of Indian long pepper, increases serum concentrations and slows elimination of theophylline (538).

(Read more about INDIAN LONG PEPPER)

ALCOHOL (ETHANOL) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = A Combining kava with alcohol may increase the risk of sedation and/or hepatotoxicity.  Details Kava has CNS depressant effects (11373,18316). Concomitant use of kava with other CNS depressants can increase the risk of drowsiness and motor reflex depression (2093,2098). Additionally, kava has been associated with over 100 cases of hepatotoxicity. There is some concern that kava can adversely affect the liver, especially when used in combination with hepatotoxic drugs (7024,7068,7086,7096,17086,57346). Clinical practice guidelines from a joint taskforce of the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) recommend that alcohol not be used with kava (110318).

CNS DEPRESSANTS Interaction Rating = Major Do not take this combination. Severity = High •  Occurrence = Probable •  Level of Evidence = A Combining kava with CNS depressants can have additive sedative effects.  Details Kava has CNS depressant effects (11373,18316). Concomitant use of kava with other CNS depressants can increase the risk of drowsiness and motor reflex depression (2093,2098). Clinical practice guidelines from a joint taskforce of the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) recommend that CNS depressants, including alcohol and benzodiazepines, not be used with kava (110318).

CYTOCHROME P450 1A2 (CYP1A2) SUBSTRATES Interaction Rating = Minor Be watchful with this combination. Severity = Moderate •  Occurrence = Unlikely •  Level of Evidence = B It is unclear if kava inhibits CYP1A2; research is conflicting.  Details Although in vitro research and a case report suggest that kava inhibits CYP1A2 (8743,12479,88593), more robust clinical evidence shows that kava has no effect on CYP1A2. In a clinical study in healthy volunteers, taking kava 1000 mg twice daily (containing a daily dose of 138 mg kavalactones) for 28 days had no effect on CYP1A2 activity (13536,98979).

CYTOCHROME P450 2C19 (CYP2C19) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, kava might increase levels of CYP2C19 substrates.  Details In vitro research shows that kava significantly inhibits CYP2C19 enzymes (8743,12479). This effect has not yet 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, kava might increase levels of CYP2C9 substrates.  Details In vitro research shows that kava significantly inhibits CYP2C9 enzymes (8743,12479). This effect has not yet 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 It is unclear if kava inhibits CYP1A2; research is conflicting.  Details In vitro research shows that kava extract significantly inhibits CYP2D6 (8743,12479). However, clinical research shows that kava does not affect the metabolism of CYP2D6 substrates in humans (13536,16848,98979).

CYTOCHROME P450 2E1 (CYP2E1) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Kava might increase levels of CYP2E1 substrates.  Details In a clinical study in healthy volunteers, taking kava 1000 mg twice daily (containing a daily dose of 138 mg kavalactones) for 28 days inhibited the metabolism of CYP2E1 substrates (13536).

CYTOCHROME P450 3A4 (CYP3A4) SUBSTRATES Interaction Rating = Minor Be watchful with this combination. Severity = Moderate •  Occurrence = Unlikely •  Level of Evidence = B It is unclear if kava inhibits CYP3AA; research is conflicting.  Details Although in vitro research suggests that kava inhibits CYP3A4 (8743,12479), more robust clinical evidence shows that kava has no effect on CYP3A4. In a clinical study in healthy volunteers, taking kava 1000 mg twice daily (containing a daily dose of 138 mg kavalactones) for 28 days had no effect on CYP3A4 activity (13536,98979).

HALOPERIDOL (Haldol) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Combining kava and haloperidol might increase the risk of cardiovascular adverse effects and hypoxia.  Details Atrial flutter and hypoxia has been reported for a patient who received intramuscular injections of haloperidol and lorazepam after using kava orally. The side effects were attributed to kava-induced inhibition of CYP2D6, but might also have been related to additive adverse effects with the concomitant use of haloperidol, lorazepam, and kava (88593).

HEPATOTOXIC DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, using kava with hepatotoxic drugs might increase the risk of liver damage.  Details Kava has been linked with over 100 cases of hepatotoxicity. Most cases occur with excessive and prolonged use. There is some concern that kava can adversely affect the liver, especially when used in combination with hepatotoxic drugs (7024,7068,7086,7096,17086,57346).

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D It is unclear if kava inhibits P-glycoprotein (P-gp); research is conflicting.  Details In vitro research shows that kava can inhibit P-gp efflux (15131). However, a clinical study in healthy volunteers shows that taking kava standardized to provide 225 mg kavalactones daily for 14 days does not affect the pharmacokinetics of digoxin, a P-gp substrate (15132,98979). It is possible that the use of other P-gp substrates or higher doses of kava might still inhibit P-gp.

ROPINIROLE (Requip) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Taking kava with ropinirole might increase the risk for dopaminergic toxicity.  Details A case of visual hallucinations and paranoid delusions has been reported for a patient who used kava in combination with ropinirole. The adverse effects were attributed to kava-induced inhibition of CYP1A2, which may have reduced the metabolism of ropinirole, resulting in excessive dopaminergic stimulation (88593).

(Read more about KAVA)

General ...There is currently a limited amount of information on the adverse effects of bamboo.

Dermatologic ...Topically, bamboo shoots have been reported to cause contact dermatitis in a 44-year-old female (33540).

Gastrointestinal ...In one case report, melanosis coli, pigmentation of the colon wall, was reported following the ingestion of bamboo leaf extract (33547).

Other ...Bamboo shoots are a source of cyanide glycosides. However, the hydrogen cyanide produced by the plant is eliminated during boiling, fermentation, or superheated steam drying of the shoots (96875). During the rescue of a male who jumped into a well which was used for bamboo shoot pickling, cyanide poisoning occurred in 8 individuals. The poisoning caused high anion gap metabolic acidosis in all patients and resulted in two deaths due to cardiac arrest. Some patients also had pulmonary edema and/or infiltration (96874).

(Read more about BAMBOO)

General ...Orally, cardamom seems to be well tolerated.

Dermatologic ...Orally, mild skin inflammation due to cardamom has been reported in one participant of a clinical trial (101887). Topically, a case report describes chronic hand dermatitis in a confectioner frequently exposed to cardamom. Skin patch tests were positive for cardamom, and for terpenoids present in the seeds (39875).

Genitourinary ...Orally, dysuria due to cardamom has been reported in one participant of a clinical trial (101887). Also, a case report describes a 5-year-old female who developed hematuria after eating ice cream flavored with cardamom. It resolved spontaneously and there was no re-challenge (95306). It is not clear if cardamom is the direct cause of hematuria in this case.

(Read more about CARDAMOM)

General ...Orally, Indian long pepper is well tolerated when used in food (101151). No adverse effects have been reported when Indian long pepper is used as medicine. However, a thorough evaluation of safety outcomes has not been conducted.

(Read more about INDIAN LONG PEPPER)

General ...Orally, kava seems to be well tolerated.
Most Common Adverse Effects:
Orally: Drowsiness, dry mouth, dizziness, gastrointestinal upset, headache, memory problems, tremor.
Serious Adverse Effects (Rare):
Orally: There have been over 100 reported cases of hepatotoxicity and a few reported cases of rhabdomyolysis.

Cardiovascular ...Long-term use of very large amounts of kava, especially in high doses (400 mg kava pyrones daily), has been associated with overall poor health including symptoms of low body weight, reduced protein levels, puffy face, hematuria, increased red blood cell volume, decreased platelets and lymphocytes, and possibly pulmonary hypertension (4032,6402). Tachycardia and electrocardiogram (ECG) abnormalities (tall P waves) have been reported in heavy kava users (6402).

Dermatologic ...Orally, kava can cause allergic skin reactions, including sebotropic eruptions, delayed-type hypersensitivity, or urticarial eruption (4032,11370,28489,57277,57325,57343,114683). In one case of kava-associated urticarial eruption, biopsy revealed neutrophilic sebaceous glands with lymphocytic infiltrate (114683). Chronic use of high doses of kava has also been associated with kava dermopathy, which consists of reddened eyes; dry, scaly, flaky skin; and temporary yellow discoloration of the skin, hair, and nails (6240,6401,8414,8417,11370,28485,57342). This pellagra-like syndrome is unresponsive to niacinamide treatment (6240,7728,11370). The cause is unknown, but may relate to interference with cholesterol metabolism (6240). Kava's adverse effects on liver function might also contribute to kava dermopathy (6401,8417). Kava dermopathy usually occurs within three months to one year of regular kava use, and resolves when the kava dose is decreased or discontinued (6401,8414). Kava dose should be decreased or discontinued if kava dermopathy occurs (6401). In addition to kava cessation, oral or topical corticosteroids have been described as treatment options in some cases of kava associated dermatitis (114683).

Gastrointestinal ...Orally, kava may cause gastrointestinal upset, nausea, or dry mouth (2093,2094,4032,11370,18316,57228,57343).

Hematologic ...Orally, chronic use of very high doses of kava has been associated with increased red blood cell volume, reduced platelet volume, reduced lymphocyte counts, and reduced serum albumin (6402,57258). Hematuria has also been reported anecdotally (6402).

Hepatic ...Since the early 2000's, hepatotoxicity has been a particular concern with kava. Worldwide, there have been at least 100 reported cases of hepatotoxicity following use of kava products (7024,7068,7086,7096,11795,17086)(57252,57254,57297). However, some experts question the clinical validity of several of these cases (11369,11371). Some cases were reported multiple times and in some cases it was unlikely that kava was the causative agent (7068,57253).
In susceptible patients, symptoms can show up after as little as 3-4 weeks of kava use. Symptoms include yellowed skin (jaundice), fatigue, and dark urine (7024,7068). Liver function tests can be elevated after 3-8 weeks of use, possibly followed by hepatomegaly and onset of encephalopathy (7024). Kava has also been reported to exacerbate hepatitis in patients with a history of recurrent hepatitis (390). However, in many cases, symptoms seem to resolve spontaneously, and liver function tests usually normalize within eight weeks (390,7068).
Liver toxicity is more frequently associated with prolonged use of very high doses (6401,57346). But there is some concern that even short-term use of kava in typical doses might cause acute hepatitis in some patients, including severe hepatocellular necrosis. The use of kava for as little as 1-3 months has resulted in need for liver transplant and death, although these events are rare (7024,7068,7086,7096,17086).
There is some speculation that the type of extraction method could be responsible for these rare cases of hepatotoxicity (17086). The "Pacific kava paradox" holds that while the alcohol and acetone extracts of kava used for commercial products cause liver toxicity, the traditional kava rhizome preparation mixed with water might not be toxic (11794,17086). However, a more recent analysis reports cases of hepatotoxicity from the aqueous kava extract and suggests that kava's hepatotoxic effects may be due to contaminants such as mold (29676). Other suggested causes of hepatotoxicity include quality of the kava plant, concomitant medications, large doses and prolonged use, and toxic constituents and metabolites of kava (57300,88532).
Some commercial kava extracts contain parts of the stems and other aerial parts in addition to the rhizome, and it has been suggested that a constituent called pipermethysine, which is only found in these aerial parts, might be partly responsible for hepatotoxicity (17086). Other constituents of kava which might contribute to hepatotoxicity are kavalactones, which are metabolized by cytochrome P450 (CYP450) enzymes in the liver. Reactive metabolites are produced which conjugate with glutathione, and might deplete glutathione in a similar manner to acetaminophen (17086). Increased levels of gamma-glutamyl transferase, involved in the production of glutathione, have been reported in chronic kava users (17086). One of the enzymes involved in production of reactive metabolites from kavalactones is cytochrome P450 2E1 (CYP2E1), which is induced by chronic alcohol intake. Alcohol may also compete for other enzymes which clear kavalactone metabolites from the body. This might explain the observation that alcohol ingestion seems to increase the risk of hepatotoxicity with kava (7068,17086).
There is also speculation that "poor metabolizers" or those patients with deficiency in the cytochrome P450 2D6 (CYP2D6) isoenzyme, which occurs in up to 10% of people of European descent, may be at increased risk for hepatotoxic effects from kava (7068). This deficiency has not been found in Pacific Islanders. However, this theory has not been confirmed.
Due to the concerns regarding the potential hepatotoxicity of kava, kava supplements were withdrawn from European and Canadian markets in 2002 (7086). However, many of the market withdrawals of kava have been lifted after re-evaluation of kava suggested that the risk of hepatotoxicity was minimal (91593,91594,91615). Still, clinical practice guidelines from a joint taskforce of the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) recommend exercising caution when using kava in patients with preexisting liver issues (110318). Until more is known, tell patients to use kava cautiously and recommend liver function tests for routine users or those with underlying liver disease.

Immunologic ...Sjögren syndrome has been associated with an herbal supplement containing kava, echinacea, and St. John's wort. Echinacea may have been the primary cause, because Sjögren syndrome is an autoimmune disorder. The role of kava in this syndrome is unclear (10319).

Musculoskeletal ...Kava has been linked with reports of rhabdomyolysis. A 34-year-old man who consumed kava tea several times a week developed rhabdomyolysis with a peak creatine kinase level of 32,500 units/liter (18212). However, there is speculation that this might have been due to product impurities rather than kava itself. Another case report describes rhabdomyolysis with myoglobinuria and a creatine kinase level of 100,500 units/liter in a 29-year-old man who had taken kava in combination with guarana and ginkgo biloba (18213).
Cases of ataxia and tremors have been reported in patients taking single doses of kava powder 205 grams (11373).

Neurologic/CNS ...Orally, kava may cause headache, dizziness, and drowsiness (4032,6402,11370,11372,11373,18316,112642). It might also cause extrapyramidal side effects such as involuntary oral and lingual reflexes, twisting movements of the head and trunk, tremors, and other parkinsonian-like symptoms possibly due to dopamine antagonism (534,4055,7727,8415,102086). In one clinical trial, patients taking a kava supplement providing 120 mg of kavalactones twice daily for 16 weeks had a 3.2-fold greater risk of experiencing tremors when compared with patients taking placebo (102086). Theoretically, kava may worsen symptoms in patients with Parkinson disease or precipitate Parkinson-like symptoms in certain patients (4055,7727). Unlike benzodiazepines, kava is not thought to be associated with impaired cognitive function (2097,2098,11373,57332,57333). However, one clinical trial shows that taking a kava supplement providing 120 mg of kavalactones twice daily for 16 weeks increases the risk for memory impairment by 55% when compared with placebo (102086).
Orally, kava may reduce alertness and impair motor coordination in a dose-dependent manner. Some preliminary reports have noted a decline in accuracy of visual attention and slower reaction times after kava ingestion, particularly at higher doses and in combination with alcohol (11373,95926). Population research has also found that ingesting large amounts of kava tea (typically 50 times higher than what is used medicinally in the US) within a 12-hour period before driving increases the odds of being involved in a serious motor vehicle crash resulting in death or serious injury by almost 5-fold when compared to not drinking kava tea (95927). Use of normal doses of kava may also affect the ability to drive or operate machinery, and driving under the influence (DUI) citations have been issued to individuals observed driving erratically after drinking large amounts of kava tea (535). However, in computer-based driving simulator tests, there are no reported adverse effects of kava on performance (95926). Additionally, other research shows that consuming over 4400 mg of kavalactones over a 6-hour kava session does not seem to impair alertness or attention when compared with non-kava drinkers (103867). Similar research using a specific psychometric tool (Brain Gauge) shows that consuming approximately 3680 mg of kavalactones in a 6-hour kava session seems to impair temporal order judgment, which is associated with the brain's ability to track the order of events, when compared with non-kava drinkers. However, it does not seem to impact cognitive domains related to focus, accuracy, timing perception, plasticity, or fatigue when compared with non-kava drinkers (110435).

Ocular/Otic ...Orally, high doses of kava may cause eye irritation (7728). There is one case report of impaired accommodation and convergence, increased pupil diameter, and oculomotor disturbance following a single dose of kava (9920).

Psychiatric ...Apathy has been associated with traditional use of kava at high doses (57313).

Pulmonary/Respiratory ...Orally, kava may cause shortness of breath, possibly due to pulmonary hypertension (6402).

Renal ...Orally, kava may cause acute urinary retention (57349).

(Read more about KAVA)