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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by Tyrannosaur on April 24, 2013, at 3:51:49
Ginkgo Biloba is a weak monoamine oxidase inhibitor.
Countless pages on the net state: "Ginkgo may enhance the effects (both good and bad) of antidepressant medications known as MAOIs, such as phenelzine (Nardil), tranylcypromine (Parnate)."
Has anybody tried combining both and can comment whether it enhanced Nardil/Parnate or just increased some side effects?
Posted by vanvog on April 24, 2013, at 4:11:01
In reply to MAOI + Ginkgo Biloba, posted by Tyrannosaur on April 24, 2013, at 3:51:49
I can not answer your question regarding MAOI + Ginkgo.
Personally I would stay away from all herbs and other voodoo-like supplements, it might give you some positive placebo but is it worth the sh1tload of potential problems and drug-interactions it might cause? In most cases there is NO scientific basis to any positive effects in combination with psych meds, to me it's like why do we need double blind placebo studies, why not just try supplementing with ANYTHING we can get our hands on until something works? Just my opinion though, I'm not a doctor/psychopharmacologist.
Just case reports, but still:
#1
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Fatal seizures due to potential herb-drug interactions with Ginkgo biloba.Abstract
Alternative therapy including herbal drugs and complementary medicine is becoming increasingly popular. However, the rise in the incidence of herb-drug interactions is causing concern, especially in the absence of warning labels addressing potential adverse effects. We present the case of a 55-year-old male who suffered a fatal breakthrough seizure, with no evidence of non-compliance with his anticonvulsant medications. The autopsy report revealed subtherapeutic serum levels for both anticonvulsants Depakote and Dilantin. Concomitant with his prescribed medications, the decedent was also self-medicating with a cornucopia of herbal supplements and nutraceuticals, prominent among which was Ginkgo biloba. Ginkgo, an herbal extract from the leaves of the Ginkgo biloba tree, has been used medicinally for centuries and has been touted as a cure for a variety of medical conditions. The induction of Cytochrome P450 enzymes by components of herbal drugs has been known to affect the metabolism of various drugs. Dilantin is primarily metabolized by CYP2C9, and secondarily metabolized by CYP2C19. Valproate metabolism is also modulated in part by CYP2C9 and CYP2C19. A recent study revealed significant inductive effect of ginkgo on CYP2C19 activity. CYP2C19 induction by ginkgo could be a plausible explanation for the subtherapeutic levels of Dilantin and Depakote. Additionally, ginkgo nuts contain a potent neurotoxin, which is known to induce seizure activity. Evidence of other herbal drugs diminishing the efficacy of anticonvulsant medication does exist; however, there has been only one other documented instance of ginkgo potentiating seizure activity in the presence of anticonvulsant therapy. Highlighting the potential adverse effects and drug interactions of ginkgo on the packaging of the drug may help prevent inadvertent use in vulnerable individuals.
http://www.ncbi.nlm.nih.gov/pubmed/16419414
-------------------#2
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Interactions between herbal medicines and prescribed drugs: a systematic review.Abstract
Despite the widespread use of herbal medicines, documented herb-drug interactions are sparse. We have reviewed the literature to determine the possible interactions between the seven top-selling herbal medicines (ginkgo, St John's wort, ginseng, garlic, echinacea, saw palmetto and kava) and prescribed drugs. Literature searches were performed using the following databases: Medline (via Pubmed), Cochrane Library, Embase and phytobase (all from their inception to July 2000). All data relating to herb-drug interactions were included regardless of whether they were based on case reports, case series, clinical trials or other types of investigation in humans. In vitro experiments were excluded. Data were extracted by the first author and validated by the second author. 41 case reports or case series and 17 clinical trials were identified. The results indicate that St John's wort (Hypericum perforatum) lowers blood concentrations of cyclosporin, amitriptyline, digoxin, indinavir, warfarin, phenprocoumon and theophylline; furthermore it causes intermenstrual bleeding, delirium or mild serotonin syndrome, respectively, when used concomitantly with oral contraceptives (ethinylestradiol/desogestrel), loperamide or selective serotonin-reuptake inhibitors (sertaline, paroxetine, nefazodone). Ginkgo (Ginkgo biloba) interactions include bleeding when combined with warfarin, raised blood pressure when combined with a thiazide diuretic and coma when combined with trazodone. Ginseng (Panax ginseng) lowers blood concentrations of alcohol and warfarin, and induces mania if used concomitantly with phenelzine. Garlic (Allium sativum) changes pharmacokinetic variables of paracetamol, decreases blood concentrations of warfarin and produces hypoglycaemia when taken with chlorpropamide. Kava (Piper methysticum) increases 'off' periods in Parkinson patients taking levodopa and can cause a semicomatose state when given concomitantly with alprazolam. No interactions were found for echinacea (Echinacea angustifolia, E. purpurea, E. pallida) and saw palmetto (Serenoa repens). In conclusion, interactions between herbal medicines and synthetic drugs exist and can have serious clinical consequences. Healthcare professionals should ask their patients about the use of herbal products and consider the possibility of herb-drug interactions.http://www.ncbi.nlm.nih.gov/pubmed/11772128
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Posted by Phillipa on April 24, 2013, at 9:26:38
In reply to Re: MAOI + Ginkgo Biloba, posted by vanvog on April 24, 2013, at 4:11:01
Herbs are scary and nothing to mess around with. Phillipa
Posted by vanvog on April 24, 2013, at 21:31:20
In reply to MAOI + Ginkgo Biloba, posted by Tyrannosaur on April 24, 2013, at 3:51:49
You have probably seen this:
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Evidence that gingko biloba extract does not inhibit MAO A and B in living human brain.Abstract
Extracts of Ginkgo biloba have been reported to reversibly inhibit both monoamine oxidase (MAO) A and B in rat brain in vitro leading to speculation that MAO inhibition may contribute to some of its central nervous system effects. Here we have used positron emission tomography (PET) to measure the effects of Ginkgo biloba on human brain MAO A and B in 10 subjects treated for 1 month with 120 mg/day of the Ginkgo biloba extract EGb 761, using [11C]clorgyline and [11C]L-deprenyl-D2 to measure MAO A and B respectively. A three-compartment model was used to calculate the plasma to brain transfer constant K1 which is related to blood flow, and lambdak3, a model term which is a function of the concentration of catalytically active MAO molecules. Ginkgo biloba administration did not produce significant changes in brain MAO A or MAO B suggesting that mechanisms other than MAO inhibition need to be considered as mediating some of its CNS effects.http://www.ncbi.nlm.nih.gov/pubmed/10698362
-------------------I am curious as to where you found this information because I checked on the web and if you read the info from shops selling some kind of Ginkgo Biloba products it's "DO NOT TAKE WITH .... OR MAOI", "Avoid Ginkgo if you are taking MAOI for depression" etc.
**************************************************There might be some truth to it though:
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Effects of herbal components on cDNA-expressed cytochrome P450 enzyme catalytic activity.Abstract
We evaluated the effects of 25 purified components of commonly used herbal products on the catalytic activity of cDNA-expressed cytochrome P450 isoforms in in vitro experiments. Increasing concentrations of the compounds were incubated with a panel of recombinant human CYP isoforms (CYP1A2, CYP2C9, CYP2C19, CYP2D6 and CYP3A4) and their effects on the conversion of specific surrogate substrates measured fluorometrically in a 96-well plate format. For each test substance, the IC50 (the concentration required to inhibit metabolism of surrogate substrates by 50%) was estimated and compared with IC50's for the positive control inhibitory drugs furafylline, sulfaphenazole, tranylcypromine, quinidine, and ketoconazole. Constituents of Ginkgo biloba (ginkgolic acids I and II), kava (desmethoxyyangonin, dihydromethysticin, and methysticin), garlic (allicin), evening primrose oil (cis-linoleic acid), and St. John's wort (hyperforin and quercetin) significantly inhibited one or more of the cDNA human P450 isoforms at concentrations of less than 10 uM. Some of the test compounds (components of Ginkgo biloba, kava, and St. John's wort) were more potent inhibitors of the isoforms 1A2, 2C19, and 2C19 than the positive controls used in each assay (furafylline, sulfaphenazole, and tranylcypromine, respectively), which are known to produce clinically significant drug interactions. The enzyme most sensitive to the inhibitory of effects of these compounds was CYP2C19, while the isoform least effected was CYP2D6. These data suggest that herbal products containing evening primrose oil, Ginkgo biloba, kava, and St. John's Wort could potentially inhibit the metabolism of co-administered medications whose primary route of elimination is via cytochrome P450.http://www.ncbi.nlm.nih.gov/pubmed/12127912
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Let's say metabolism inhibition of the MAOI you take is a good thing, how much Ginkgo do you have to take exactly to have a significant positive effect yet avoid nasty interactions and Ginkgo side effects?
I would still stay away from herbs and Ginkgo in particular but again it's just my opinion and I'm NOT the smartest guy I know.
Posted by Tyrannosaur on April 25, 2013, at 1:08:01
In reply to Re: MAOI + Ginkgo Biloba, posted by vanvog on April 24, 2013, at 21:31:20
> I am curious as to where you found this information
Just do a google search with this: "Ginkgo may enhance the effects (both good and bad) of antidepressant medications known as MAOIs"
Numerous pages comes up.
Personally I've tried a lot of herbs and similar supplements and they've provided very little beneficial effects. But since i read the above statement Ginkgo got me interested. If i could have gotten some positive anecdotal reports of the combination of Biloba + MAOIs i might've tried it. But no one here seems to have heard of it so far, and I'm not in the mood to go the experimenting route atm. Especially since the combination of ginseng and MAOIs have at times resulted in disaster.
Kinda off-topic but what NRIs except for Bupropion, Reboxetine and Nortriptyline is there, that i could combine with Parnate?
Posted by vanvog on April 25, 2013, at 6:20:29
In reply to Re: MAOI + Ginkgo Biloba » vanvog, posted by Tyrannosaur on April 25, 2013, at 1:08:01
>Kinda off-topic but what NRIs except for Bupropion, Reboxetine and Nortriptyline is there, that i could combine with Parnate?
Nortriptyline is a Tricyclic (TCA). I guess Wellbutrin is technically an NDRI. There are selective NRIs like Reboxetine and Atomoxetine (Strattera) which according to Gillman are quite safe with MAOIs. As for TCAs you have so many options, just search for it on babble and you will find many reports on all kinds of combos of TCAs with MAOIs. Of all TCAs only clomipramine and imipramine are NOT SAFE. Basically you can try any other antidepressant which does NOT have SRIs properties, things like mirtazapine, trazodone and actually anything else except an SNRI/SSRI.
What's your current MAOI dose? I'm on 120 mg/day of Parnate myself. How did Wellbutrin worked in the cocktail for you, I wanted to start a trial but my supply is limited and I would not like to waste it for nothing.
Posted by Tyrannosaur on April 25, 2013, at 17:30:00
In reply to Re: MAOI + Ginkgo Biloba, posted by vanvog on April 25, 2013, at 6:20:29
> Nortriptyline is a Tricyclic (TCA). I guess Wellbutrin is technically an NDRI. There are selective NRIs like Reboxetine and Atomoxetine (Strattera) which according to Gillman are quite safe with MAOIs. As for TCAs you have so many options, just search for it on babble and you will find many reports on all kinds of combos of TCAs with MAOIs. Of all TCAs only clomipramine and imipramine are NOT SAFE. Basically you can try any other antidepressant which does NOT have SRIs properties, things like mirtazapine, trazodone and actually anything else except an SNRI/SSRI.
>
> What's your current MAOI dose? I'm on 120 mg/day of Parnate myself. How did Wellbutrin worked in the cocktail for you, I wanted to start a trial but my supply is limited and I would not like to waste it for nothing.
>
>Actually i meant Nardil, but for unknown reason i must've typed Parnate. Wellbutrin is indeed marketed for its dopamine action. But I've also read that its effect on dopamine is pretty much negligible, and that it mainly acts as a NRI.
The reason i ask is because MAOIs tend to release octopamine which in fact lowers norepinephrine, despite that MAOIs also blocks the breakdown of norepinephrine. This could be countered with a NRI, but most doctors are not keen on combining meds with MAOIs, according to their literature most TCAs and Bupropion is contraindicated. Despite that many clinical trials and prominent psychiatrists like Ken Gillman for example say otherwise.
So i wanted to hear if there are other NRIs out there that could be combined with MAOIs. (If my doctor won't like the idea of adding Bupropion or TCAs)
Posted by Tyrannosaur on April 28, 2013, at 7:20:59
In reply to Re: MAOI + Ginkgo Biloba » vanvog, posted by Tyrannosaur on April 25, 2013, at 17:30:00
That octopamine decrease norepinephrine is just a theory so far with no proof to back it up. But who knows?
Posted by vanvog on April 29, 2013, at 4:37:09
In reply to Re: MAOI + Ginkgo Biloba, posted by Tyrannosaur on April 28, 2013, at 7:20:59
>That octopamine decrease norepinephrine is just a theory so far with no proof to back it up. But who knows?
Exactly, who knows? I've seen some very knowledgeable people whom I would trust saying this. Let's just say many people have positive results with Wellbutrin and Parnate for a good reason yet again who knows why with pharmacodynamics of Welly being so complicated.
A few more thoughts on GINKGO and why NOT to try it:
- In the US supplements (and herbs especially in most other countries) are poorly regulated, with herbal source material such as Ginkgo there is just no way of knowing how much is too much, it can vary greatly from from manufacturer to manufacturer, bottle to bottle and pill to pill.
- Ginkgo biloba may itself be an MAOI. The data are conflicting, you may wind up with a hell of a lot less MAO than you expected.
This is the end of the thread.
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