Herbal Contraindications and Drug Interactions plus Herbal Adjuncts with Medicines, expanded 4th edition by Francis Brinker. Sandy, Oregon: Eclectic Medical Publications; 2010. Softcover; 598 pages. ISBN: 978-1-888483-14-7. $68.70.

It is almost axiomatic in modern medical and public health thinking that with the steadily increasing growth of the use of herbs and other dietary supplements in the United States and almost all other countries around the world—particularly the developed or industrialized countries—there is a significant segment of the population that uses both conventional medicines and herbal preparations. This increased concomitant use, at least in theory, would suggest a rise in herb-drug interactions (HDIs), most of which are usually presumed to have an adverse effect on the consumer/patient.

Add to this the plethora of publications in the past decade or more in which medical researchers have published papers warning of impending HDIs based solely on results of in vitro research, such data being of arguably questionable relevance to actual human biochemistry or pharmacology. And not to be forgotten are all those formerly dire predictions of adverse HDIs based on purely theoretical or speculative considerations (e.g., echinacea [Echinacea spp., Asteraceae] aerial and/or root preparations used with hepatotoxic drugs).

Since 1997, probably the most responsible compiler and communicator of an evidence-based approach to HDIs has been Francis Brinker, a naturopath by training, and probably one of America’s clearest voices for rational phytotherapy, i.e., the practice of herbal medicine based both on modern research as well as the robust body of empirical knowledge, particularly that gleaned from the tradition of Eclectic Medicine of the late 1800s and early 1900s. Previous versions of this book provided clinicians, researchers, herbalists, etc, with a ranking of the available evidence on a wide range of HDIs, i.e., is the interaction merely proposed or is it documented, i.e., based on one of the levels of evidence provided by Dr. Brinker. And, if it is proposed, is it based on theory and/or speculation owing to the pharmacology of the herb and the drug? Or, perhaps, is it based on results from an in vitro study? Or, is the documented interaction based on a single case report in the literature, or a controlled clinical trial? And so on. Instead of merely listing speculated or reported interactions, Dr. Brinker has always dug down into the literature to document the source of the information according to a hierarchy of evidence.

Now this most-welcome 4^th edition greatly expands on the previous (Herb Contraindications & Drug Interactions, 3rd. ed.) with the addition of a new layer of clinically-relevant information, as the expanded title suggests (“…plus Herbal Adjuncts with Medicines). Dr. Brinker is probably the first author I can recall having read who reminds the reader that some interactions can actually have a beneficial effect, i.e., mitigating the adverse effects of a conventional medicine. Such a beneficial interaction includes silymarin-rich extracts of milk thistle (Silybum marianum, Asteraceae) seeds to mitigate the adverse effects of hepatotoxic medications. Another beneficial interaction can be the enhancement of a drug’s action, e.g., extracts of devil’s claw (Harpagophytum procumbens, Pedialaceae) tuber to enhance outcomes and/or reduce use of analgesics or NSAIDs (nonsteroidal anti-inflammatory drugs) for osteoarthritis or rheumatic conditions.

There are many in the herbal medicine and growing integrative medicine community who have a markedly different view on the effects herbal preparations can have on a person who is already using conventional pharmaceutical drugs. Instead of focusing only on the adverse effect an herb may have on the efficacy of a drug (which is the normal mindset of a conventionally-trained health professional), the herbalist and/or integrative practitioner may also see the same situation in reverse; that is, why not look at the potential benefits of combining herbs with drugs? And, to his credit, Dr. Brinker provides in a new 30-page Appendix E (“Herbals as Potential Complementary Adjuncts with Medicines”) a compelling aggregation of examples where using herbs with conventional medications may be a responsible and beneficial option. Sub-sections of this appendix include Potentially Beneficial Combinations of Herbals with Drugs, Herbal Aids for Modifying Substance Abuse, Complementing Treatment of Inflammations, Enhancing Chemotherapy and Chemoprevention or Reducing the Adverse Effects, Herbals for Preventing and Healing Radiation Adverse Effects and/or Enhancing Radiotherapy or Photodynamic Therapy, Herbal and Anti-infection Agents.

The first 50-plus% of the book, “Herbal Agents” contains a list of 321 herbs and the evidence-based listing of the types of interactions which are known or believed to be associated with them. (Additional herbs are included in the appendices.) The main section follows the same format that Dr. Brinker has created in the previous editions of this book, but significantly more information (e.g., over 1,600 new reference citations) has been added since the 3rd edition, published in 2001, much of such additional information having been added to the online complement to the 3rd edition, at the publisher’s website (below).

The various appendices (i.e., in addition to the new E, already noted above) provide significant value: Herbals to be Used with Caution (A); Herbal-Drug Interactions (B); Herbals Contraindicated for Mothers and Children (C); and Vitamin/Mineral/Drug Interactions (D).

As he did for years until the publication of the present volume, the author will post free updates to this book on the publisher’s website, www.eclecticherb.com/emp.

I have relied on Dr. Brinker’s 3rd edition and its online updates for much of my research and writing over the past decade, even though numerous HDI books have been published by other authors. Despite some valuable data in other publications (Mitchell Stargrove and Jonathan Treasure’s recent tome is quite detailed, impressive and useful, i.e., for a limited number of botanicals), it is Dr. Brinker whom I consider the dean of the HDI compilation and critical assessment in the current literature. Now that a decade’s worth of information is available in one volume, I know that this will become one of my closest dog-eared bibliographic allies in the coming months and years.

—Mark Blumenthal Founder and Executive Director,
American Botanical Council Editor-in-Chief,
HerbalGram
Austin, TX