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Could you provide some examples of potentially dangerous interactions between these products and scheduled substances that doctors could potentially miss?

Cases have been published reporting enhanced anticoagulation and bleeding when patients on long-term warfarin therapy also took Salvia miltiorrhiza (danshen). Garlic decreases the area under the plasma concentration-time curve (AUC) and maximum plasma concentration of saquinavir, but not ritonavir and paracetamol (acetaminophen), in volunteers. Garlic also increases the clotting time and international normalised ratio of warfarin and caused hypoglycaemia when taken with chlorpropamide. Ginkgo biloba can cause bleeding when combined with warfarin or aspirin (acetylsalicylic acid), raised blood pressure when combined with a thiazide diuretic and there is one report of a caused coma when warfarin was combined with trazodone in patients. Panax ginseng (ginseng) reduces the blood concentrations of alcohol and warfarin, and can induce mania when used concomitantly with phenelzine. However, interestingly ginseng increased the efficacy of influenza vaccination. There have been reports that Scutellaria baicalensis (huangqin) ameliorates irinotecan-induced gastrointestinal toxicity in cancer patients. Piper methysticum (kava) increased the 'off' periods in patients with parkinsonism taking levodopa and induced a semicomatose state when given concomitantly with alprazolam. Kava enhanced the hypnotic effect of alcohol in mice, but this was not observed in humans. Silybum marianum (milk thistle) decreased the trough concentrations of indinavir in humans. Piperine from black (Piper nigrum Linn) and long (P. longum Linn) peppers increased the AUC of phenytoin, propranolol and theophylline in healthy volunteers and plasma concentrations of rifamipicin (rifampin) in patients with pulmonary tuberculosis. Eleutheroccus senticosus (Siberian ginseng) increased the serum concentration of digoxin, but did not alter the pharmacokinetics of dextromethorphan and alprazolam in humans. Hypericum perforatum (hypericum; St John's wort) decreased the blood concentrations of ciclosporin (cyclosporin), midazolam, tacrolimus, amitriptyline, digoxin, indinavir, warfarin, phenprocoumon and theophylline, but did not alter the pharmacokinetics of carbamazepine, pravastatin, mycophenolate mofetil and dextromethorphan. Cases have been reported where decreased ciclosporin concentrations led to organ rejection. Hypericum (St Johns Wort) also caused breakthrough bleeding and unplanned pregnancies when used concomitantly with oral contraceptives. It also caused serotonin syndrome when used in combination with selective serotonin reuptake inhibitors (e.g. sertraline and paroxetine).

There are also many examples of beneficial interactions, such as co-enzyme Q10 which reduces statin toxicity, or arginine and ginkgo which oppose the sexual dysfunction side effects caused by SSRI’s. Or melationin supplementation that corrects melatonin deficiency induced by beta-blockers. Fish oils enhance anti-inflammatory, antiarrhythmic, anti-lipemic, antidepressant, and neuroleptic meds, beta-blockers, lithium and insulin. There are many more such examples.

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