Although it is always important to determine what other therapies a patient is taking, Dr. Joseph I. Sirven (“Dangerous duo: Antiepileptics plus herbals,” Pearls, Current Psychiatry, July 2007) betrays a lack of knowledge about botanical medicine. No herbalist prescribes water hemlock, which is not available at health food stores and has been known to be a deadly poison since the time of Socrates. Yohimbine is a drug, not a botanical, although it is derived from the yohimbe plant. St. John’s wort—which was not discussed in the article—induces the cytochrome system, especially the 3A enzymes and the multidrug resistance transporter Pglycoprotein, and should not be taken with antiepileptic drugs (AEDs).
Antispasmodic herbs such as black cohosh and kava are unlikely to induce seizures, although they might potentiate AEDs and could help to lower dosages of these medications. Ginkgo seeds are a popular food in China and Korea because cooking inactivates toxins in the seeds. Guarana acts like caffeine and may cause vasoconstriction. Ephedra, which is only available in low doses or from Chinese herbalists who use small quantities for short-term respiratory illness, has a similar effect and could possibly interact with AEDs.
I urge clinicians to obtain information about these remedies from professionals specializing in the medicinal use of herbs to improve the care of patients who use complementary and alternative medicine.
Karen S. Vaughan
Brooklyn, NY
Dr. Sirven Responds
The reader and I both believe in delivering accurate information about the use of herbals and botanicals. Although botanicals carry many promises for the treatment of neurologic and psychiatric disease, there are also a number of risks—which was the rationale for publishing a “Pearls” article on this topic.
My experience more than qualifies me to comment on herbal use. I am a practicing, epilepsy fellowship-trained, board-certified neurologist who teaches, publishes, and conducts research on antiepileptic drugs and surveys ideas on complementary and alternative medicine (CAM) use in patients with seizures and epilepsy. Apparently the reader’s passion for the topic led to several inaccuracies and mischaracterizations about the “Pearls” article. Contrary to the reader’s claims, there were no errors in the information presented.
My practice at a tertiary care epilepsy center places me in the unfortunate position of seeing serious and even fatal outcomes that result from poor clinical care with botanicals. I agree that the clinical use of botanicals should be supervised by professionals who are trained in oriental medicine and are registered herbalists, but in collaboration with neurologists, psychiatrists, and other practitioners who are charged with caring for patients with serious and refractory epilepsy and psychiatric conditions—patients likely to be taking antiepileptics.
Because the use of antiepileptic drugs and herbals has increased significantly, it is important for clinicians to understand all interactions between these 2 classes of agents. I am compelled to ensure that other practitioners are aware of potential drug interactions so that we can improve the care of patients likely to use CAM.
The last paragraph of my article notes that many patients do not tell their neurologists or other healthcare practitioners about their CAM use, and herein lies the problem. CAMs are readily available, and patients will take botanicals and herbals without professional guidance. Thus, a respectful team approach is necessary for medicine to achieve good health outcomes for all.
Joseph I. Sirven, MD
Associate professor of neurology
Mayo Clinic College of Medicine
Phoenix, AZ