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Drug Information

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Melody Siu

on 20 November 2013

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Transcript of Drug Information

Herbal Medicine: Biomolecular and Clinical Aspects. 2nd edition. Benzie IFF, Wachtel-Galor S, editors. Boca Raton (FL): CRC Press; 2011. Chapter 9 Ganoderma lucidum (Lingzhi or Reishi). A Medicinal Mushroom. Sissi Wachtel-Galor, John Yuen, John A. Buswell, and Iris F. F. Benzie
Drug Information
Step 1 - Secure requestor demographics
Conclusion
Important to learn to understand the correct steps to approach to patient's enquiry
search and have critical appraisal for useful references and evaluate information to see if it is valid
Develop strategies in responding to patient questions
Treat the patients, not the symptoms!!
Case
Mr. PO was recently discharged from hospital for pneumonia. He came to the pharmacy today for refill of his warfarin, a medication which Mr. PO has been taking for years for arrhythmia. During conversation, Mr. PO expressed the desire of taking lingzhi for boosting his immune system. What will be your advice?
Mr. PO- a male patient
Age: unknown
Step 4 - Develop strategy and conduct search
Step 5 -
Perform Evaluation, Analysis & Synthesis

Step 6 - Formulate an answer
Step 7 - Conduct Follow-up & Documentation
References

Race: Unknown
Weight: Unknown
Secondary Literature
Micromedex
Pub Med
British National Formulary
Benefits of Lingzhi
Antitumour
Antioxidant
Immunostimulatory properties
Antihypertensive
etc
Lingzhi and warfarin
Recommendation
Tell him the possible effect of taking warfarin and lingzhi together
Suggest other lifestyle changes to boost immune system, for example do more sports, smoking cessation (if any), drink less (if any), dietary change
If he insists on taking lingzhi, tell him to take lingzhi regularly, not to change diet significantly.
Warfarin
Oral anticoagulant (BNF)
prevent new clots from forming or existing clots from getting larger
Given to patients with high chance to form blood clot, like those who have atrial fibrillation
Lingzhi causes platelet inhibition
Increased risk of bleeding when the patient is taking anticoagulant(eg warfarin) or antiplatelet(eg aspirin)
1. Abourashed, E.; Khan, I. (2011). Leung's Encyclopedia of Common Natural Ingredients: Used in Food, Drugs and Cosmetics. Wiley.
2. Ansell, J.; Fuster, V.; Halperin, J.; Hirsh, J. (2003). American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy. American Heart Association Journal. Volume 107. 1692-1711.
3. Benzie, I.; Wachtel-Galor, S. (2011). Herbal Medicine: Biomolecular and Clinical Aspect 2nd Ediion. CRC Press.
4. Boh, B.; Berovic, M.; Zhang, J.; Zhi-Bin, L. (2007). Ganoderma lucidum and its pharmaceutically active compounds. Biotechnology Annual Review. Volume 13. 265-301.
5. Chen, X.; Chen, L.; Wang, Y.; Xu, Z.; Zhong, Z. (2011). Ganoderma lucidum polysaccharides: immunomodulation and potential anti-tumor activities. American Journal of Chinese Medicine. Volume 39. 15-27.
6. Daugherty, N.; Smith, K. (2006). Dietary Supplement and Selected Food Interactions With Warfarin. Orthopedics. Volume 29.
7. Ulbricht, C et al. (2010), Reishi Mushroom (Ganoderma lucidum): Systematic Review by the Natural Standard Research Collaboration. Journal of the Society for Integrative Oncology. Volume 8. 148-159.
8. University of Illinois Medical Center at Chicago. (2009). Warfarin Use in adults. University of Illinois Medical Center at Chicago.
9. Olver, I. (2011). Perspectives on Complementary and Alternative Medicines. World Scientific.
10. Yue, GG et al. (2013). Immunomodulatory activities of Ganoderma sinense polysaccharides in human immune cells. Nutrition and Cancer. Volume 65. 765-774.
11. Accessed on 17th of November, 2013. Reishi Mushroom. Retrieved from http://www.drugs.com/npc/reishi-mushroom.html
12. Accessed on 18th of November, 2013. Medications for Arrhythmia. Retrieved from http://www.heart.org/HEARTORG/Conditions/Arrhythmia/PreventionTreatmentofArrhythmia/Medications-for-Arrhythmia_UCM_301990_Article.jsp
13. The British National Formulary
14. Drugs.com
15. Drug insert of warfarin
16. Micromedex 2.0
Mr. PO
The desire of taking lingzhi
for boosting his immune system
Taking warfarin for years
for arrhythmia
Scientific name of Lingzhi- Ganoderma lucidum. Most pharmacological studies have been done on extracts of red Lingzhi. Bioactivities exhibited: 1)
Antitumour
or cytotoxic activities, 2) Central effects (sedative, analgesic, anticonvulsive), 3) Cardiovascular effects (both hypertensive and hypotensive as well as increase of coronary blood flow), 4) Antiallergic effects (inhibition of histamine release), 5)
Antioxidant
effects, 6) Antiviral activities against hepatitis B, HSV-1 & 2, HIV-1, EBV, Flu A and VSV, 7)
Immunomodulating
effects, 8) Hypoglycemic activities, 9)
Platelet aggregation inhibitory effects
with adenosine being the active agent, 10) Hypolipemic/hypocholesterolemic effects 11) Others: anticholingergic, anti-inflammatory, antiulcer, vasodilative, antifatigue, diuretic
Leung's Encyclopedia of Common Natural Ingredients: Used in Food, Drugs and Cosmetics
Step 3 - Define & Understand the Question
Effect of Lingzhi in Immune System
Immunomodulatory
significant stimulatory effects on PBMC (Peripheral blood mononuclear cell) proliferation
Step 2 - Obtain Background Information
Diagnosis
Arrhythmia
Past & Current Medical Histories
Pneumonia
Concurrent Medication
Warfarin
Unknown dose
Drug Allergy
Unknown
Dietary Habit
Unknown
Our results showed that the polysaccharide-enriched fraction of GS hot water extract (400 μg/ml) exhibited
significant stimulatory effects on PBMC proliferation
. When the fruiting bodies of GS were divided into pileus and stipe parts and were separately extracted, the GS stipe polysaccharide-enriched fraction (50-400 μg/ml) showed concentration-dependent immunostimulating effects in PBMC. The productions of
tumor necrosis factor, interleukin (IL)-10, and transforming growth factor
were significantly
enhanced
by this fraction. In addition, the proportion of
CD14(+) monocyte subpopulation
within the PBMC was specifically
increased
. The IL-10 and IL-12 productions in monocyte-derived dendritic cells were significantly enhanced by GS stipe fraction
Immunomodulatory activities of Ganoderma sinense polysaccharides in human immune cells. Nutrition and Cancer
Discharged from hospital for pneumonia
Weakened immune system
The most important pharmacologically active constituents of G. lucidum are triterpenoids and polysaccharides. Triterpenoids have been reported to possess hepatoprotective, anti-hypertensive, hypocholesterolemic and anti-histaminic effects, anti-tumor and anti-engiogenic activity,
effects on platelet aggregation and complement inhibition
.

Ganoderma lucidum and its pharmaceutically active compounds. Biotechnology Annual Review
Tertiary Literature
Leung's Encyclopedia of Common Natural Ingredients: Used in Food, Drugs and Cosmetics
Perspectives on Complementary and Alternative Medicines
Katzung and Trevor’s Pharmacology
Drugs.com
Herbal Medicine: Biomolecular and Clinical Aspect. 2nd Edition
Insert of warfarin
AHA/ACC Scientific Statement.
University of Illinois Medical Center at Chicago Clinical Care Guidelines, Warfarin Use in Adults, January 2009
Reishi Mushroom ( Ganoderma lucidum ): Systematic Review by the Natural Standard Research Collaboration
Primary Literature
American Journal of Chinese Medicine
American Heart Association
Journals
Case studies
Articles
Drugs.com
The effect of Lingzhi on the cardiovascular system has been investigated. Decreases in high blood pressure were reported to be attributed to the ganoderic acids. Angiotensin-converting enzyme-inhibiting triterpenes from Lingzhi have been described.

Inhibition of cholesterol biosynthesis, enhanced antioxidase activity,
decreased platelet aggregation
, and reduced lipid peroxidation have been demonstrated in animal and in vitro experiments
Anticoagulants (blood thinners) work by making it harder for the blood to clot, or coagulate. They aren't designed to dissolve existing blood clots. They
prevent new clots from forming or existing clots from getting larger
. Because a common type of stroke is caused by a blood clot obstructing blood flow to the brain, anticoagulants are often prescribed for people with certain conditions to prevent the occurrence of a first stroke or to prevent the recurrence if the patient has already had a stroke.
Anticoagulants are also given to certain people at risk for forming blood clots, such as those with artificial heart valves or who have atrial fibrillation.
AHA/ACC Scientific Statement. American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy.
If INR is relatively constant and is within the desire range,
Keep the dose of warfarin
Advise the patient to keep his diet similar
Follow up frequency may decrease
Documentation
Verification process
Liability reduction
For follow up of the patient
Privacy!!!
Recommend follow up twice a week for the first two weeks, to monitor his INR
If INR is too high / low,
Ask the patient if there is any significant change in his diet.
If not, adjust the dosing of warfarin.
Follow up frequency remain unchanged until his INR become relatively constant in the desired range
UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE, WARFARIN USE IN ADULTS , January 2009
American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy. American Heart Association Journal.
Caution is warranted, however, as
Lingzhi causes platelet inhibition
, thus the
risk of bleeding is increased
when the patient is taking anticoagulant or antiplatelet drugs like
warfarin
and aspirin
Perspectives on Complementary and Alternative Medicines
Reishi Mushroom ( Ganoderma lucidum ): Systematic Review
by the Natural Standard Research Collaboration
Careful monitoring is key when a patient is treated with warfarin. Patients should consult their physician when they plan to start a
new supplement
or diet. If the dietary supplement or food is not reviewed in this paper, it may still interact with warfarin. In order to monitor for potentiation or inhibition of warfarin,
check the INR
more frequently during the
first two weeks
of beginning or discontinuing a dietary supplement or new food.

Dietary supplements and foods that affect anticoagulation should be
discontinued at least 14 days prior to surgical procedures
. Refer to an article by Trapskin and Smith8 for recommendations on preoperative discontinuation of some of the most frequently used herbal products.
Dietary Supplement and Selected Food Interactions With Warfarin. Noelle E. Daugherty, PharmD; Kelly M. Smith, PharmD , Orthopedics April 2006 - Volume 29 · Issue 4
Insert of warfarin
Ganoderma lucidum polysaccharides: Imunomodulation and potential anti-tumor activities. American Journal of Chinese Medicine
Ganoderma lucidum (G. lucidum), a basidiomycete white rot fungus, has long been prescribed to prevent and treat various human diseases, particularly in China, Japan, and Korea. Several classes of bioactive substances have been isolated and identified from G. lucidum, such as triterpenoids, polysaccharides, nucleosides, sterols, and alkaloids, among others. This paper examines the potential role of G. lucidum polysaccharide (GLPS) in tumor therapy and the possible mechanisms involved. Both in vitro and in vivo studies suggested that the anti-tumor activities of GLPS are mediated by its i
mmunomodulatory,
anti-angiogenic, and cytotoxic effects. GLPS
affects immune cells and immune-related cells including B lymphocytes, T lymphocytes, dendritic cells, macrophages, and natural killer cells
. In addition, recent data also suggest that GLPS suppresses tumorigenesis or inhibits tumor growth through direct cytotoxic effect and anti-angiogenic actions. However, many questions still need to be answered before both G. lucidum and GLPS can be widely accepted and used as anti-tumor agents
Recommendation
Monitor for signs and symptoms of bleeding, stop taking both when there is high chance of bleeding
Mind allergy to lingzhi
Dietary supplements and foods that affect anticoagulation should be discontinued at least 14 days prior to surgical procedures
Immunomodulatory activities of Ganoderma sinense polysaccharides in human immune cells.
Nutrition and Cancer
Validity:
First study on immunodulatory activities of Ganoderma sinense, primary

Result:
ganoderma sinese, a allied species of ganoderma lucidum has immunostimulatory effect on human peripheral blood mononuclear cells

Relevance:
relatively low, does not show effect of ganoderma lucidum directly
Ganoderma lucidum polysaccharides: Imunomodulation and potential anti-tumor activities. American Journal of Chinese Medicine
Reishi Mushroom (Ganoderma lucidum): Systemic Review
Validity:

Systemic review based on many databases and research->reliable
Result:

Function of Ganoderma lucidum and its benefits
Relevance:

Relate it to the fact that the patient needs to boost its immune system due to his pneumonia
Others:
Well-organized, easy to find the information we want to know
Herbal Medicine: Biomolecular and Clinical Aspect
Validity:
Contain many results of extensive research
Result
Analysis of the usefulness of Ganoderma lucidum
Relevance:
In-depth information about lingzhi

Validity:

Carry out both in vitro and in vivo experiment

Result:

Anti-tumor activities of GLPS are mediated by its immunomodulatory, anti-angiogenic, and cytotoxic effects

Relevance:
show immunomodulatory of ganoderma lucidum directly
Ganoderma lucidum and its pharmaceutically active compounds.
Biotechnology Annual Review
Validity:
Carry out both in vitro and in vivo experiment

Result:
Ganoderma lucidum possess hepatoprotective, anti-hypertensive, hypocholesterolemic and anti-histaminic effects, anti-tumor and anti-engiogenic activity, effects on platelet aggregation and complement inhibition.

Relevance:
show various effects of ganoderma lucidum
Micromedex
Validity
:
Meta-analysis and based on evidence-based clinical reference

Result
:
A concise and precise guideline to the use of lingzhi

Relevance
:
highlights lingzhi's immunomodulatory property and its complementary and alternative medicine indications that can be used in immune disorders
Drugs.com
Validity
:
Meta-analysis but NOT intended for medical advice, diagnosis or treatment
Result
:
Shows a wide range of information about lingzhi but not concise and user friendly enough
Relevance
:
suggests the dose by The Pharmacopoeia of the People's Republic of China and lists the effect of lingzhi on the cardiovascular system, showing decreased platelet aggregation in animal and in vitro experiment
Others:
Advertisement
BNF
Validity
:
Provides the most updated drug information as it is updated half yearly and also based on clinical evidence

Result
:
Shows the drug profile (indications, side effects, dose, route of administration, etc.) clearly

Relevance
:
Therapeutic class of warfarin: oral anticoagulant
PubMed
Validity
:
Depends on different sources, need to be evaluated base on the method of investigation, author, etc of each source

Result and Relevance
:
A lot of relevant resources, including journals, case studies can be found

Other:

Quite user-friendly, easy to search for information
Leung's Encyclopedia of Common Natural Ingredients: Used in Food, Drugs and Cosmetics
Validity
:
Collates, summarises and categorises primary and secondary literature from various sources
Result
:
provides a good and concise overview to lingzhi but not as in-depth as a full length study
Relevance
:
Lists more than 11 bioactivities exhibited by lingzhi including immunomodulating effects and platelet aggregation inhibitory effects
Others:
Well-organized
Ganoderma lucidum polysaccharides: Imunomodulation and potential anti-tumor activities.
American Journal of Chinese Medicine -
Validity:

The American Heart Association is the nation’s oldest, largest voluntary organization devoted to fighting cardiovascular diseases and stroke -> reliable
Scientific Statements -- educate basic scientists, clinical scientists, and clinicians on the scientific basis of disease and its application to the practice of medicine with regard to both prevention and management
Result:

How anticoagulants help preventing arrhythmia
Relevance:
High relevance, have to know about mechanism of warfarin before drawing conclusion


Validity:
Medicine is the official journal of The Association of Professors of Medicine, a prestigious group comprised of chairs of departments of internal medicine at more than 125 medical schools across the country --> very reliable
Result:
Lingzhi has immunomodulatory, anti-angiogenic, and cytotoxic effects
Relevance:
Relevant to whether Lingzhi can help Mr. PO to boost his immune system

AHA/ACC Scientific Statement. American Heart Association/ American college of Cardiology Foundation Guide to Warfarin .
Perspectives on Complementary and Alternative Medicines
Validity:

integrates primary and secondary literature

Result:

concise overview of lingzhi

Relevance:

Highlights the interactions between lingzhi and warfarin- increased risk of bleeding
University of Illinois Medical Center at Chicago Clinical Care Guidelines, Warfarin use in Adults, January 2009
Validity:
Clinical evidence base
Works of health care professionals, including pharmacist and doctors

Result:
Information about INR and warfarin dosing in clear table form

Relevance:
About dosing of warfarin, provide information about follow up
Full transcript