Clinically Significant Drug-Drug Interactions

With OTC and Herbal Products

PROBLEM
Patients are increasingly using over-the-counter (OTC) supplements and herbal
products for both preventative and therapeutic purposes.

Many OTC products can have serious consequences to the cardiovascular (CV) system
via drug-drug interactions.

SOLUTION
Avoid combining potentially interacting OTC supplements or herbal products with CV
medications as outlined in Table 1.

TABLE 1: Products That Interact with CV Medications1-6

Monitoring
Supplement or
CV Medication Interaction Parameter/
Herbal Product
Recommendation

Angiotensin- Increases effects of ACEIs, Blood pressure

Night-blooming cereus
Converting leading to hypotension
Enzyme
Inhibitors Decreases effectiveness
Green tea, Yohimbine of ACEIs, leading to Blood pressure
(ACEIs)
hypertension

Decreases effects of
Alpha-Blockers Butcher’s Broom, Blood pressure
alpha-blockers, leading to
Yohimbine
hypertension

Danshen, Garlic, Ginkgo Electrocardiogram;

Increases bleeding risk
biloba, Saw palmetto avoid if possible
Antiplatelets Increases activity of
Signs and symptoms of
St. John’s wort clopidogrel, leading to
bleeding
increased bleed risk

Fumitory, Lily of the Increases effects of beta-

Blood pressure and
valley, Night-blooming blockers, leading to
heart rate
cereus hypotension and bradycardia
Beta-Blockers
Decreases effects of
Green tea, Ma-huang Blood pressure and
beta-blockers, leading to
(ephedra), Yohimbine heart rate
hypertension and tachycardia

Fumitory, Grapefruit
Increases effects of CCBs,
juice, Hawthorn, Khella, Blood pressure and
leading to vasodilation,
Lily of the valley, Night- heart rate
hypotension, and bradycardia
Calcium Channel blooming cereus
Blockers (CCBs)
Decreases the effects
Blood pressure and
St. John’s wort of CCBs, leading to
heart rate
hypertension and tachycardia

Digoxin serum
Causes hypokalemia,
concentration,
Aloe vera, Licorice increasing risk of digoxin
serum potassium,
toxicity
electrocardiogram

Danshen, Fumitory,
Digoxin serum
Hawthorn, Lily of the Potentiates action of digoxin,
concentration,
Digoxin valley, Night-blooming increasing risk for toxicity
electrocardiogram
cereus, Strophanthus

Digoxin serum
Decreases digoxin
St. John’s wort concentration,
concentration
electrocardiogram

Chan Su, Danshen, Digoxin serum

Interacts with digoxin assay
Ginseng, Uzara root concentration

Potentiates action of nitrates,

Nitrates Hawthorn leading to vasodilation and Blood pressure
hypotension

Monoamine Capsicum, Ma-huang

Oxidase (ephedra), St. John’s Increases blood pressure Blood pressure
Inhibitors wort

Liver fu Serum
Increases effects of
Spironolactone Licorice potassium nction test;
spironolactone
avoid use if possible

Alfalfa, Bilberry,
Danshen, Dong quai,
International normalized
Fenugreek, Garlic,
Increases bleeding risk ratio, signs and
Ginger, Ginkgo biloba,
symptoms of bleeding
Warfarin Grapefruit juice, Khella,
Saw palmetto

International normalized
Ginseng, Green tea, Soy
Decreases effects of warfarin ratio due to need for
milk, St. John’s wort
potential dose increase

Monitoring
Supplement or
CV Medication Interaction Parameter/
Herbal Product
Recommendation
Electrocardiogram
Avoid use in patients
Echinacea, St. John’s
Increases QT interval with a prolonged QTc
wort
and/or congenital QT
Amiodarone syndrome

Decreases effects of
Grapefruit juice, St. Electrocardiogram
amiodarone, leading to
John’s wort Avoid if possible
potential arrhythmias

Electrocardiogram
Echinacea, Ma-huang Avoid use in patients
(ephedra), St. John’s Increases QT interval with a prolonged QTc
Class I wort and/or congenital QT
syndrome
Antiarrhythmic
Drugs
Lily of the valley Increases effects of quinidine Avoid

Decreases effectiveness, Electrocardiogram

St. John’s wort
leading to arrhythmias Avoid use if possible

Increases effects of statins

Grapefruit juice Symptoms of myalgias
and risk of myalgias
Statins
Increases risk of hepatotoxic Liver function test
Echinacea
effects Avoid use if possible

PREVENT POTENTIAL ERRORS

Educate patients and providers about the potential adverse effects of OTC products
and drug-drug interactions with CV medications.

Closely monitor patients with CV disease for harmful effects or toxicities from OTC
products.

Perform accurate patient medication histories to ensure all OTC products are known;
encourage patients to report all OTC and herbal products.

Create OTC/herbal products drug-drug interactions alert database in the electronic

medical record.

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ACC.org/Infographics
©2021 American College of Cardiology W21014