Musculoskeletal System
Respiratory System
EENT
Cardiovascular System
Gynecology
Nervous System
Gastrointestinal System
Genitourinary System
Endocrinology
Hematology
Dermatology

Herb-Drug Interactions:

Pharmacokinetics

1) Absorption
2) Metabolism - often affected by non-alcoholic fatty liver disease
3) Distribution
4) Elimination

Pharmacodynamics

The study of how drugs actually work in the body. For the most part completely not understood, just started lookin at the interaction between 2 drugs within the last year, much less addressing how 5 + drugs work together

Proton pump inhibitors does interact with hydrochloric acid, lack of that causes lack of intrinsic factor creating B12 deficiency -> pernicious anemia. low HCl akes proteins not be broken down effectively. Taking PPIs for 2+ years showed a significant INCREASE in hip fractures (Ca malabsorption), also a proness of pneumonia (reflux is not inhibited, just acidity, fluids reflux into the larynx to the lung)

Statins. Now being used as a primary interaction - to prevent those at risk, though they have not been shown to really prevent heart disease. Recommended for those w/ 2 risk factors for heart dz (being male AND being over 50 are BOTH risk factors). Block the formation of cholesterol, but also CoenzymeQ10 & Coenzyme CoA (low CoQ10 -> heart failure)

Estrogens. use up 3 major substances: deplete B6, Magnesium, Zinc

Thyroxine (Sythroid): too much inhibits Ca absorption

Nutrient-Drug Interactions

Vitamin D
Corticosteroids: interefere w/ conversion of Vitamin D to its active form in the kidney. To replace they need the converted form which requires a Rx.
Barbituates: intereferes w/ metabolism of vitamin D
Cimetidine: reduces vitamin D activation by the liver

Vitamin K comes from the intestines
Antibiotics: decreases intestinal synthesis of vitamin K
Warfarin: decreases anticoagulant effects of warfarin
Mineral Oil: interferes w/ absorption w/ vitamin K
Phentoin: reduces serum levels of vitamin K

Vitamin B6
Corticosteroids: increased excretion of Vitamin B6
Estrogens & Oral contraception: increased utilization of Vitamin B6
Levodopa: decreases effectiveness of L-Dopa by converting it in to dopamine outside the blood-brain barrier

Folic Acid
Estrogens & Oral Contraception: increased utilization of folate
Acetylsalicylic Acid (Aspirin): reduces folate levels
Methotrexate: direct antagonism d/t competition for active site on dihydrofolate reductase which decreases nucleic acid synthesis; can use 1 mg. folate daily if treating RA to reduce methotrexate toxicity

Vitamin C
Acetylsalicylic Acid (Aspirin): increases excretion of VitaminC
Tobacco: lowers serum levels of Vitamin C
Warfarin: increases anti-coagulant effects of warfarin

Calcium
Corticosteroids: interefere w/ Ca absorption & metabolism by their effect on Vitamin D
Tetracyclines: combine w/ Ca so that neither are absorbed (to avoid take them seperated by about 2 hours)
Thyroxine: causes excess Ca excretion

Iron
NSAIDS: irritation of gastric mucosa can -> mild blood loss & iron deficiency anemia
Tetracyclines: decreases absorption of both
Thyroxine: impairs absorption of thyroxine (give ~ 2 hours apart to avoid)
Warfarin: binds w/ iron, decreasing iron absorption

Magnesium
Corticosteroids: increase excretion of Mg
Diuretics: increases excretion of Mg (potassium sparing diuretics also spare Mg)
Tetracyclines: binds & decreases absorption of both substances
Warfarin: binds w/ Mg, thereby decreasing Mg absorption

Potassium
Corticosteroids: increase Potassium ecretion

Sodium
Corticosteroids: decrease excretion of Na

Zinc
Warfarin: binds w/ Zinc, decreasing absorption

Tryptophan
Anti-depressants that affect serotonin levels possible potentiation of the effects of the anti-depressants (risk of serotonin syndrome)

Tyrosine
MAO inhibitors: possible hypertensiive crisis if used w/ phenylalanine

Herb-Drug Interactions

Garlic
may potentiate warfarin

Dang Gui
mild antagonism of Warfarin

Grapefruit
increases liver enzyme levels - metabolism of Ca channel blockers, seldane, & cyclosporine in such a manner so as to increase serum levels of those drugs
Decreases absorption of penicillin & erythromycin

Ephedra
Contraindicated for use w/ anti-hypertensive medication
contraindicated w/ anti-thyroid medication
May cause cardiac arrythmia if used w/ digoxin

Gan Cao
potentiates effects of both glucocorticoids and mineralocorticoid (pseudo-aldosterone effects)
can cause hypertension, edema, hypernatremia, & hypokalemia due to aldosterone-like activity
de-glycyrrhizinated licorice root (DGL) has very little if any aldosterone-like activity - great tx for GERD

St. John's Wort
may potentiate MAO inhibitors
may potentiate SSRI's
increases liver enzyme systems, therefore increasing metabolism of MANY substances
decreases efficacy of protease inhibitors, oral contraceptives

Physical Exam
A. Observation of the whole body
B. Inspection
-Appearance, color, deformity, relationship to body
C. Palpation-Tenderness, Temperature (back of hand), Swelling, Spasm, Crepitus (audible or tactile)
D. ROM
-Measured in degrees of a circle - joint at center
-Abnorally limited by pain, spasmm inflammation, adhesions, deformity, swelling
-Passive
-Active - compare both with opposite side
E. Joint Position
-Position of function
-Position of comfort
F. Measurement
-Atrophy vs. Hypertrophy
G. Neurological Exam
-Muscle strength
-Cutaneous sensation - dermatomes
-DTR's