Two years ago, Fred Bingham was on the verge of fainting in his New York City office. Panic set in for the 49-year-old PWA at the thought of losing consciousness. “What’s happening to me?” he wondered as he groped for a seat. A day earlier, he had added kava kava—a commonly used, relatively safe anti-anxiety South Pacific root extract—to his longstanding mix of mood-stabilizing and anti-anxiety drugs. Bingham later realized that the kava kava had increased the tranquilizing effect of one of the meds, causing even greater sedation. The result, he says, was “waves of passing out.” So, ironically, the herb he was taking to help counter anxiety had ended up worsening it. He landed in the emergency room, where doctors observed him for several hours until the episode passed.

The funny thing is, Bingham is no herbal neophyte. For years he had been combining herbs and meds, with thriving health to show for it. His experience had even inspired him to found a PWA buyers club, Direct Access Alternative Information Resources. He made sure that its website offered reams of alternative treatment info. Yet at the time he swallowed his first kava kava caps, their possible drug interaction had not been reported, and so he was blissfully unaware of the risks.

The consciousness-lowering event that Bingham describes is a cautionary tale for the growing number of PWAs who are combining herbs with meds. Earlier this year, some people were shocked to learn that St. John’s wort—used to treat depression—had been shown to significantly lower blood levels, and effectiveness, of indinavir (Crixivan). The herb may have similar effects on other protease inhibitors and non-nukes (NNRTIs) (see “Curb the Herb,” POZ, April 2000). So while many HIVers understand that herbs, used appropriately, can be safe and effective (often with fewer side effects than drugs), fewer realize that herbal medicine is far from risk-free. Many of the potential downsides have been known for decades, but it has taken the growing interest in drug-herb combinations to finally spark even minimal research on interactions. What follows are some strategies to help you avoid such potential herbal pitfalls as side effects, drug interactions, allergies and even dangerous products.

SIDE EFFECTS: Like pharmaceuticals, every herb has a range of chemical activity and can potentially cause side effects (see “Natural Selection”), depending on how much you take and for how long, as well as on your own “biochemical individuality”—your unique sensitivity to various substances. With certain herbs, long-term use and high doses are inappropriate and can lead to side effects, especially for people with HIV. Licorice extract, for instance, can be used in small quantities for four to six weeks in a Chinese herbal formula. But large doses for short periods or small amounts for more than six weeks can cause high blood pressure,  potassium loss, edema (swelling from fluid accumulation) and hormonal imbalances. Even single doses of some powerful herbal stimulants used for bronchitis or low sexual energy, such as ephedra, guarana and yohimbe, can pose a risk, especially for people with high blood pressure or heart problems. Expert advice from a health practitioner and good background info are advisable for anyone considering herbal use—and an absolute must for those with serious conditions. Pregnant or breastfeeding women may need to be especially cautious.

ALLERGIC REACTIONS: Some herbs that are safe for most people might cause a reaction in your body. Among those reported to occasionally induce reactions are chamomile, cayenne, echinacea, garlic, kava kava, kelp and valerian. Be alert for unusual symptoms such as rash, nausea or upset stomach, especially when first starting a remedy. If you think you’re having an allergic reaction, stop taking the herb and talk to your doctor immediately.

TOXIC HERBS: Most herbs are safe when taken as directed. But plants containing certain types of alkaloids (a large family of complex chemicals) can be toxic, especially to the liver and kidneys. Because they can possibly trigger dangerous reactions, the following herbs should not be used internally unless directed and monitored by a knowledgeable practitioner: aconite, chaparral, comfrey, germander (often substituted for the safe sedative herb skullcap), mistletoe, pennyroyal and sassafras.

INTERACTIONS: Since herbs act as medicines, it is possible for them to counteract or potentiate (increase) the effects of pharmaceuticals or other herbs taken simultaneously. Some plants may have both effects: Herbal stimulants can significantly—sometimes even dangerously—increase the action of any other type of upper, while counteracting the intended effects of some sedatives and downers. A good guideline is to avoid combining an herb with similar-acting drugs or herbs. One example: If garlic or ginkgo biloba are combined with warfarin (Coumadin), heparin or aspirin—all of which act as blood thinners—the result can be excessive bleeding. For the same reason, people with hemophilia in particular should not use garlic and ginkgo together. On the other hand, some herbs may counteract the negative effects of certain drugs. For instance, milk thistle can reduce liver damage from several toxic drugs while not interfering with their therapeutic action.

RELIABLE PRODUCTS: Unfortunately, the lack of government-mandated quality assurance means that herbal products can vary in potency and quality and may even be misidentified (see “Choose Me,” POZ, April 2000). Besides obtaining product recommendations from an alternative practitioner, it may be wise to buy from reputable companies known to sell quality products (see Resources, below). Experts advise avoiding self-prescribed (as opposed to practitioner-recommended) premixed Chinese herbal products, some of which are known to be mislabeled, adulterated with pharmaceuticals or mixed with toxic herbs or heavy metals.

EXPERT HELP: There are reliable sources of information worth consulting, but self-diagnosis and self-prescribing can be risky. Look to naturopathic physicians, herbalists and other alternative practitioners (some acupuncturists, chiropractors and nutritionists are versed in herbs). If possible, seek out those who are also knowledgeable about pharmaceuticals, especially anti-HIV medicines. And don’t forget your own body’s symptoms for guidance on the “what, why and how” of safe herb use. While many MDs may not be adequately trained when it comes to medicinal plants, some are aware of interactions, and most can help with diagnosing problems. To prevent harmful interactions and side effects, and to avoid duplication of medicines, keep your doctor, pharmacist and alternative practitioner informed about all of the treatments you’re taking.

After Fred Bingham’s near-fainting spell, he went cold turkey on the kava kava when taking anti-anxiety meds. And while he still uses herbs in an informed way to improve his health, he notes, “I’ll certainly be more cautious the next time I decide to mix plants with pharmaceuticals.” Touché.

Some reliable sources of info and products

Websites: (Herb Research Foundation);
(Henriette’s Herbal Homepage); (Direct Access Alternative Information Resources); (American Association of Naturopathic Physicians)

Books: Physician’s Desk Reference for Herbal Medicines (Medical Economics Company); Herb Contraindications and Drug Interactions, by Francis Brinker, ND (Eclectic Medical Publications); The New Holistic Herbal, by David Hoffman (Element Press); A-Z Guide to Drug-Herb-Vitamin Interactions, edited by Schuyler W. Lininger Jr. (Prima Health)

Reputable herbal product companies: Eclectic Institute, Gaia Herbs, Health Concerns, Herb Pharm, Jarrow, Kyolic, Nature’s Herbs, Source Naturals, Zand