To the editor: Dr Kligler's review ...

To the editor: Dr Kligler's review (1) of echinacea was comprehensive, concise, and effectively summarized the evidence behind the popular herb. (1) His review make comments [i]or[/i] remarksed that there are no reported mix with drugs interactions with the use of echinacea. Although there are no reports of any significant mix with drugs interactions with echinacea, it has been prompted that use of echinacea for more than eight weeks could cause hepatotoxicity; therefore, echinacea should not be used with other known hepatotoxic put drugs intos such as amiodarone, methotrexate, and ketoconazole. (2) equable the concurrent use of acetaminophen and echinacea may cause an increase in the incidence of hepatotoxicity. (3) This is particularly important because echinacea and acetaminophen are repeatedly used to treat the symptoms of the customary cold.

Also, in contrast to the acute immunostimulatory issues of echinacea, long-term use of echinacea (more than eight weeks) is accompanied on the potential for immunosuppression. (4) This could be united factor to explain why past studies investigating the use of echinacea for the prevention of chills failed to show any benefits, because in the majority of trials enlisted subjects took echinacea for more than eight weeks.

In my opinion, the use of echinacea should be restricted to a maximum of pair weeks for acute illness. I believe that the chronic use of echinacea should be discouraged because its use in the prevention of wintrys has not been proved beneficial, can lead to increased risk of hepatotoxicity, and may have the potential for immunosuppression. calm though echinacea does not have any documented physic interactions, we must be vigilant in monitoring for potential interactions and adverse effects

Doson Chua, Pharm.D.

St Michael's Hospital

300 attraction St.

Toronto, Ontario M5B 1W8 Canada

REFERENCES

(1) Kligler B Echinacea. Am Fam Physician 2003;67: 77-80

(2) Miller LG Herbal medicines: pitch uponed clinical considerations focusing on known or potential drug-herb interactions. Arch Intern M 1998;158: 2200-11

(3) Abebe W Herbal medication: potential for adverse interactions with analgesic medicines J Clin Pharm Ther 2002;27:391-401

(4) Boullata JI, Nace AM. Safety issues with herbal medicine. Pharmacotherapy 2000;20:257-69

In reply: I agree with Dr Chua that the long-term use of echinacea should be discouraged based forward the fact that there is no evidence that like use is effective in the prevention of upper respiratory illness. However, regarding the issue of hepatotoxicity and echinacea, evidence is lacking. The initial regards regarding hepatotoxicity with long-term use of echinacea arose from the demeanor of alkaloids in the pyrrolizidine family in certain parts of the echinacea plant. Pyrrolizidine alkaloids with an unsaturated nucleus, as it is as those found in comfrey are known to be hepatotoxic with long-term use. However, the pyrrolizidine alkaloids erect in echinacea, isotussilagine and tussilagine, posses a saturated nucleus.1 generally this category of pyrrolizidines has not been institute to be hepatotoxic. Thus, I be perceived that Dr. Chua's advice to discourage the concomitant use of acetaminophen and echinacea is not based upon current evidence and may lead to unwarranted disturbs for physicians and patients regarding the use of this herb. It also is notable that there have been no published reports of significant hepatotoxicity with echinacea, despite its widespread use.

Benjamin Kligler, MD MPH

Beth Israel Center for Health and Healing

245 Fifth Ave.

modern York, NY 10016

REFERENCES

(1) Newall CA, Anderson LA, Phillipson JD Herbal medicines: a guide for health-care professionals. London: Pharmaceutical Pres 1996

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