Critical evaluation of causality assessment of herb-drug interactions in patients

Br J Clin Pharmacol. 2018 Apr;84(4):679-693. doi: 10.1111/bcp.13490. Epub 2018 Jan 29.


The aim of this review was to assess the severity of adverse drug reactions (ADRs) due to herb-drug interactions (HDI) in patients taking herbs and prescribed medications based on published evidence. Electronic databases of PubMed, the Cochrane Library, Medline and Scopus were searched for randomized or nonrandomized clinical studies, case-control and case reports of HDI. The data were extracted and the causal relationship of ADRs as consequences of HDI assessed using Horn's drug interaction probability scale or Roussel Uclaf Causality Assessment Method scoring systems. The mechanism of interaction was ascertained using Stockley's herbal medicine interaction companion. Forty-nine case reports and two observational studies with 15 cases of ADRs were recorded. The majority of the patients were diagnosed with cardiovascular diseases (30.60%), cancer (22.45%) and renal transplants (16.32%) receiving mostly warfarin, alkylating agents and cyclosporine, respectively. HDI occurred in patients resulting in clinical ADRs with different severity. Patients may poorly respond to therapeutic agents or develop toxicity due to severe HDI, which in either scenario may increase the cost of treatment and/or lead to or prolong patient hospitalization. It is warranted to increase patient awareness of the potential interaction between herbs and prescribed medicines and their consequences to curb HDI as a potential health problem.

Keywords: adverse drug reactions; causality assessment; herb-drug interactions; herb-induced liver injury; herbal drugs; side effects.

Publication types

  • Review

MeSH terms

  • Drug-Related Side Effects and Adverse Reactions / epidemiology*
  • Herb-Drug Interactions*
  • Humans
  • Plant Preparations / administration & dosage
  • Plant Preparations / adverse effects*
  • Randomized Controlled Trials as Topic
  • Severity of Illness Index


  • Plant Preparations