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"Polyherbacy": Herbal Supplements as a Form of Polypharmacy in Older Adults

University of Iowa Hospitals and Clinics Iowa City, Iowa

To the Editor:

Excessive or inappropriate medication use has been acknowledged as one of the most significant health issues affecting the geriatric population (1). The increasing utilization of herbs and other dietary supplements by older adults (2–4) has added a new layer of complexity to the problem represented by polypharmacy in the elderly. We present a case that illustrates the potential impact that herbal use may have on the clinical management of elderly patients.

Case

Mrs. S is an 83-year-old woman who came to our Geriatrics Clinic with a complaint of fatigue and recurrent falls. She had a history of hypertension, hyperlipidemia, stroke, and glaucoma. Her medications included hydrochlorothiazide, glaucoma eye drops, and a dietary supplement. The physical examination revealed a pulse rate of 72 bpm lying down and 94 bpm standing up. Blood pressure was 148/72 mmHg lying down and 140/70 mmHg standing up; respiratory rate 18 rpm and temperature 36.9°C. The thyroid was not palpable. Lungs, heart, abdomen, and extremities were normal. Her gait was wide based. She was cognitively and functionally intact. Electrocardiogram showed left ventricular hypertrophy. Laboratory work yielded normal blood count, electrolytes, renal and liver profiles, and B₁₂ level. Low-density lipoprotein cholesterol was elevated. Her thyroid-stimulating hormone (TSH) was suppressed.

Mrs. S was asked to discontinue her supplement and bring it to her next appointment for evaluation. She was asked also to stop her diuretic and to begin aspirin and a statin.

At the next visit, Mrs. S's supplement was found to contain numerous sea algae (micro-macro algae, Hawaiian Pacific spirulina, wakame powder, Japanese chlorella, Nova Scotia dulse, dunaliella salina, kombu seaweed), alfalfa, royal jelly, bee pollen, barley malt, licorice, Panax ginseng, Ginkgo biloba, stevia, astragalus, and other herbs. Orthostasis had resolved, but the patient was still mildly hypertensive. Fatigue had improved considerably. Repeat TSH and free T4 were normal.

Discussion

In older adults using herbal supplements, the potential risk for adverse herb–disease interactions is rather significant. The following potential adverse herb–disease interactions were identified in Mrs. S's case:

• • Use of sea algae may precipitate clinical or subclinical hyperthyroidism due to their high iodine content (5). Mrs. S's TSH normalized after interruption of her supplement. To our knowledge, hyperthyroidism has never been previously described in association with the algae contained in this particular supplement;
  
• • Licorice and ginseng have been linked to hypertension (6,7);
  
• • Ginseng may exacerbate hypotension as well (8);
  
• •Ginkgo biloba may increase the risk of bleeding in a patient with falls and using aspirin (9).
  

Health care providers should always inquire about herbal use as a routine part of history-taking and should also be aware of the side effects that may result from such products (10). It may be time to incorporate the term "polyherbacy" into our geriatric vocabulary.

Acknowledgments

Address correspondence to Jose Ness, MD, Division of General Internal Medicine, Department of Internal Medicine, SE624GH, 200 Hawkins Drive, Iowa City, IA 52242. E-mail: jose-ness{at}uiowa.edu

References

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5. Coronas J, Cruz Caparros G, Laynez Bretones F, Diez Garcia F. Hyperthyroidism secondary to kelp tablet ingestion. Med Clin.. 2002;118:797-798.
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