Written by Dr. Galina Kosyak,
Patients rarely file herbal products under “medication”, so they rarely mention them. For anyone doing medication reconciliation or patient education, that silence is a practical problem: herbal products are pharmacologically active, and several carry well-characterised interactions. Here is how to ask, what to ask about, and why the label limits what you can assess.
Ask a patient what medications they take and you will usually get a reasonable list. Ask what else they take and the list often grows – a turmeric capsule every morning, something for sleep a friend recommended, a mushroom powder in the smoothie, an echinacea tincture kept in the cupboard for winter.
That second list rarely makes it into the chart. Not because patients are concealing anything, but because most of them do not file these products under “medication” at all. They are food. They came from a shop, not a pharmacy. Nobody wrote a prescription.
For anyone doing medication reconciliation, patient education or care coordination, that gap is a practical problem rather than a philosophical one. Herbal products are pharmacologically active. As the National Center for Complementary and Integrative Health puts it plainly in its clinician guidance, herbal products carry the same dangers as other pharmacologically active compounds, even though the public tends to assume otherwise.
Why the question usually fails
The standard phrasing does most of the damage. “Are you taking any other medications?” invites a patient to mentally exclude anything sold in the vitamin aisle. “Any supplements?” is better, though many people interpret “supplements” narrowly – a multivitamin, perhaps, but not the herbal tincture or the powdered extract.
Three reframings tend to work better in practice:
Ask about the container, not the category. “What’s in your medicine cabinet besides your prescriptions? Anything in a bottle, a capsule or a dropper?” This invites an inventory rather than a judgement about what counts.
Ask about purpose. “Is there anything you take for sleep, for energy, for joints, for digestion?” Patients who would never describe themselves as supplement users will readily describe what they take and why.
Ask them to bring the bottles. A photograph of the labels on a phone is enough. This single request resolves more ambiguity than any amount of questioning, for reasons that become clear below.
It also helps to signal that the question is clinical rather than disapproving. Patients who expect to be lectured tend to answer briefly. Patients who understand you are checking for interactions tend to be thorough.
What actually matters clinically
The literature on herb-drug interactions is uneven – a great deal of it is inferred from animal studies or cell assays rather than observed in patients. NCCIH is explicit about this, and it is worth carrying that caution into practice rather than treating every theoretical interaction as established fact.
That said, several are well enough characterized to warrant routine attention. NCCIH’s own clinician digest on herb-drug interactions highlights a short list worth knowing by name:
- St John’s wort carries a high risk of interaction through enzyme induction, with documented effects on cyclosporine, oral contraceptives and digoxin. Of everything on the shelf, this is the one to ask about directly.
- Ginkgo biloba increases bleeding risk in patients on warfarin, and is incompatible with efavirenz.
- Goldenseal reduced metformin levels by roughly a quarter in an NCCIH-funded study – a relevant signal for any patient managing glucose.
- Green tea at high doses reduces the effectiveness of nadolol and atorvastatin.
- Asian ginseng has mixed evidence around calcium channel blockers, statins, antidepressants and warfarin.
- Chamomile, cranberry and cat’s claw each carry plausible interactions – with oral contraceptives, warfarin and anticoagulants respectively – on thinner evidence.
The perioperative period deserves separate attention. Several widely used botanicals affect platelet function or interact with anaesthesia, which is why most surgical practices ask patients to stop herbal products one to two weeks before an operation. Patients frequently do not connect that instruction to the bottle in their kitchen, because in their mind it is not a drug. Making the instruction concrete – naming the products, not the category – improves compliance considerably.
The label problem, and why it limits what you can assess
Here is where the bottles matter. Suppose a patient reports taking “echinacea”. That word alone is close to useless clinically.
There are several species sold under that name, and they are not equivalent. The same applies across the botanical shelf: different species share a common name, and different parts of the same plant – root, leaf, aerial parts, bark – differ substantially in composition. An extract and a powdered whole herb of the same species are not interchangeable either, and the concentration ratio is frequently absent from the label altogether.
So the useful information on a supplement label is narrow and specific:
- The botanical name. Hydrastis canadensis is goldenseal. Other species contain the same headline compound and are cheaper. Without the binomial, the identity is not guaranteed.
- The part of the plant. Root and rhizome behave differently from aerial parts.
- The form. Extract or whole herb, and at what ratio.
- A lot number and date. Basic, and the quickest indication that someone is keeping records.
There is one more line worth teaching patients to read, and it is the only mandatory disclosure about the supply chain on the entire package. US labelling rules require the name and address of the manufacturer, packer or distributor – any one of the three satisfies the requirement. If the company named did not make the product, it must say so, using a qualifier such as “Distributed by” or “Manufactured for”. Nothing requires the country of manufacture to appear anywhere.
The practical consequence is that an American address on a bottle tells you where a company is, not where a product was made. A handful of manufacturers publish this detail openly; AMPEXT, a US plant-extraction company, has written a plain-English explanation of what supplement labels do and do not disclose, which is a useful thing to point patients toward when they ask how to compare products.
Documenting it
Whatever the patient reports belongs in the record in the same way a prescription would – product name, botanical name if available, dose, frequency, how long they have been taking it, and why. “Takes herbal supplements” is not documentation; it is a note that the question was asked.
Two habits make this sustainable. Re-ask at every reconciliation rather than once at intake, because supplement use is episodic and often seasonal. And record the reason alongside the product – a patient taking valerian for sleep and a patient taking valerian because a relative suggested it are different conversations when the time comes to discuss stopping.
The underlying point
None of this requires taking a position on whether herbal products are beneficial. The clinical question is narrower and more answerable: what is this patient actually ingesting, and does it interact with anything else they are taking.
That question cannot be answered if it is never asked in language the patient recognises, and it cannot be answered accurately if the answer arrives as a common plant name with no species, no plant part and no form attached.
Ask about the cabinet. Ask them to bring the bottles. Write down what the label says.
About the author
Galina Kosyak, PhD in Medical Sciences, is Medical and Scientific Advisor at AMPEXT (American Plant Extraction). A physician trained in physical medicine and rehabilitation, she earned her medical degree in 1999 and later a PhD in Medical Sciences, and spent many years as a Senior Research Scientist at the Research Institute of Medical and Social Expertise and Rehabilitation, where she conducted clinical research in rehabilitation medicine. At AMPEXT she reviews educational articles and product monographs for accuracy and balance against current evidence. Full biography and editorial policy: ampext.com/information/author-g-kosyak
Disclosure: the author is affiliated with AMPEXT, which is named in this article.
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