What herbals should be avoided while taking steroids, such as prednisone?

Herbal Supplements to Avoid While Taking Steroids

Several herbal supplements should be avoided while taking steroids such as prednisone due to potential dangerous interactions that can affect drug metabolism, increase side effects, or reduce therapeutic efficacy.

Key Herbal Supplements to Avoid

Herbs that Interact with Steroid Metabolism:

• St. John's Wort: Must be avoided as it's a strong inducer of cytochrome P450 3A4 enzymes, which can accelerate steroid metabolism and reduce effectiveness 1, 2. Requires a 2-week washout period before starting or after stopping 1.
• Licorice (Glycyrrhiza glabra): Avoid due to potential additive effects with corticosteroids and interference with the pharmacological effects of other medications like spironolactone 3, 4.
• Ginseng (Panax ginseng): Should not be used with corticosteroids because of possible additive effects that could increase steroid-related side effects 3.

Herbs that Affect Blood Pressure (Important with Steroids):

• Ma Huang (Ephedra): Avoid as it can raise blood pressure, which is particularly concerning since steroids can also cause hypertension 1.
• Yohimbine: Avoid due to increased risk of hypertension, especially problematic with steroids that can already elevate blood pressure 1.
• Nettle: Can induce hypotensive action and has diuretic effects that may complicate fluid/electrolyte balance in patients on steroids 1.

Herbs with Immunomodulatory Effects:

• Echinacea and other immunostimulants: Should not be given with immunosuppressants like corticosteroids as they work in opposing ways 3.

Timing Considerations

For patients who need to discontinue herbal supplements before starting steroid therapy:

• Most herbs with significant interactions should be discontinued at least 2 weeks before starting steroid therapy 1
• For surgical patients on steroids, herbs like St. John's wort, ginseng, and garlic should be held for 2 weeks prior to procedures 1

Monitoring Recommendations

When patients are on steroids and have been taking herbal supplements:

1. Monitor blood pressure more frequently, especially if the patient was taking herbs known to affect blood pressure
2. Watch for signs of altered steroid efficacy (either increased or decreased effects)
3. Monitor for exacerbation of steroid side effects, particularly:
   • Fluid retention
   • Blood glucose levels (especially with herbs like karela and ginseng that may affect glucose) 3
   • Electrolyte imbalances

Special Considerations

• Pregnancy and breastfeeding: Additional caution is needed when combining steroids with herbal supplements during pregnancy or breastfeeding 1
• Perioperative period: If a patient is taking steroids and requires surgery, particular attention should be paid to discontinuing problematic herbal supplements 1

Common Pitfalls to Avoid

1. Assuming "natural" means safe: Many patients incorrectly believe herbal supplements are always safe because they're natural
2. Incomplete medication history: Patients often don't report herbal supplement use unless specifically asked
3. Delayed effects: Some herb-drug interactions may not be immediately apparent but can develop over time
4. Variable product quality: Herbal supplements lack standardization, making effects and interactions unpredictable 5

Always ask patients specifically about herbal supplement use when prescribing steroids, as many patients don't consider these to be "medications" and may not disclose their use unless directly questioned.