(317) Ginkgo Biloba Interaction with Non-Steroidal Anti-Inflammatory Drugs and The Potential Risk of Bleeding

Publication Number: 991

Background: Ginkgo Biloba (GB) is a herbal product used to enhance cognitive functions, blood flow improvement, as an antioxidant, and for its antiplatelet activity. Some studies showed that GB may increase the risk of bleeding by impairing platelet aggregation.

Objectives: This review aims to assess the relatedness of the potential drug-herbal interaction between GB and NSAIDs as a part of drug –herbal interaction assessment project initiated by the Saudi Food and Drug Authority.

Methods: This safety review utilized several sources. First, a systematic literature search was performed in Cochrane, PubMed, and Google Scholar. Also, a search was performed in Adis Insight database, and the Natural Medicines Database. The search included published work from inception to February 2022 for eligible English publications with appropriate keywords (Table 1). Moreover, a search in the World Health Organization (WHO) database (VigiBase) was conducted in February 2021 to retrieve all reported cases worldwide of potential drug-herbal interaction between GB and NSAIDs. The assessment was performed and guided by the Strength-of-Recommendation Taxonomy tool. The interaction rate was determined based on the level of significance.

Results: We found four published case reports, one randomized clinical trial (RCT), and 2 observational studies that reported GB interaction with NSAIDs. Case reports retrieved from the literature were reported with ibuprofen (n=1), Aspirin (n=3), and rofecoxib (n=1). Case reports suggest a temporal pharmacodynamics interaction between GB and NSAIDs, resulting in bleeding. One of the cases reported a temporal fatal intracerebral mass bleeding in a healthy subject who used to take GB and started ibuprofen 4 weeks prior to his death with no other confounders. In the observational studies, the researchers reported some cases of bleeding with the concomitant administration of GB and NSAIDs. However, the RCT that included a small sample size did not find a clinically or a statistically significant increased risk of bleeding with the concomitant use of aspirin and GB in adults. The search in VigiBase revealed 13 interactions between GB with aspirin (n=7), meloxicam and naproxen (n=1), diclofenac (n=2), and ibuprofen (n=3). Overall, the interaction severity was high and caused life-threatening reactions. The interaction rate was moderate required avoiding the combination, and the likelihood of occurrence was probable.

Conclusions: The available evidence shows that there is a possible pharmacodynamics interaction between GB and NSAIDs. Further assessment by well-designed pharmacoepidemiological studies is needed to determine the magnitude of the interaction.