Current Drug Safety - Volume 20, Issue 2, 2025

The concomitant use of herbal remedies in conjunction with conventional cardiac medications has increased significantly in recent years, primarily due to improvements in the quality standards of herbal medicines and the pervasive belief that natural products pose no harm to the human body. Contrary to this belief, multiple phytoconstituents found in herbal products have the potential to interact with conventional cardiac drugs, potentially resulting in severe adverse effects.

This review aimed to elucidate the intricacies of these interactions highlighting herbal medications that interact with established pharmaceuticals used for the treatment of cardiovascular disorders. Moreover, the review draws attention to safety concerns and preventative steps that should be taken by patients and medical professionals. This endeavor is vital to avert adverse events stemming from such interactions.

Our approach entailed a comprehensive literature review employing keywords such as “mechanisms of herb-drug interactions,” “herbal medications,” and “cardiovascular disorders”. The drugs presented in this review were selected based on their popularity among the general population, frequency of their employability, and potential to manifest drug interactions. We sourced pertinent information from reputable databases, including PubMed, Scopus, and Elsevier.

Heart or blood vessel disorders are referred to as cardiovascular diseases (CVDs), which include conditions such as heart failure, stroke, hypertensive heart disease, and peripheral arterial disease. The primary underlying factor for the development of CVDs is dyslipidemia, which can be treated with classical antihyperlipidemic drugs such as statins, ezetimibe, and PCSK9-inhibitors. The use of herbal remedies is often unregulated, and there is a lack of scientific evidence supporting their use, particularly in the management of heart failure. Patients may not disclose their use of herbal remedies to health care practitioners, which can result in potential harm.

Uncontrolled dyslipidemia leads to hypercholesterolemia, which can result in atherosclerotic plaques and blocked arteries and veins. Herbal remedies and botanical products are also used to prevent or treat illnesses, and many prescription pharmaceuticals are made from plant compounds. Herbal remedies are often preferred because of the belief that they are safe and have no potential to cause harm. However, there is insufficient scientific data to support the use of herbal remedies, especially when treating heart disease. Using herbal remedies in conjunction with medicinal pharmaceuticals may result in unfavorable effects.

Some drugs cause tongue disorders as adverse effects. Most of the drug-induced tongue disorders are benign and will resolve after drug discontinuation. However, the changes in the color or appearance of the tongue may frighten patients and decrease compliance with drug therapy.

To review the literature to find all reports of drug-induced tongue disorders, their presentation, management, and outcome of patients.

The search was conducted in Google Scholar and PubMed using key words “ageusia,” “burning tongue,” “coated tongue,” “drug-induced taste disturbances,” “dysgeusia,” “glossitis,” “glossodynia," “hairy tongue,” “hypogeusia,” “stomatodynia,” “stomatopyrosis,” “swollen tongue” “tongue discoloration,” “tongue irritation,” “tongue numbness, “tongue oedema,” and “tongue ulcer. All reports that were published from 1980 to 2022 in the English language were included in the study. Reports that were not in English language but had English abstracts with adequate data for extraction were also included.

A total of 208 case reports and case series were included. The most reported drug classes were antineoplastic and immunomodulating agents and anti-infectives for systemic use, and the most common tongue disorders were tongue discoloration and black hairy tongue. Having good oral hygiene and discontinuing the offending drug could manage and resolve the problem.

Drug-induced tongue disorders are not rare adverse drug reactions. They are benign in most cases, and withholding offending agents results in significant improvement or complete resolution of tongue lesions.

Hyperprolactinemia is a commonly underestimated adverse effect of antipsychotic medications. There are still no consensus guidelines for the optimal monitoring and treatment strategies.

The aim of the study was to assess the monitoring and treatment practices of antipsychotic-induced hyperprolactinemia, in addition to the prevalence and risk factors associated with it.

A retrospective cohort observational study was conducted among patients attending the psychiatric clinics at an academic tertiary hospital in Riyadh, Saudi Arabia, from May 2020 until May 2021, by reviewing each patient’s medical record for up to five years.

Among the 662 patients, 35 patients (5.3%) and 242 patients (36.6%) had their serum prolactin levels monitored (at baseline and at follow-up, respectively). The prevalence of hyperprolactinemia was observed in 212 patients (32%). Only 76 patients (36%) were symptomatic. Female gender, younger age, and bipolar disorder had a significantly higher risk of developing hyperprolactinemia. 60% of the confirmed cases received treatment, of which 76 (60%) were adherent to treatment guidelines. The most common treatment strategies implemented were dose reduction (42.5%) and aripiprazole augmentation (29.1%).

It is imperative to conduct a baseline check of prolactin levels before commencing any antipsychotic therapy. Similarly, routine prolactin level monitoring is recommended regardless of symptoms in patients treated with antipsychotics with a possible prolactin-raising effect. Adherence to evidence-based treatment guidelines can improve patient quality of life and therapeutic compliance.

Hand–Foot Syndrome (HFS), also known as palmar–plantar erythrodysesthesia, is a common reaction to Tyrosine Kinase Inhibitors (TKIs), which can often lead to discontinuation of the drug. Lenvatinib is a recently approved drug for the treatment of endometrial carcinoma, which has been proven to provide a better overall survival rate and longer duration of progression-free survival among patients with advanced endometrial cancer. Herein, we have reported a case of carcinoma endometrium with metastasis who had to discontinue the use of lenvatinib due to the adverse drug reaction.

A 60-year-old female patient with carcinoma endometrium with metastasis, post radical hysterectomy with bilateral salpingo–oophorectomy with omentectomy, was started on tablet lenvatinib 8 mg once daily orally for 15 days. After 12 days of treatment, the patient noticed painful lesions with reddish-black discoloration over the left forearm and dorsal aspect of the left hand and fingers, and was diagnosed with lenvatinib-induced hand-foot syndrome. Lenvatinib was discontinued and tab. prednisolone 30mg was taken orally. The reaction subsided after five days.

Hand-foot syndrome is one of the commonest ADRs due to the use of lenvatinib. Lenvatinib is an oral formulation that patients can take at their homes. Hence, educating patients regarding the HFS is important so that they report it to the treating physicians on time. It is also essential to educate patients regarding the precautions to be taken to avoid hand-foot syndrome. This will help the physicians with the early discontinuation and appropriate treatment with corticosteroids, which will help in improving the quality of life of the patients already suffering from cancer.

Levetiracetam, a relatively recent addition to antiepileptic medications, is known for its broad-spectrum efficacy in treating partial and generalized tonic-clonic seizures in individuals of all age groups. Despite its favourable tolerability profile, rare instances of psychiatric side effects have been reported. This case study presents a rare occurrence of significant behavioural changes attributed to levetiracetam in a young female patient.

A 40-year-old woman with a long-standing history of epilepsy, well-managed with medication, presented with abrupt-onset behavioural changes, including irritability, aggression, crying spells, insomnia, increased talkativeness, and screaming. Notably, these behavioural changes were unrelated to seizure activity and emerged without precedent. A dose reduction of levetiracetam was also attempted, which proved ineffective in mitigating her symptoms.

Consequently, the drug was discontinued, resulting in the resolution of the behavioural symptoms. This case highlights levetiracetam as the likely causative factor behind the observed significant behavioural changes.

Prescribing cascade is a condition in which a drug administered to a patient causes an adverse reaction that is misinterpreted as a new condition, resulting in the addition of a new drug.

Here, we report the case of an elderly female patient who suffered from metabolic, neurologic, and urinary consequences of a prescribing cascade of antiemetic, antiepileptic, and dopaminergic drugs. While levosulpiride caused Parkinsonian symptoms, the dopaminergic drugs and valproate caused refractory hyponatremia followed by altered sensorium, and clidinium contributed to urinary retention.

The case highlights the need to be vigilant for adverse consequences of the prescribing cascade, especially for antiemetic drugs, such as levosulpiride, because of its propensity to induce extrapyramidal reactions in older patients. In cases of refractory hyponatremia, a trial of de-challenge of valproate and dopaminergic drugs should be considered. The identification and removal of the culprit drugs can rescue the patient from a disabling cycle of adverse drug reactions.

With the increasing use of traditional medicine, there is a need to be vigilant in identifying and reporting adverse reactions associated with them. Punarnava Mandura is a commonly used Ayurvedic medicine for the treatment of anemia. It is well tolerated by the patients. To our knowledge, allergic reactions to Punarnava Mandura have not been reported in the literature. We reported a case of adverse cutaneous reaction, which was probably associated with Purnarnava Mandura.

A 60-year-old female patient developed skin rashes over her neck region after taking Punarnava Mandura and other drugs for osteoarthritis. She recovered upon withdrawal of all the medicines and treatment with anti-allergic drugs. The patient re-initiated treatment for joint pain except for Punarnava Mandura and completed the course without a recurrence of the event making the Punarnava Mandura the culprit drug.

Punarnava Mandura may cause allergic reactions, and clinicians should keep such adverse reactions in mind when using traditional medicine and report them to increase the scientific literature in this area.

Serotonin syndrome is a potentially life-threatening condition that can occur as a result of the therapeutic use of serotonergic medications or drug interaction. In this study, we describe two cases of serotonin syndrome-associated hypertensive crisis following linezolid use.

The first patient was a 52-year-old female who was admitted due to a diabetic foot infection and pneumonia associated with a decreased consciousness level. Serotonin syndrome occurred 24 hours after starting the linezolid use. Resistant hypertension was the main hemodynamic finding. It could not be controlled with amlodipine, valsartan, prazosin, and nitroglycerin infusion. Resistant hypertension and other symptoms of serotonin syndrome were resolved about 48 hours after discontinuation of linezolid use.

The second case was a man with a history of kidney transplant, diabetes, and hypertension. He was admitted to the ICU due to severe COVID-19. Broad-spectrum antibiotics [linezolid, cefepime], and remdesivir was initiated. Following intubation, continuous infusion of fentanyl was used for sedation. Within 24 hours after fentanyl and linezolid initiation, severe agitation, eye clonus, hyperreflexia, hypertension [160-186 /90-110 mmHg], and tachycardia [>100/min] were noted. With the possible diagnosis of serotonin syndrome, fentanyl was discontinued, and morphine was initiated. The patient’s symptoms improved 48 hours after discontinuation of fentanyl.

Both patients had a history of well- controlled hypertension. Hypertensive crisis has occurred after recent or concurrent use of serotonergic agents with linezolid. A thorough evaluation of the patient’s medical history and current condition can help clinicians prevent this syndrome in critically ill patients.