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Also stomach ulcer gastritis symptoms cheap 10mg rabeprazole otc, the ginger products used were not mentioned and some patients were taking more than one potentially interacting supplement gastritis not healing buy 20mg rabeprazole visa. Mechanism Ginger (Zingiber officinale) has sometimes been listed as a herb that interacts with warfarin5 gastritis diet 24 order rabeprazole 10mg line,6 on the basis that in vitro it inhibits platelet aggregation. However, this antiplatelet effect has generally not been demonstrated in controlled clinical studies (three of which have been reviewed7) although in one other study ginger had antiplatelet effects that were synergistic with those of nifedipine,8 see nifedipine, below. Importance and management Evidence from a controlled study suggests that ginger does not increase the anticoagulant effect of warfarin. Interactions of warfarin with garlic, ginger, ginkgo, or ginseng: nature of the evidence. Ginger + Caffeine For mention that sho-saiko-to (of which ginger is one of 7 constituents) only slightly reduced the metabolism of caffeine in one study, see Bupleurum + Caffeine, page 90. Ginger + Carbamazepine For mention that saiko-ka-ryukotsu-borei-to and sho-saiko-to (of which ginger is one of a number of constituents) did not affect the pharmacokinetics of carbamazepine in animal studies, see Bupleurum + Carbamazepine, page 90. Ginger + Isoniazid For details of an animal study to investigate a possible interaction between isoniazid and Trikatu, an Ayurvedic medicine containing ginger, black pepper and long pepper, see Pepper + Isoniazid, page 316. Ginger + Nifedipine A small study found that antiplatelet effects for ginger were synergistic with those of nifedipine, but any effect needs confirmation. Evidence, mechanism, importance and management In a small study in 10 hypertensive patients and another in 10 healthy subjects, ginger 1 g daily for 7 days given with nifedipine 10 mg twice daily for 7 days inhibited platelet aggregation by up to three times more than nifedipine alone. Nifedipine alone also had antiplatelet effects, but these were not as great as aspirin 75 mg 206 Ginger alone. The ginger used in this study was dried, but no other details about the preparation were given. Calcium-channel blockers are not generally viewed as antiplatelet drugs, and the finding of synergistic antiplatelet effects between nifedipine and aspirin in this report and its clinical relevance needs further study. Furthermore, this study suggests that ginger alone may have similar antiplatelet effects to low-dose aspirin alone; however, this antiplatelet effect has generally not been demonstrated in other controlled clinical studies of ginger (three of which have been reviewed2). Therefore, it is difficult to make any clinical recommendations on the basis of this one small study. Synergistic effect of ginger and nifedipine on human platelet aggregation: a study in hypertensive patients and normal volunteers. Ginger + Ofloxacin For mention that sairei-to and sho-saiko-to (of which ginger is one of a number of constituents) do not affect the pharmacokinetics of ofloxacin, see Bupleurum + Ofloxacin, page 90. Ginger + Rifampicin (Rifampin) For details of an interaction between rifampicin and Trikatu, an Ayurvedic medicine containing ginger, black pepper and long pepper, see Pepper + Rifampicin (Rifampin), page 318. Ginger + Tolbutamide For conflicting evidence from animal studies that sho-saiko-to (of which ginger is one of 7 constituents) might increase or decrease the rate of absorption of tolbutamide, see Bupleurum + Tolbutamide, page 90. Constituents Ginkgo leaves contain numerous flavonoids including the biflavone glycosides such as ginkgetin, isoginkgetin, bilobetin, sciadopitysin, and also some quercetin and kaempferol derivatives. Terpene lactones are the other major component, and these include ginkgolides A, B and C, and bilobalide, Ginkgo extracts may be standardised to contain between 22 and 27% flavonoids (flavone glycosides) and between 5 and 12% terpene lactones, both on the dried basis. The leaves contain only minor amounts of ginkgolic acids, and some pharmacopoeias specify a limit for these. However, evidence from clinical studies using the specific probe substrate caffeine suggests that this is not clinically relevant with therapeutic doses of ginkgo. Ginkgo is unlikely to affect the activity of P-glycoprotein to a clinically relevant extent (see digoxin, page 213). The ginkgolides are thought to possess antiplatelet and antiinflammatory properties and it has been used for cerebrovascular and peripheral vascular disorders, tinnitus, asthma and to relieve the symptoms of altitude sickness. Ginkgo seeds contain some toxic constituents; nevertheless, they are used in China and Japan, including as a food. Interactions overview Ginkgo appears to decrease the levels of omeprazole; it seems likely that most other proton pump inhibitors will be similarly affected. Some evidence suggests that diltiazem and nifedipine levels may be raised by ginkgo, whereas nicardipine levels may be reduced. Isolated case reports also suggest that ginkgo may cause seizures in patients taking phenytoin and/or valproate and one case had decreased phenytoin and valproate levels. Phenobarbital levels do not appear to be significantly affected, although this is based on experimental data only.

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Although inter-conduit pits have the disadvantage of adding substantial flow resistance gastritis symptoms lap band purchase discount rabeprazole, they perform the highly advantageous function of trapping an air-water meniscus and minimizing the embolism event such that it does not compromise the conducting system (Figure 16B diet during gastritis attack rabeprazole 10mg lowest price, C) gastritis symptoms and diet rabeprazole 20 mg generic. The homogenous pits of angiosperm vessels have pores narrow enough to trap the meniscus with a P min negative enough to hold against a substantial range of negative P values (Figure 16D). The wider margo pores cannot sustain a very negative P min, but they can generate just enough pressure difference to aspirate the solid torus against the pit aperture on the water-filled side (Petty 1972). In this way, the torus can seal off the pit with a sufficiently negative P min to minimize air passage (Figure 16D). While inter-conduit pits minimize the propagation of embolism, as the next section indicates, they nevertheless play a major role in limiting the tensional gradient that can be generated by the cohesion-tension mechanism. Limits to negative P values: the problem of cavitation Periodically, the cohesion-tension mechanism comes under question for its prediction of liquid pressures that fall below the vapor pressure of water, and also below pure vacuum for a gas (Canny 1998; Zimmermann et al. Clearly, for the cohesion-tension mechanism to operate, transition from the liquid phase to the vapor phase must be suppressed, and the xylem sap must remain in a metastable liquid state. The xylem sap is in effect super-heated, although "super-tensioned" is more descriptive. The liquid water column becomes analogous to a solid whose strong atomic and intermolecular bonds allow it to be placed under tension; i. The concept of metastable water is foreign to the macroscopic world of normal human experience, hence the cohesiontension skeptics. But in these familiar cases, the phase change to vapor (cavitation) is nucleated by contact with foreign agents that destabilize the inter-molecular hydrogen-bonding of liquid water (Pickard 1981). Such "heterogeneous nucleation" of cavitation is typically triggered by minute and ubiquitous gas bubbles in the system. When care is taken to minimize such heterogeneous nucleation, liquid water can develop substantially metastable negative P values. Species can differ considerably in their maximum hydraulic conductivity (x axis intercept) and how readily they lose it to cavitation (from Hacke et al. There is abundant evidence that cavitation "pressures" in plants are negative enough for the cohesion-tension mechanism to operate. Such pressures are determined from a "vulnerability curve" which usually plots the hydraulic conductivity (reciprocal of resistivity) of the xylem (often as a percentage loss from maximum) as a function of the P value in the xylem sap. Curves are generated in several ways, but the centrifuge method is commonly used because of its rapidity (Alder et al. Stems or roots are spun in a custom centrifuge rotor that places their xylem under a known tension at the center of rotation. The conductivity is measured either during or between spinning, and the experiment is continued until the conductivity has dropped to negligible values, thus indicating complete blockage of flow by cavitation. Typical species-specific variation is shown in Figure 17A, and Figure 17B compares the P value causing complete loss of xylem conductivity with the minimum P values measured in nature for 102 species (Sperry 2000). Clearly, the xylem of some species cavitates much more readily than others, but these vulnerable species also do not develop very negative P values in nature. Across the board, the minimum P is generally less negative than the value of P at zero conductivity, as is required by the cohesion-tension mechanism. Although the centrifuge method is widely accepted for conifers and for short-vesseled angiosperms, there is some controversy about its ability to measure the vulnerability of longvesseled taxa where many conduits can exceed the length of the spinning conductivity segment. Response curves in these taxa indicate that a significant number of these large vessels cavitate at very modest negative P values. Comparisons with other methods have verified this type of curve in many (Christman et al. A major cause of the cavitation in plant xylem is air-seeding through the inter-conduit pits that normally are responsible for confining gas embolism (Crombie et al. The P min of inter-conduit connections is easily measured from the positively applied gas pressure that just breaches their seal (Christman et al. From a variety of techniques employed across a wide range of species, the P min range of inter-conduit pitting is generally indistinguishable from the range of P values that cause cavitation.

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G Garlic + Food the information regarding the use of garlic with food is based on experimental evidence only gastritis exercise generic 20 mg rabeprazole with mastercard. Evidence treating gastritis with diet buy 20 mg rabeprazole mastercard, mechanism gastritis baby cheap rabeprazole 20 mg mastercard, importance and management In a study in rats that were fed a high-fat or low-fat diet, and also given garlic oil or its constituents diallyl sulfide and diallyl disulfide, there were no biochemical changes between the groups attributable to an interaction between the garlic oil and dietary fat. For the lack of pharmacokinetic interaction of garlic with caffeine, see caffeine, page 200. Effects of garlic oil and its organosulfur compounds on the activities of hepatic drug-metabolizing and antioxidant enzymes in rats fed high- and low-fat diets. Garlic + Gentamicin the information regarding the use of garlic with gentamicin is based on experimental evidence only. The animal data suggest that it is possible that some garlic constituents, or substances derived from them, might prove to protect against the hepatotoxicity from higher than therapeutic doses of paracetamol, but this requires further study. Protective effect of diallyl sulfone against acetaminophen-induced hepatotoxicity in mice. Garlic + Isoniazid the interaction between garlic and isoniazid is based on experimental evidence only. While the authors speculate that garlic extract may induce enzymes in the intestinal mucosa, which interferes with the absorption of isoniazid, they suggest that the findings cannot be explained solely on this basis. Importance and management the evidence is limited to this one study, and because the mechanism is unknown, a crude garlic extract was used, and the data are from rabbits, it is difficult to apply these findings to a clinical setting. However, if the reduction was shown to be replicated in humans then isoniazid efficacy might be reduced, so further study is warranted. Until more is known, a conservative approach would be to suggest some caution with the use of garlic supplements in patients taking isoniazid. Garlic + Protease inhibitors A garlic supplement reduced the plasma levels of saquinavir in one study, but had little effect in another. Another garlic supplement did not significantly affect the pharmacokinetics of a single dose of ritonavir. The garlic was taken in the form of a dietary supplement (GarliPure, Maximum Allicin Formula caplets) twice daily for 20 days. Fourteen days after the garlic supplement was stopped the saquinavir pharmacokinetics had still not returned to baseline values. The garlic was given in the form of capsules (Natural Source Odourless Garlic Life Brand). Allicin is thought to have inhibited the activity of P-glycoprotein in vitro, which caused the build-up of ritonavir within the cell. All garlic supplements should probably be avoided in those taking saquinavir as the sole protease inhibitor, but note that this is no longer generally recommended. The effect of garlic on saquinavir levels in the presence of ritonavir (as a pharmacokinetic enhancer) does not appear to have been studied. Garlic + Paracetamol (Acetaminophen) Studies in healthy subjects found that garlic did not affect the pharmacokinetics of single-dose paracetamol to a clinically relevant extent. Clinical evidence A study in 16 healthy subjects found that the use of an aged garlic extract (approximately equivalent to 6 to 7 cloves of garlic daily) for 3 months had little effect on the metabolism of a single 1-g oral dose of paracetamol. The effect of diallyl sulfone 25 mg/kg was equivalent to that of the known antidote, acetylcysteine. Garlic kinetic effect on single-dose ritonavir was not clinically important, but this requires confirmation in a multiple-dose study. Effect of short-term administration of garlic supplements on single-dose ritonavir pharmacokinetics in healthy volunteers. Severe gastrointestinal toxicity with concomitant ingestion of ritonavir and garlic. He was also taking enalapril 20 mg, furosemide 40 mg and pravastatin 20 mg (dosage frequency not stated). This effect on platelet aggregation has, on at least two documented occasions, led to spontaneous bleeding in the absence of an anticoagulant. Importance and management Information about an adverse interaction between coumarin anticoagulants and garlic seems to be limited to these two reports, with warfarin and fluindione.

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The influence of coffee with milk and tea with milk on the bioavailability of tetracycline chronic gastritis rheumatoid arthritis discount rabeprazole online. For information on the pharmacokinetics of individual flavonoids present in cola gastritis diet purchase rabeprazole master card, see under flavonoids gastritis no appetite order rabeprazole 20mg overnight delivery, page 186. Interactions overview Cola contains significant amounts of caffeine, therefore the interactions of caffeine, page 97, should be applied to cola, unless the product is specified as decaffeinated. By virtue of its caffeine content cola may also cause serious adverse effects if used with other drugs or herbs with similar effects, such as ephedra, page 176. Cola may reduce the bioavailability of halofantrine and increase the risk of developing hypertension. For information on the interactions of individual flavonoids present in cola, see under flavonoids, page 186. Carbonated cola beverages are acidic, and they can therefore interact with drugs by altering gastric acidity. The best example of this is that they can increase the absorption of the azole antifungal drugs ketoconazole and itraconazole. However, this mechanism is not going to be applicable to herbal medicines containing cola extracts, and these interactions are not therefore covered here. Other constituents include flavonoids from the flavanol group (such as catechin and epicatechin), amines, an anthocyanin pigment (kola red) and betaine. Use and indications the main use of cola seed is as a stimulant for depression, tiredness and poor appetite, and as a diuretic. Evidence, mechanism, importance and management There is a possibility that the effect of cola on blood pressure might differ from that of pure caffeine. There appear to be very few published studies of the effect of cola on blood pressure; however, in the Nurses Health prospective cohort studies, both sugared cola and diet cola beverages were associated with an increased risk of developing hypertension with increased intake. However, the modest hypertensive effects of the caffeine content of cola may be of importance. See Caffeine + Antihypertensives, page 99, for further discussion of the adverse effect of caffeine on blood pressure. Clinical evidence In a study in 15 healthy subjects, a single 500-mg dose of halofantrine was given alone or with cola 12. Similar reductions were seen in the major metabolite of halofantrine, N-desbutylhalofantrine. Mechanism the authors suggest that caffeine, or other consituents of cola such as catechins or tannins, may have formed a complex with halofantrine to reduce its absorption. Importance and management Evidence appears to be limited to this one study, which found a modest reduction in the bioavailabilty of halofantrine. Nevertheless, as there is the potential that this interaction could lead to malaria treatment failure, it may be prudent to advise patients to avoid taking cola during treatment with halofantrine. Note that the effects of caffeine from cola-containing herbal medicine or supplement will be additive with those of other caffeinecontaining foods or beverages. Cola + Herbal medicines Cola + Halofantrine Cola appears to moderately reduce the bioavailability of halofantrine. The caffeine content of cola suggests that it may interact with other herbal medicines in the same way as caffeine, see Caffeine + Herbal medicines; Bitter orange, page 101, and Ephedra + Caffeine, page 176. Constituents the leaves and flowers of coltsfoot contain mucilage composed of polysaccharides, which include arabinose, fructose, galactose, glucose and xylose, and the carbohydrate inulin. Flavonoids (such as rutin, isoquercetin and hyperoside), polyphenolic acids, triterpenes and sterols are present, and sesquiterpenes including bisabolene derivatives and tussilagone may also be found. All parts of the plant may contain the pyrrolizidine alkaloids isotussilagine, senecionine, senkirkine and tussilagine in variable amounts. Extracts have anti-inflammatory and antispasmodic activity and tussilagone alone has been found to be a cardiovascular and respiratory stimulant. The concentration of the most toxic pyrrolizidine alkaloid, senkirkine, is thought to be too low to cause toxicity if used infrequently, and tussilagine is unsaturated and therefore less toxic. Use and indications Coltsfoot is traditionally used in cough and cold preparations Interactions overview No interactions with coltsfoot found. For information on the pharmacokinetics of the alkaloid constituent, berberine, see under berberine, page 58. Constituents the thread-like rhizomes contain isoquinoline alkaloids, mainly berberine and coptisine.

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