title: The effect of echinacea (Echinacea purpurea root) on cytochrome P450 activity in vivo.
abstract: BACKGROUND
  Echinacea is a widely available over-the-counter herbal remedy. Tinctures of echinacea have been shown to inhibit cytochrome P450 (CYP) in vitro. The effect of echinacea (Echinacea purpurea root) on CYP activity in vivo was assessed by use of the CYP probe drugs caffeine (CYP1A2), tolbutamide (CYP2C9), dextromethorphan (CYP2D6), and midazolam (hepatic and intestinal CYP3A).
  
  
  METHODS
  Twelve healthy subjects (6 men) completed this 2-period, open-label, fixed-schedule study. Caffeine, tolbutamide, dextromethorphan, and oral and intravenous midazolam were administered before and after a short course of echinacea (400 mg 4 times a day for 8 days) to determine in vivo CYP activities.
  
  
  RESULTS
  Echinacea administration significantly increased the systemic clearance of midazolam by 34%, from 32 +/- 7 L/h to 43 +/- 16 L/h (P =.003; 90% confidence interval [CI], 116%-150%), and significantly reduced the midazolam area under the concentration-time curve by 23%, from 127 +/- 36 microg. h/L to 102 +/- 43 microg. h/L (P =.024; 90% CI, 63%-88%). In contrast, the oral clearance of midazolam was not significantly altered (P =.655; 90% CI, 75%-124%), 137 +/- 19 L/h compared with 146 +/- 71 L/h. The oral availability of midazolam after echinacea dosing was significantly increased (P =.028; 90% CI, 108%-153%), from 0.23 +/- 0.06 to 0.33 +/- 0.13. Hepatic availability (0.72 +/- 0.08 versus 0.61 +/- 0.16; P =.006; 90% CI, 73%-90%) and intestinal availability (0.33 +/- 0.11 versus 0.61 +/- 0.38; P =.015; 90% CI, 125%-203%) were significantly altered in opposite directions. Echinacea dosing significantly reduced the oral clearance of caffeine, from 6.6 +/- 3.8 L/h to 4.9 +/- 2.3 L/h (P =.049; 90% CI, 58%-96%). The oral clearance of tolbutamide was reduced by 11%, from 0.81 +/- 0.18 L/h to 0.72 +/- 0.19 L/h, but this change was not considered to be clinically relevant because the 90% CIs were within the 80% to 125% range. The oral clearance of dextromethorphan in 11 CYP2D6 extensive metabolizers was not affected by echinacea dosing (1289 +/- 414 L/h compared with 1281 +/- 483 L/h; P =.732; 90% CI, 89%-108%).
  
  
  CONCLUSIONS
  Echinacea (E purpurea root) reduced the oral clearance of substrates of CYP1A2 but not the oral clearance of substrates of CYP2C9 and CYP2D6. Echinacea selectively modulates the catalytic activity of CYP3A at hepatic and intestinal sites. The type of drug interaction observed between echinacea and other CYP3A substrates will be dependent on the relative extraction of drugs at hepatic and intestinal sites. Caution should be used when echinacea is coadministered with drugs dependent on CYP3A or CYP1A2 for their elimination.
authors.affiliation: Department of Medicine, Indiana University School of Medicine, Indianapolis, 46202-2879, USA. jcgorski@iupui.edu
authors.forename: J Christopher
authors.initials: JC
authors.lastname: Gorski
authors.forename: Shiew-Mei
authors.initials: SM
authors.lastname: Huang
authors.forename: Amar
authors.initials: A
authors.lastname: Pinto
authors.forename: Mitchell A
authors.initials: MA
authors.lastname: Hamman
authors.forename: Janna K
authors.initials: JK
authors.lastname: Hilligoss
authors.forename: Narjis A
authors.initials: NA
authors.lastname: Zaheer
authors.forename: Mehul
authors.initials: M
authors.lastname: Desai
authors.forename: Margaret
authors.initials: M
authors.lastname: Miller
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Hall
mesh_terms: D000284:Administration, Oral; D000328:Adult; D019540:Area Under Curve; D002110:Caffeine / Q000008:administration & dosage / Q000493:pharmacokinetics; D003577:Cytochrome P-450 Enzyme System / Q000187:drug effects*; D003915:Dextromethorphan / Q000008:administration & dosage / Q000493:pharmacokinetics; D020900:Echinacea; D005260:Female; D041743:Herb-Drug Interactions; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008874:Midazolam / Q000008:administration & dosage / Q000493:pharmacokinetics; D008517:Phytotherapy; D010936:Plant Extracts / Q000008:administration & dosage / Q000494:pharmacology*; D018517:Plant Roots; D012016:Reference Values; D014044:Tolbutamide / Q000008:administration & dosage / Q000493:pharmacokinetics
chemical_list: D010936:Plant Extracts; D002110:Caffeine; D003915:Dextromethorphan; D003577:Cytochrome P-450 Enzyme System; D014044:Tolbutamide; D008874:Midazolam