A 42-year-old man comes to the office for follow up. He was diagnosed with diabetes mellitus 5 years ago. A few months ago, he began an insulin regimen that allowed for excellent glycemic control. Recently, however, he missed his follow-up appointments despite frequent reminders from the office staff; his last clinic visit was 4 months ago. Temperature is 37.1 C (98.8 F). BMI is 29 kg/m². Fasting blood glucose is 142 mg/dL and glycosylated hemoglobin level is 8.1%. Both tests were within normal limits previously. On further review, the patient says that he began to use the herbal preparation ginkgo biloba. He decided to use herbal remedies because "it's always better to use natural medicines." Use of this supplement is most associated with which of the following side effects?

Question

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Explanation: Ginkgo biloba leaf extract is an increasingly popular herbal supplement that many patients use as a "memory booster" because of its suggested propensity for increasing cerebral blood flow. Some studies have suggested that ginkgo is at least somewhat effective in the treatment of intermittent claudication and Alzheimer disease. Ginkgo has been associated with a number of side effects, including seizures, headaches, irritability, restlessness, diarrhea, nausea, and vomiting. It is most notorious for increasing the risk of bleeding and its potentiation of the effects of anticoagulant therapy through various mechanisms, including the inhibition of platelet-activating factor. Several cases of serious intracerebral bleeding associated with ginkgo use have been reported; in most cases, patients were concurrently taking anticoagulant medications. (Choice A) Psychosis may arise as a side effect of multiple prescription medications. Some examples include corticosteroids, appetite suppressants, quinacrine, antidyskinetics (eg, levodopa, carbidopa, amantadine), and isotretinoin. (Choice B) Hepatotoxicity has been associated with usage of unsaturated pyrrolizidine alkaloids, found in several herbal supplements including comfrey (used for joint symptoms), which is widely available in the United States. Other herbal medications and supplements associated with hepatotoxicity include ephedra (or Ma-Huang, used for respiratory symptoms, as a weight loss agent, and as a stimulant) and jin bu huan (a Chinese medicine used as a sedative and analgesic). jin bu huan (Choice C) Aconite is an ingredient in some Chinese herbal medicines used to treat pain or heart failure. It is known to cause serious and sometimes fatal arrhythmias (eg, ventricular tachycardia, torsade de pointes). (Choice D) Stevens-Johnson syndrome (SJS) is characterized by erosion of mucous membranes, small blisters on purpuric macules, and atypical target lesions. Drugs known to cause SJS include antibiotics (eg, sulfonamides, aminopenicillins, quinolones, cephalosporins) and anticonvulsants (eg, lamotrigine, phenytoin, carbamazepine). Educational objective: Ginkgo biloba leaf extract is used by many patients as a "memory booster" because of its suggested propensity for increasing cerebral blood flow. It is most notorious for an increased risk of bleeding and a potentiation of the effects of anticoagulant therapy through various mechanisms, including the inhibition of platelet-activating factor.

A 42-Year-Old Man Comes to the Office for Follow Up