There are three main groups of ginseng that are classified based on their geographic origin (Hughes et al. 2004). These are Asian ginseng, American ginseng, and Siberian ginseng, with the pharmacologically active ingredient in ginseng being ginsenosides (Hughes et al. 2004, Leak 1999, Kaye et al. 2000). Asian and American ginsengs have been used to increase resistance to environmental stress, promote diuresis, stimulate the immune system, and aid digestion (Ng et al. 1987, Jellin et al. 2003). Further, while Asian ginseng has shown promise in improving cognition when combined with the herbal agent Ginkgo, American ginseng has been studied for its potential to stimulate human tumor necrosis factor-a (TNF-a) production in cultured human white blood cells (Jellin et al. 2003, Zhou and Kitts 2002). American ginseng may also possess hypoglycemic activity (Jie et al. 1984, Sotaniemi et al. 1995). Such effects have been observed in both normal and diabetic subjects and may be attributed to ginseng components, specifically ginsenoside Rb2 and panaxans I, J, K, and L (Yokozawa et al. 1985, Oshima et al. 1985, Konno et al. 1985, Konno et al. 1984, Tokmoda et al. 1984).

Typically ginseng is well tolerated, but side effects such as bleeding abnormalities secondary to antiplatelet effects, headache, vomiting, Stevens-Johnson syndrome, epistaxis, and hypertension have been reported (Baldwin 1986, Hammond and Whitworth 1981, Dega et al. 1996, Greenspan 1983, Hopkins et al. 1988, Palmer et al. 1978, Kuo et al. 1990)

Table 10.2 Herbal medications associated with bleeding abnormalities.

Bilberry Bromelain Chamomile Dandelion root Dong quai Fenugreek Feverfew Fish oil Flaxseed oil Garlic Ginger Ginkgo biloba Ginseng

Grape seed extract Horse chestnut Kava kava Meadowsweet Motherwort Red clover Tamarind Turmeric Willow

(see Table 10.2). Drug interactions between Asian ginseng and calcium channel blockers, warfarin, phenelzine, and digoxin have also been noted (Hughes et al. 2004). It may be advisable that ginseng be avoided by interventional pain patients on anticoagulant medications such as warfarin, heparin, aspirin, and NSAIDs. Further, because of ginseng's association with hypertension and the deleterious outcomes linked to chronic hypertension, the pain practitioner should be aware of whom and for how long patients may have been taking this herbal product. Since many agents can cause generalized vasodilation, hemodynamic lability may be seen.

Regarding ginseng's interaction with antidepressants such as monoamine oxidase inhibitors, concurrent use of ginseng with phenelzine sulfate should be avoided as manic episodes have been reported with routine use of both (Shader and Greenblatt 1985, Jones and Runikis 1987). Finally, as a result of ginseng's potential to cause decreased blood glucose levels, it should be used cautiously in diabetic patients on insulin or other oral hypoglycemic agents and blood glucose levels should be monitored.

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