Ethiopian Traditional and Herbal Medications and their Interactions with Conventional Drugs

Author(s): Alevtina Gall, BS, BA; Zerihun Shenkute, RPh

Reviewer(s): David Kiefer, MD; J. Carey Jackson, MD, MPH, MA

Date Authored: November 03, 2009

Contents

Methods

Author Alevtina Gall discussed the use of traditional medicine by Ethiopian patients with Dr. J. Carey Jackson, Medical Director of the International Medicine Clinic at Harborview Medical Center, and with Zerihun Shenkute, co-author of this article and pharmacist at Harborview. Zerihun Shenkute contributed information based on professional knowledge of pharmacy and Western medicine, experience as a pharmacist serving Ethiopian immigrant patients, and firsthand cultural knowledge of Ethiopian communities' traditional and herbal medicine practices. Information was also obtained through a literature review that included studies of patient-health care provider relationships and current scientific data regarding chemical interactions of herbs and conventional drugs.

Brief History of Traditional Medicine in Ethiopia

The first recorded epidemic that occurred in Ethiopia dates back to 849 following the expulsion of Abba Yohannes, the head of the Ethiopian church, from the land. The plague and famine that ensued was perceived as God’s punishment for Yohannes’ misdeeds. In a terrified letter to Abba Yohannes, the Ethiopian emperor wrote that “great tribulations have come upon our land, and all our men are dying of the plague and all of our beasts and cattle have perished” (Pankhurst, 1990).

: The Biofarm Project, Addis Ababa, Ethiopia; Copyright: WHO/P. Virot

It is impossible to pinpoint the birth of medicine in Ethiopia, but certainly the evolution of curative practices closely follows the path of a disease. Traditional medical practitioners mostly implement herbs, spiritual healing, bone-setting and minor surgical procedures in treating disease. Ethiopian traditional medicine is vastly complex and diverse and varies greatly among different ethnic groups. Most traditional medical practices in Ethiopia rely on an explanation of disease that draws on both the “mystical” and “natural” causes of an illness and employ a holistic approach to treatment (Bishaw, 1991).

Under the rule of Menelik (1865-1913) Western medicine became significantly more incorporated into the Ethiopian medical system. Numerous medical envoys from abroad, starting with the Italians and Russians, were influential in building hospitals, providing medical training and participating in vaccination campaigns. However, most medical establishments primarily served the urban elites and foreign missionaries and were concentrated in the major cities (Pankhurst, 1990).

Despite Western medicine becoming more widespread in Ethiopia, Ethiopians tend to rely more on traditional medicine. Conventional medical services remain concentrated in urban areas and have failed to keep pace with the growing population, keeping health care access out of reach for most Ethiopians living in Ethiopia. Because traditional medicine is culturally entrenched, accessible, and affordable, up to 80% of the Ethiopian population relies on traditional remedies as a primary source of health care (Kassaye et al., 2006). Moreover, Western medicine has become more focused on preventative measures and people seeking curative practices still rely on indigenous medicine as the primary source for health care (Pankhurst, 1990). The influence of traditional medicine is also seen in Ethiopian migrant populations. In countries with substantial Ethiopian immigrant populations, traditional herbs, medical devices, and practitioners are readily available (Papadopoulos, 2002).

Ethiopian Immigrants and Self-Medication

Most immigrants who come from countries that rely on traditional medicine continue to use that form of medicine in conjunction with the use of conventional medical facilities. Despite the prevalence of self-medication in immigrant populations and the potential for adverse herb-drug interactions, relatively few studies have assessed these risk factors in various groups. One recent study looking at the use of herbal medicine in Hispanic immigrants found that 80.3% used complementary medicine and the majority did not inform their physician (Howell et al., 2006). Another study found that only 5% of Chinese immigrants surveyed reported that their physician had ever asked about their use of traditional medicine (Wu et al., 2007).

In North America the Ethiopian immigrant population is more diffuse, thus, traditional medical practitioners (TMPs) may be inaccessible and cultural misunderstandings may compound frustration with the conventional medical system (Hodes, 1997). Despite the lack of TMPs, herbal remedies are easily obtained and widely used by the immigrant population. In many cases Ethiopian patients use traditional remedies in combination with prescribed conventional medications for related or unrelated health conditions without informing their physician.

: Market, Alem Kitmama, Ethiopia; Copyright: WHO/P. Virot

Ethiopian patients who use traditional medicine and do not inform their health care providers may do this for several reasons. They may be self-treating an unrelated illness and do not think that it is significant. For instance, a widespread Ethiopian remedy for the common cold involves the consumption of large quantities of garlic and ginger, which has the potential to interact with anti-coagulant, hypoglycemic, and cholesterol-lowering medications (refer to following table). Patients may feel that they will be judged by their physicians if they disclose their use of traditional medicine (Shenkute, 2008). Cultural differences in understanding and treating symptoms of illnesses may contribute to patients feeling misunderstood by their health care providers and being more likely to seek satisfactory treatment in the form of traditional medicine (Hodes, 1997).

Role of the Health Care Provider

As national borders become more porous and the movement of people more widespread it is increasingly more important for health care providers to be aware of the cultural background of their patients. The use of traditional medicine by immigrant patients presents a unique concern. On the one hand, the concern is practical because so many commonly used traditional remedies have the potential to adversely interact with conventional medicines. On the other hand, the use of traditional medicine brings up the issue of culturally constructed notions of health and illness and demands a place in health care provision discourse.

It is imperative that health care providers are aware of traditional medicines that their patients may be using. Unusual changes in a patient’s state of health or reaction to a prescribed medication may be explained by the concurrent use of traditional medicine. Health care providers should closely observe their patients and be conscious of adverse herb-drug interactions. Talking to patients about traditional therapies is crucial and should be done in a nonjudgmental manner to encourage the patient to feel comfortable in sharing this information with their health care provider. Asking the right questions in multiple ways may be useful in clarifying whether a patient is using traditional medicine for an illness that is related or unrelated to the health concern that brought them to the hospital or clinic (Shenkute, 2008; Jackson, 2008).

Commonly Used Conventional Medicines and Potential for Adverse Herb-Drug Interactions

Many herbal substances that are used in Ethiopian traditional medicine are also used as ingredients and spices in Ethiopian food. Consumption of these herbs and spices as part of a normal diet is not likely to cause adverse herb-drug interactions because they are consumed in relatively small quantities. However, when these herbs and spices are utilized for medicinal purposes there may be an increased likelihood of adverse interactions with conventional medicines. There are several classes of medications that are at a higher risk for adverse herb-drug interactions, including anti-arrhythmic, anti-seizure, anti-diabetic, and anti-coagulant medication. Health care providers are particularly attuned to these interactions because these drugs are typically monitored with serum levels and serum markers (e.g., warfarin, digoxin). The risk is increased because of the chemical composition of these medicines and because they treat some of the most common illnesses in the Ethiopian immigrant population (Jackson, 2008). The following table summarizes the most commonly used herbs and spices in Ethiopia and their potential drug interactions (Fullas, 2003).

Table: Commonly Used Herbs and Spices in Ethiopia and their Potential Drug Interactions

: Ethiopian Health and Nutrition Research Institute (EHNRI); Copyright: WHO/P. Virot

This table is best used when interviewing patients about laboratory findings or side effects when an interaction may be suspected. Conversely, it can be used to help caution patients about potential interactions, if particular herbs or spices are consumed in large volumes.

ALERT: In the table, an asterisk (*) indicates an interaction that would be rare when the spices and herbs are used as food additives, but occasionally may be encountered when the spices and herbs are consumed in large quantities medicinally. In other words, under normal uses, an interaction is unlikely, but given known medicinal use by East African patients, it is possible.

From a naturopathic or Western herbal perspective, it’s hard to imagine people consuming spices in large enough quantities to be pharmacologically active. However, in many countries, notably Ethiopia, spices are used specifically for their medicinal value and are consumed in quantities far exceeding how they would be used as a normal food additive, not just in terms of volume, but in frequency of dosing. For example, with garlic, many cloves may be crushed and consumed many times a day for medicinal purposes. Pharmacists with extensive experience managing Ethiopian patients for diabetes, anticoagulation, and hypertension will see complications of herb-spice drug interactions not routinely encountered in naturopathic medicine.

Language key: (A)– Amharic (T)– Tigrinya (O)– Oromo

Herb/Spice	Common Uses	Drugs Affected	Mechanism	Consequences
Basil Ocimum basilicum Besobila (A) Zahahene (O)	Mostly culinary Medicinal: headache, insect repellent, malaria	Anticoagulants Hypoglycemic agents	Oil extract has been found to increase clotting time Synergistic interaction with insulin and oral hypoglycemic agents	Increased chance of bleeding May further lower blood glucose
Black Mustard Brassica nigra Senafitch (A) (T) Senafitcha (O)	Culinary use Medicinal use: stomach ache, constipation, bloating, amoebic dysentery and abortifacient Also used for wound dressing.	Proton Pump Inhibitors H₂ receptor antagonists Anticoagulants May interact with aspirin	Mustard seeds and oilmay increase production of stomach acid Allyl thiocyanate is an irritant that can cause severe burns and tissue necrosis (Fullas 2003) High concentration of Vitamin K	Interferes with antacid treatment Antagonizes effects of Warfarin
Black seed Nigella sativa Tiqur azmud (A) Awoseta (T) Gura (O)	Culinary uses Medicinal: headache, stomachache, abortifacient	Anti-coagulants Anti-hypertensives Insulin and oral hypoglycemic drugs	Platelet aggregation inhibition Increases pancreatic insulin secretion Evidence in animal studies of reduced arterial blood pressure by increasing vasodilation and inhibiting contraction. Evidence of pregnancy inhibitor in rats (Fullas, 2003)	Increased risk of bleeding Synergistic action with medication that lowers blood pressure and blood glucose
Herb/Spice	Common Uses	Drugs Affected	Mechanism	Consequences
Capsicum pepper Cayenne pepper Capsicum annum Berbere (A)	Mostly culinary Medicinal: stomach ache, antimicrobial	Anti-coagulants Anti-hypertensives ACE inhibitors	Capsaicin may inhibit platelet aggregation Increases production of catecholamines Decreases blood glucose levels and stimulates insulin release	Increased risk of bleeding May counteract mechanism of anti-hypertensives Recorded incidences of increased cough when combined with ACE inhibitors
Cinnamon Cinnamomum zelanicum Qarafa (A) Crefte (T) Carafu (O)	Culinary Medicinal: treatment for cold symptoms	Antacids Tetracyclines	Claimed to increase stomach acid Experimental evidence of tetracycline dissolution rate interference	May counteract antacids May inhibit tetracycline action
Coriander Coriandrum sativum Dimbelal (A) Zagada (T) Shucar (O)	Mostly culinary Medicinal: stomach ache and colic	Insulin and oral hypoglycemic agents	Unknown, but has been shown to be effective in treating stomach upset (Fullas 2003)	*Lowers blood sugar levels;
Herb/Spice	Common Uses	Drugs Affected	Mechanism	Consequences
Cumin Cuminum cyminum Ensilal (A) Kemano (T) Hawaja (O)	Mostly culinary	Hypoglycemic agents Anticoagulants	May have hypoglycemic properties May have anticoagulating properties	Hypoglycemia Increased risk of bleeding
Dingetegna(A) No common English name Taverniera abyssinica	Medicinal only for stomach upset Fever reduction	No specific class	Antispasmodic properties may affect absorption of medication	Decreased absorption of medication
Fenugreek Trigonella foenum-graceum Abish (A) Halbata (O)	Mostly culinary Medicinal: stomachache, antispasmodic, powder used for wound dressing	Antidiabetic drugs Lipid lowering drugs Thyroid Replacement Therapy Warfarin	Studies have shown that fenugreek acts synergistically with blood glucose lowering drugs Decreases total cholesterol and LDLs Alters T₃ and T₄ levels Anticoagulating properties	Hypoglycemia Lower cholesterol Reduced intestinal absorbance of medication Increased risk of bleeding
Herb/Spice	Common Uses	Drugs Affected	Mechanism	Consequences
Flaxseed and flaxseed oil Linum usitatissimum Telba (A) Lina (T) Konfur (O)	Medicinal: purgative, diuretic, laxative	Anti-coagulants Cardiac glycosides Laxatives Insulin and oral hypoglycemic agents Hormonal drugs Lipid lowering agents	Flaxseed and oil decrease platelet aggregation, increase effects of lipid lowering and hypoglycemic agents Lignans (phyto-estrogens) from flaxseed (not oil) possess hormonal effects As a bulk forming laxative, flaxseed may bind to cardiac glycosides and other orally administered medications and prevent absorption Flaxseed enhances laxative effects of stool softeners	*Increased risk of bleeding Reduced intestinal absorbance of oral medication; as any fiber source Increased risk of hypoglycemia Possible dehydration from increased laxative effects of flaxseed (Due to absorption of liquid by fiber. It is important for patient to drink enough water.)
Garlic Allium sativum Nech shinkrut (A) Tsada shgurti (T) Qullabbiiadii (O)	Culinary Medicinal: common cold, malaria, cough, pulmonary TB, hypertension, wounds, STDs, asthma, parasitic infections, toothache, diabetes, hemorrhoids	Antiplatelets Anticoagulants Insulin and oral hypoglycemic agents Cholesterol lowering drugs Thyroid replacement therapy	May be additive with cholesterol-lowering drugs Hypertensive activity but it is not known if this effect is antihypertensive drug additive Decreases T₃ and T₄levels May have blood thinning properties	Possible increased risk of bleeding; Reverses effects of orally administered thyroxine
Ginger Zingiber officinale Zingibil (A) (T)	Culinary Medicinal: stomachache, cough, fever, influenza	Antacids Anticoagulants	Irritates gastric mucosa Decreases platelet aggregation	Inhibits antacid therapy Increased risk of bleeding
Herb/Spice	Common Uses	Drugs Affected	Mechanism	Consequences
Khat Catha edulis Chat (A) Ciut (T) (O)	Mostly recreational Medicinal: stimulant, mental illness, gonorrhea, common cold	Amphetamines Amoxicillin and ampicillin, PCN others	Cathinone (active ingredient) may act synergistically with amphetamines Tannins (component of Khat) complexes with ß-lactam antibiotics	Possible additive effect with amphetamines Decreases absorbability of b-lactam antibiotics Lowers seizure threshold, Increases b.p and heart rate and induces cardiac arrythmias.
Peppermint Mentha piperita Nanna (A) (O) Semhal (T)	Medicinal: common cold, headache	Felodipine and simvastatin Iron Warfarin Acid Suppression therapy (antacids)	Inhibits gut wall metabolism of felodipine and simvastatin Decreases absorption of non-heme iron Reduces Warfarin internal normalized ratio to sub-therapeutic levels	Increased risk of clots if patient is in a hypercoagulable state Non-absorption of felodipine, simvostatin and iron Increases GERD symptoms unless taken as enteric-coated capsules
Rue Ruta chalepensis Tenadam (A) (T) Talatam (O)	Medicinal: common cold, stomachache, diarrhea, influenza	Psoraien Ultraviolet (PUVA) therapy Warfarin	No major interactions reported 5-methoxy psoralen content of rue may increase phototoxic response May interact with Warfarin	Anticoagulant effects maybe additive
Turmeric Curcuma longa Ird (A) (O)	Mostly culinary Medicinal: used topically for “crying eyes” in children	Antiplatelets and anticoagulants Insulin and oral hypoglycemics	Has been shown to inhibit platelet aggregation in vitro Curcuminoids and sesquiterpene components of turmeric have hypoglycemic	Increased risk of bleeding (theoretical risk; has not been demonstrated) Reduces blood sugar levels

Language key: (A) – Amharic (T) – Tigrinya (O) – Oromo

References

Bishaw, M. (1991). Promoting traditional medicine in Ethiopia: a brief historical review of government policy. Social Science and Medicine, 33, 193-200.

Fullas, F. (2003). Spice plants in Ethiopia: their culinary and medicinal applications. Iowa, USA: Library Congress Cataloging.

Fullas, F. (2001). Ethiopian Traditional Medicine: Common Medicinal Plants in Perspective. Iowa, USA: Library Congress Cataloging.

Hodes, R. (1997). Cross-cultural medicine and diverse health beliefs Ethiopians abroad. Western Journal of Medicine, 166, 29-36.

Howell, L., Kochhar, K., Saywell, R., Zollinger, T., Koehler, J., Mandzuk, C., Sutton, B., Sevilla-Martir, J., Allen, D. (2006). Use of herbal remedies by Hispanic patients: do they inform their physician? The Journal of the American Board of Family Medicine, 19, 566-578.

Jackson, J.C. (Feb. 8, 2008) Personal interview with Medical Director of International Medicine Clinic (HMC) on topic of Ethiopian traditional medicine use in immigrant patients (Haborview Medical Center, Seattle, WA).

Kassaye, K.D., Amberbir, A., Getachew, B., Mussema, Y. (2006). A historical overview of traditional medicine practices and policy in Ethiopia.Ethiopian Journal of Health Development, 20, 127-134.

Pankhurst, R. (1990). An introduction to the medical history of Ethiopia. New Jersey, USA: The Red Sea Press, Inc.

Papadopoulos, R., Lay, M., Gebrehiwot, A. (2002 May). Cultural snapshots: A guide to Ethiopian refugees for health care workers. Research Center for Trans-cultural Studies in Health. Middlesex University, London. Available on-line:http://www.mdx.ac.uk/www/rctsh/embrace.htm

Shenkute, Z. (Feb. 4, 2008) Personal interview with HMC Pharmacy Services pharmacist on topic of Ethiopian traditional medicine use in immigrant patients (Harborview Medical Center, Seattle, WA)

Wu, A., Burke, A., LeBaron, S. (2007) Use of traditional medicine by immigrant Chinese patients. Family Medicine, 39, 195-200.

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