Can you talk more about ashwagandha (an adaptogen). I know it has been used for centuries in Ayurvedic medicine, correct?
Yes, and in traditional Chinese medicine. Adaptogens are recognized for a lot of roles in Indian and Asian cultures. Ashwagandha can potentially help folks with some bacterial infections, help decrease inflammation in the body, and most importantly – and why I think it’s everywhere in the market – help decrease cortisol levels. Cortisol is a hormone that’s released when we’re in that stressed response, whether it’s physiological or psychological.
There are a bunch of adaptogens being used in products for stress relief: mushrooms, ashwagandha, rhodiola, cordyceps, wild gooseberry. But really, ashwagandha and lemon balm at this time are the only ones that have some evidence to help deal with that stress response system.
Ashwagandha has also been shown to be effective for insomnia and for general anxiety disorder. So that’s where we have good evidence: stress, sleep, anxiety.
Do you recommend ashwagandha to patients for stress?
I do suggest it for patients sometimes. I do like other modalities as well – massage, yoga, guided imagery, therapeutic touch – because sometimes patients don’t want to take a supplement, or it might interact with some other things they are taking, but it is one of the options.
What can you tell us about dosing? Unlike taking an aspirin when you have a headache, adaptogens work over time, correct?
Correct. It’s not to treat acutely, like I’m having a panic attack. It’s more of a continuous daily treatment. Studies, though, looking at continuous use have been short, only about three months. So anything beyond that window still needs research to see if people are experiencing anything long term, or if it decreases in its effectiveness.
Some of these products on the market, such as coffee or alcohol alternatives, have a list of herbs and ingredients along with ashwagandha with only a combined milligram amount. So how do you know if you are taking a safe dose?
You don’t. Often, that’s for proprietary reasons. That’s why I always advise using monotherapy products, so you know the true product and what’s in it. If the product just has a list of ingredients, that just increases the risks.
How can consumers be sure they are using ashwagandha safely?
I think the first thing, whether it’s ashwagandha or any other herb, is one, talk to their provider to make sure it’s OK in combination with other things they are doing and taking. And it’s important to try to find a good-quality product, although, that’s a challenge here in the United States, because not all our products are standardized.
You want to ask: Was the herb harvested at the right time of year? Did the makers use the right plant part (e.g. the roots compared with the leaves)? Are you using the right dose? Are you using a reputable company? Is what’s on the label in the product?
One thing that’s recommended is that the product label indicate an independent, third-party review, correct?
Yes. There are four entities out there that evaluate these products. If what’s in the product is on the label, the manufacturers are able to display a seal of approval.
The United States Pharmacopeia (USP) is one. That’s the government agency and the one that you see the most of. The others are Consumer Labs (CL), Good Manufacturing Practices (GMP) and the National Sanitation Foundation (NSF). It’s just an extra layer of protection that they have evaluated the product. If it doesn’t have a seal, than either we didn’t evaluate, or it didn’t pass.
Leaves of the ashwagandha plant.
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Are there potential side effects with ashwagandha?
There are always potential side effects. Nothing is 100% safe when you take it by mouth. With ashwagandha, you may have stomach issues, such as diarrhea, nausea, vomiting. But normally that occurs at high doses over a long period of time. Overall, it’s pretty well-tolerated.
However, there have been some reports of liver complications. It’s not as significant as it is with kava, for example, another adaptogen. Kava has had some reports of liver failure, liver transplant and death. And it’s put in a lot of these other products. It was significant enough that in the early 2000s, Europe and Canada took kava off the market. We didn’t do that in the United States. But we had a warning to professionals and providers and folks to be aware.
But here’s the concern. You don’t need a prescription for these products. You don’t need a referral to see a specialist. You just go to the store, and you take these products. And if you don’t have an open line of communication with your provider about what you are taking and then you start feeling ill, they might do some lab work, and you have significant issues with your liver, and they are trying to figure out what’s going on. And if you don’t share that you use these other products, then they can’t take care of you completely.
I will say Europe and Canada, after the 2000s, lifted the ban on kava a little bit, but liver issues are always something we need to keep in mind with other adaptogens.
What about drug interactions?
There are a few drug interactions that occur. A big category with ashwagandha are diabetes medications, because the combination will increase patients’ risk for hypoglycemia, so low blood sugars. Now if doctors know about it, they may be able to adjust doses to where they feel comfortable with that combination, so, again, they need to know about it.
There are also concerns with some thyroid medications where ashwagandha might increase the effects, and it might affect high blood pressure medications. And serious interactions can occur with benzodiazepines, anticonvulsants or barbiturates.
What about interactions with other medical issues?
Pregnant women should not take ashwagandha, as it can cause spontaneous abortion. Research on its use during lactation is not clear, but it’s safest not to use it while breastfeeding either. Immuno-compromised patients and patients with hormone-specific prostate cancer should not take ashwagandha. And surgery candidates should always include herbal supplements on their medication use list and stop taking them prior to surgery as ordered. Some herbs, like ginseng, garlic and ginkgo biloba, can cause serious bleeding complications.
Is there anything we missed you would you like to add?
“Keep in mind that ashwagandha might be something we shouldn’t reach for right away. We might have other options that are safer for patients based on their medical history and possibly covered by insurance. Also, regardless of which route they take, patients and providers need to try to figure out what is the underlying cause of the problem. Because ultimately stress is an epidemic, and there are a lot of complications and health conditions that can result downstream.
