{"tracks":{"tech":[{"id":"tech-meds","title":"Medications","summary":"Generic and brand names, drug classes, duplications, interactions, dosage forms, side effects and allergies, indications, stability and storage: PTCE 2026 domain 1, the largest part of the exam (35% of scored items).","blueprint":["ptce.1"],"lessons":[{"id":"tech-meds-names-and-stems","title":"Generic names, brand names and drug stems","minutes":12,"level":"foundation","scope":"ptce","blueprint":["ptce.1.1"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":[]},{"id":"tech-meds-classes-cardio-diabetes","title":"Drug classes: heart, blood pressure, clotting and diabetes","minutes":13,"level":"core","scope":"ptce","blueprint":["ptce.1.1"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-meds-classes-cns-resp-gi-infection","title":"Drug classes: brain, pain, lungs, gut and infections","minutes":15,"level":"core","scope":"ptce","blueprint":["ptce.1.1"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-meds-duplication","title":"Therapeutic duplication","minutes":11,"level":"core","scope":"ptce","blueprint":["ptce.1.2"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-meds-interactions","title":"Drug interactions and contraindications","minutes":15,"level":"core","scope":"ptce","blueprint":["ptce.1.3"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"tech-meds-dosage-forms-routes","title":"Dosage forms, routes, strengths and duration","minutes":14,"level":"core","scope":"ptce","blueprint":["ptce.1.4"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"tech-meds-side-effects-allergies","title":"Side effects, adverse reactions and allergies","minutes":13,"level":"core","scope":"ptce","blueprint":["ptce.1.5"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-meds-indications","title":"Indications: matching drugs to conditions","minutes":11,"level":"foundation","scope":"ptce","blueprint":["ptce.1.6"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-meds-stability","title":"Stability: suspensions, insulins, vaccines and injectables","minutes":14,"level":"core","scope":"ptce","blueprint":["ptce.1.7"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"tech-meds-storage","title":"Storage: temperature, light and restricted access","minutes":13,"level":"core","scope":"ptce","blueprint":["ptce.1.8"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]}]},{"id":"tech-law","title":"Federal requirements","summary":"Federal pharmacy law a technician uses every shift: controlled substances, restricted-drug programs, recalls, DSCSA, waste and the other acts that shape daily work.","blueprint":["ptce.2"],"lessons":[{"id":"tech-law-schedules","title":"Controlled substance schedules I–V","minutes":10,"level":"foundation","scope":"ptce","blueprint":["ptce.2.2"],"objectives":4,"questions":5,"status":"source-checked","prerequisites":[]},{"id":"tech-law-cs-prescriptions","title":"Controlled substance prescriptions: refills, transfers and partial fills","minutes":12,"level":"core","scope":"ptce","blueprint":["ptce.2.2"],"objectives":5,"questions":7,"status":"source-checked","prerequisites":["tech-law-schedules"]},{"id":"tech-law-cs-handling","title":"Handling controlled substances: ordering to disposal","minutes":12,"level":"core","scope":"ptce","blueprint":["ptce.2.3"],"objectives":5,"questions":6,"status":"source-checked","prerequisites":["tech-law-schedules"]},{"id":"tech-law-restricted-programs","title":"Restricted-drug programs: pseudoephedrine and REMS","minutes":12,"level":"core","scope":"ptce","blueprint":["ptce.2.4"],"objectives":5,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"tech-law-recalls","title":"FDA drug recalls and the pharmacy recall workflow","minutes":9,"level":"foundation","scope":"ptce","blueprint":["ptce.2.5"],"objectives":4,"questions":5,"status":"source-checked","prerequisites":[]},{"id":"tech-law-dscsa","title":"DSCSA: serialization, tracing and suspect product","minutes":10,"level":"core","scope":"ptce","blueprint":["ptce.2.6"],"objectives":4,"questions":5,"status":"source-checked","prerequisites":[]},{"id":"tech-law-waste-hazardous","title":"Pharmaceutical waste and hazardous drugs","minutes":11,"level":"core","scope":"ptce","blueprint":["ptce.2.1"],"objectives":4,"questions":5,"status":"source-checked","prerequisites":[]},{"id":"tech-law-other-acts","title":"Other federal laws: FDCA, PPPA, HIPAA and OBRA-90","minutes":10,"level":"foundation","scope":"workplace","blueprint":["tech.workplace"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]}]},{"id":"tech-safety","title":"Patient safety and quality","summary":"How technicians prevent, catch and report medication errors: high-alert and look-alike drugs, error-proof habits, knowing when to get the pharmacist, event reporting, error types and infection prevention.","blueprint":["ptce.3"],"lessons":[{"id":"tech-safety-high-alert-lasa","title":"High-alert and look-alike/sound-alike medications","minutes":10,"level":"foundation","scope":"ptce","blueprint":["ptce.3.1"],"objectives":3,"questions":6,"status":"ai-draft","prerequisites":[]},{"id":"tech-safety-error-prevention","title":"Error-prevention strategies: zeros, abbreviations, barcodes and patient ID","minutes":10,"level":"foundation","scope":"ptce","blueprint":["ptce.3.2"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["tech-safety-high-alert-lasa"]},{"id":"tech-safety-pharmacist-referral","title":"Issues that need the pharmacist","minutes":9,"level":"foundation","scope":"ptce","blueprint":["ptce.3.3"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-safety-event-reporting","title":"Event reporting and quality improvement","minutes":10,"level":"core","scope":"ptce","blueprint":["ptce.3.4"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-safety-error-types","title":"Types of prescription errors and how to catch them","minutes":12,"level":"core","scope":"ptce","blueprint":["ptce.3.5"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":["tech-safety-error-prevention"]},{"id":"tech-safety-infection-prevention","title":"Infection prevention and cleaning","minutes":8,"level":"foundation","scope":"ptce","blueprint":["ptce.3.6"],"objectives":3,"questions":5,"status":"source-checked","prerequisites":[]}]},{"id":"tech-order","title":"Order entry and processing","summary":"Read and enter prescriptions, decode sigs and medical terms, do the core pharmacy calculations, and handle NDCs, lot numbers, expiration dates, administration supplies and returns.","blueprint":["ptce.4"],"lessons":[{"id":"tech-order-reading-rx","title":"Reading a prescription and the order workflow","minutes":11,"level":"foundation","scope":"ptce","blueprint":["ptce.4.1"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-order-sig-codes","title":"Sig codes, abbreviations and medical terminology","minutes":12,"level":"foundation","scope":"ptce","blueprint":["ptce.4.1"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["tech-order-reading-rx"]},{"id":"tech-order-conversions","title":"Conversions and dimensional analysis","minutes":13,"level":"foundation","scope":"ptce","blueprint":["ptce.4.1"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"tech-order-days-supply","title":"Days supply and quantity to dispense","minutes":13,"level":"foundation","scope":"ptce","blueprint":["ptce.4.1"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["tech-order-conversions"]},{"id":"tech-order-dose-concentration","title":"Doses, concentrations and percent strength","minutes":14,"level":"core","scope":"ptce","blueprint":["ptce.4.1"],"objectives":4,"questions":8,"status":"source-checked","prerequisites":["tech-order-conversions"]},{"id":"tech-order-dilution-iv","title":"Dilutions and IV flow rates","minutes":13,"level":"core","scope":"ptce","blueprint":["ptce.4.1"],"objectives":3,"questions":8,"status":"source-checked","prerequisites":["tech-order-dose-concentration"]},{"id":"tech-order-ndc-lot-expiry","title":"NDC numbers, lot numbers and expiration dates","minutes":11,"level":"foundation","scope":"ptce","blueprint":["ptce.4.3"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"tech-order-equipment","title":"Administration equipment and supplies","minutes":12,"level":"foundation","scope":"ptce","blueprint":["ptce.4.2"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["tech-order-dose-concentration"]},{"id":"tech-order-returns","title":"Returns, credits and reverse distribution","minutes":10,"level":"foundation","scope":"ptce","blueprint":["ptce.4.4"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["tech-order-ndc-lot-expiry"]}]},{"id":"tech-work","title":"Beyond the exam: workplace skills and career","summary":"Skills the PTCE 2026 does not test but the job does: insurance claims and rejections, nonsterile compounding and alligation, sterile and hazardous-drug basics, pharmacy automation, expanded technician roles, counter communication, and keeping your credential current.","blueprint":["tech.workplace"],"lessons":[{"id":"tech-work-billing-claims","title":"Third-party billing, claims and rejection codes","minutes":14,"level":"core","scope":"workplace","blueprint":["tech.workplace"],"objectives":5,"questions":7,"status":"ai-draft","prerequisites":["tech-order-days-supply"]},{"id":"tech-work-nonsterile-compounding","title":"Nonsterile compounding basics and alligation","minutes":15,"level":"core","scope":"workplace","blueprint":["tech.workplace"],"objectives":5,"questions":7,"status":"ai-draft","prerequisites":["tech-order-dose-concentration"]},{"id":"tech-work-sterile-hazardous","title":"Sterile compounding and hazardous drugs: the basics","minutes":15,"level":"core","scope":"workplace","blueprint":["tech.workplace"],"objectives":5,"questions":7,"status":"ai-draft","prerequisites":["tech-safety-infection-prevention"]},{"id":"tech-work-technology-automation","title":"Pharmacy technology and automation","minutes":12,"level":"core","scope":"workplace","blueprint":["tech.workplace"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["tech-safety-error-prevention"]},{"id":"tech-work-expanded-roles","title":"Expanded technician roles: vaccines, point-of-care testing and medication histories","minutes":13,"level":"core","scope":"workplace","blueprint":["tech.workplace"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["tech-safety-pharmacist-referral"]},{"id":"tech-work-counter-communication","title":"Communication at the counter and when to get the pharmacist","minutes":12,"level":"foundation","scope":"workplace","blueprint":["tech.workplace"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["tech-safety-pharmacist-referral"]},{"id":"tech-work-career","title":"Your career after the exam: recertification, credentials and CE","minutes":14,"level":"foundation","scope":"workplace","blueprint":["tech.workplace"],"objectives":5,"questions":7,"status":"ai-draft","prerequisites":[]}]}],"pharmd":[{"id":"pd-foundations","title":"Biomedical foundations","summary":"The physiology, immunology, microbiology and pathophysiology a pharmacist needs to predict what a disease does and what a drug will change: control loops, immune responses, microbial structure and the recurring patterns of disease.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-foundations-homeostasis","title":"Homeostasis and control loops","minutes":13,"level":"foundation","scope":"naplex","blueprint":["naplex.3.c.1","acpe.bio"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-foundations-immunology","title":"Immunology for pharmacists","minutes":15,"level":"foundation","scope":"naplex","blueprint":["naplex.3.c.5","naplex.2.c","acpe.bio"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-foundations-microbiology","title":"Microbiology for pharmacists","minutes":15,"level":"foundation","scope":"naplex","blueprint":["naplex.3.c","naplex.1.a.1","acpe.bio"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-foundations-pathophysiology","title":"Pathophysiology patterns: inflammation, ischemia, neoplasia and fibrosis","minutes":14,"level":"foundation","scope":"naplex","blueprint":["naplex.3.c.1","acpe.bio"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]}]},{"id":"pd-medchem","title":"Medicinal chemistry","summary":"How a drug's structure decides its behavior: functional groups and ionization, structure–activity relationships of key classes, stereochemistry and receptor binding, and the chemistry of metabolism, prodrugs and reactive metabolites.","blueprint":["naplex.1.a.1"],"lessons":[{"id":"pd-medchem-ionization","title":"Functional groups, pKa and ionization","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1","naplex.1.a.3"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-medchem-sar","title":"Structure–activity relationships of key drug classes","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["pd-medchem-ionization"]},{"id":"pd-medchem-stereochemistry","title":"Stereochemistry and drug–receptor binding","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-medchem-metabolism","title":"Metabolism chemistry: phase I, phase II, prodrugs and reactive metabolites","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1","naplex.3.c.6"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["pd-medchem-ionization"]}]},{"id":"pd-pharmacology","title":"Pharmacology and toxicology","summary":"How drugs act on receptors, how the autonomic nervous system predicts drug effects and poisonings, why adverse reactions and interactions happen, and how common poisonings are treated.","blueprint":["naplex.1.a.1"],"lessons":[{"id":"pd-pharmacology-receptors","title":"Receptor theory and dose–response","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pharmacology-autonomic-toxidromes","title":"Autonomic pharmacology and toxidromes","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1","naplex.3.c.6"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":["pd-pharmacology-receptors"]},{"id":"pd-pharmacology-adr","title":"Adverse drug reaction mechanisms","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1","naplex.3.c.5"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pharmacology-interactions","title":"Drug-interaction mechanisms","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1","naplex.3.c.3"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-pharmacology-antidotes","title":"Toxicology and antidotes","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.1.a.1","naplex.3.c.6"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["pd-pharmacology-autonomic-toxidromes"]}]},{"id":"pd-pk","title":"Pharmacokinetics","summary":"How the body absorbs, distributes and clears drugs, and how to use those parameters to design regimens, adjust for kidney and liver function, and interpret drug levels.","blueprint":["naplex.1.a.2","naplex.1.c.9"],"lessons":[{"id":"pd-pk-parameters","title":"ADME and core PK parameters","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.1.a.2","naplex.1.c.9"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-pk-dosing-regimens","title":"Dosing regimens: loading, maintenance and steady state","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.1.a.2","naplex.1.c.9"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":["pd-pk-parameters"]},{"id":"pd-pk-organ-function","title":"Renal and hepatic dose adjustment","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.1.a.2","naplex.1.c.1","naplex.1.c.9"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":["pd-pk-parameters"]},{"id":"pd-pk-tdm","title":"Therapeutic drug monitoring: vancomycin, aminoglycosides, digoxin and lithium","minutes":18,"level":"advanced","scope":"naplex","blueprint":["naplex.1.a.2","naplex.1.c.9","naplex.3.d.2"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":["pd-pk-dosing-regimens","pd-pk-organ-function"]},{"id":"pd-pk-binding-nonlinear","title":"Protein binding, phenytoin and nonlinear kinetics","minutes":15,"level":"advanced","scope":"naplex","blueprint":["naplex.1.a.2","naplex.1.c.9"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":["pd-pk-dosing-regimens"]}]},{"id":"pd-pharmaceutics","title":"Pharmaceutics and biopharmaceutics","summary":"How dosage forms are designed, how drugs dissolve and degrade, how generic and biosimilar products are judged equivalent, and how to store and handle them safely.","blueprint":["naplex.1.a.3"],"lessons":[{"id":"pd-pharmaceutics-release","title":"Dosage-form design and release mechanisms","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.1.a.3","naplex.2.a.3"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pharmaceutics-dispersed-systems","title":"Solutions, suspensions, emulsions and solubility","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.a.3"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pharmaceutics-bioequivalence","title":"Bioavailability, bioequivalence and the Orange Book","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.1.a.3","naplex.2.b"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pharmaceutics-stability","title":"Stability, degradation and storage","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.a.3","naplex.2.d"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pharmaceutics-biologics","title":"Biologics, biosimilars and the Purple Book","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.a.3","naplex.2.b","naplex.2.d"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]}]},{"id":"pd-pgx","title":"Pharmacogenomics","summary":"How inherited gene variants change drug response: translating genotype to phenotype, applying CPIC recommendations for the key gene–drug pairs, reading and communicating a pharmacogenomic report, and the privacy, ethics and coverage issues around testing.","blueprint":["naplex.1.a.2"],"lessons":[{"id":"pd-pgx-genotype-phenotype","title":"From genotype to phenotype","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.1.a.2"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pgx-enzyme-pairs","title":"Gene–drug pairs I: clopidogrel, codeine, tramadol and warfarin","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.1.a.2"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":["pd-pgx-genotype-phenotype"]},{"id":"pd-pgx-risk-pairs","title":"Gene–drug pairs II: HLA, thiopurines, fluoropyrimidines and statins","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.1.a.2"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["pd-pgx-genotype-phenotype"]},{"id":"pd-pgx-reports-ethics","title":"Reading a PGx report, communicating results, and ethics, privacy and coverage","minutes":14,"level":"advanced","scope":"naplex","blueprint":["naplex.1.a.2","naplex.4.d","naplex.3.e"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["pd-pgx-genotype-phenotype"]}]},{"id":"pd-druginfo","title":"Drug information","summary":"Choose the right drug information resource, answer requests systematically, and find official FDA and NIH regulatory information.","blueprint":["naplex.1.f"],"lessons":[{"id":"pd-druginfo-resources","title":"Primary, secondary and tertiary resources","minutes":10,"level":"core","scope":"naplex","blueprint":["naplex.1.f"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-druginfo-request-workflow","title":"Answering a drug information request","minutes":11,"level":"core","scope":"naplex","blueprint":["naplex.1.f"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["pd-druginfo-resources"]},{"id":"pd-druginfo-regulatory","title":"Regulatory information sources","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.1.f","naplex.2.a.4"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["pd-druginfo-resources"]}]},{"id":"pd-biostats","title":"Biostatistics and evidence-based practice","summary":"Read study designs, statistical tests, effect measures, bias and pharmacoeconomic results well enough to judge whether a finding should change practice.","blueprint":["naplex.1.e","naplex.1.c.8"],"lessons":[{"id":"pd-biostats-study-designs","title":"Study designs and the hierarchy of evidence","minutes":11,"level":"core","scope":"naplex","blueprint":["naplex.1.e"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-biostats-tests-inference","title":"Statistical tests, p-values and confidence intervals","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.e"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["pd-biostats-study-designs"]},{"id":"pd-biostats-effect-measures","title":"Effect measures: RR, RRR, ARR, NNT, OR and HR","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.c.8","naplex.1.e"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["pd-biostats-tests-inference"]},{"id":"pd-biostats-bias-validity","title":"Bias, confounding and validity","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.1.e"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["pd-biostats-study-designs"]},{"id":"pd-biostats-econ-development","title":"Pharmacoeconomics and drug development","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.c.8","naplex.1.d"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]}]},{"id":"pd-cardio","title":"Cardiovascular therapeutics","summary":"Hypertension, lipids, heart failure, acute coronary syndromes, atrial fibrillation and venous thromboembolism: first-line choices, dosing, monitoring and interactions, checked against the guidelines current in October 2026.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-cardio-hypertension","title":"Hypertension: the 2025 guideline in practice","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-cardio-dyslipidemia","title":"Dyslipidemia: LDL goals, statins and add-on therapy","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-cardio-heart-failure","title":"Heart failure: GDMT for HFrEF and therapy for HFpEF","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-cardio-acs-antiplatelets","title":"Acute coronary syndromes and antiplatelet therapy","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-cardio-atrial-fibrillation","title":"Atrial fibrillation: stroke prevention, rate and rhythm","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.1.c"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-cardio-vte","title":"Venous thromboembolism: DOACs, heparins, warfarin and HIT","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.1.c"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]}]},{"id":"pd-endo","title":"Endocrine therapeutics","summary":"Drug therapy for type 2 diabetes, insulin and hypoglycemia, thyroid disease, osteoporosis and corticosteroid or adrenal problems: first-line choices, monitoring, counseling and the calculations that go with them.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-endo-t2d","title":"Type 2 diabetes pharmacotherapy","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-endo-insulin","title":"Insulin therapy and hypoglycemia","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.e","naplex.1.c.4"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["pd-endo-t2d"]},{"id":"pd-endo-thyroid","title":"Thyroid disorders","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-endo-bone","title":"Osteoporosis and bone health","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.e"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-endo-steroids","title":"Corticosteroids and adrenal insufficiency","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.e","naplex.1.c.4"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]}]},{"id":"pd-pulm-gi","title":"Respiratory and GI therapeutics","summary":"Asthma and COPD inhaled therapy, acid-related disease and H. pylori, inflammatory bowel disease and the complications of cirrhosis: guideline-based first-line choices, monitoring and counseling.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-pulm-gi-asthma","title":"Asthma: GINA tracks, step therapy and inhaler technique","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.g"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pulm-gi-copd","title":"COPD: GOLD 2026 groups, inhaled therapy and exacerbations","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":["pd-pulm-gi-asthma"]},{"id":"pd-pulm-gi-acid","title":"GERD, peptic ulcer disease and H. pylori","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.3.f"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-pulm-gi-ibd-liver","title":"Inflammatory bowel disease and complications of cirrhosis","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]}]},{"id":"pd-renal","title":"Renal, fluids and electrolytes","summary":"Chronic kidney disease, acute kidney injury and nephrotoxic drugs, potassium and sodium disorders, and acid–base interpretation, with worked 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gap","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.1.c"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]}]},{"id":"pd-neuro-psych","title":"Neurology and psychiatry","summary":"Epilepsy, Parkinson's disease and dementia, migraine and stroke prevention, depression and anxiety, bipolar disorder and schizophrenia, ADHD and substance use disorders: drug selection, monitoring, interactions and safety programs, checked against FDA labels and federal sources current in October 2026.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-neuro-psych-epilepsy","title":"Epilepsy: drug selection, interactions and levels","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.1.a.2"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"pd-neuro-psych-parkinsons-dementia","title":"Parkinson's disease and dementia","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.2.a.4"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"pd-neuro-psych-migraine-stroke","title":"Migraine and secondary stroke prevention","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.3.e"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"pd-neuro-psych-depression-anxiety","title":"Depression and anxiety disorders","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.2.a.4"],"objectives":5,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-neuro-psych-bipolar-schizophrenia","title":"Bipolar disorder and schizophrenia","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.1.c.9"],"objectives":5,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-neuro-psych-adhd-sud","title":"ADHD and substance use disorders","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.4.b","naplex.2.a.4"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":[]}]},{"id":"pd-pain-heme-onc","title":"Pain, rheumatology, hematology and oncology","summary":"Drug therapy for pain and opioid safety, rheumatoid arthritis and gout, common anemias and sickle cell disease, oncology supportive care and transplant immunosuppression: first-line choices, boxed warnings, monitoring and the calculations that go with them.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-pain-heme-onc-pain-opioids","title":"Pain management, opioids and analgesic safety","minutes":17,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.1.c.4","naplex.4.b"],"objectives":5,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-pain-heme-onc-rheum","title":"Rheumatoid arthritis and gout","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.2.a.4","naplex.3.d"],"objectives":5,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-pain-heme-onc-anemia","title":"Anemias, ESAs and sickle cell disease","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.1.c.2","naplex.2.a.4"],"objectives":5,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-pain-heme-onc-supportive-care","title":"Oncology supportive care","minutes":17,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.1.c.1","naplex.3.e"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-pain-heme-onc-transplant","title":"Transplant immunosuppression basics","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.2.a.4"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":["pd-endo-steroids"]}]},{"id":"pd-womens-derm-eye","title":"Women's and men's health, dermatology and eye care","summary":"Contraception and emergency contraception, menopause hormone therapy and prescribing in pregnancy and lactation, BPH, erectile dysfunction and testosterone, and common skin and eye conditions: method selection, CDC eligibility rules, safety warnings and counseling.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-womens-derm-eye-contraception","title":"Contraception and emergency contraception","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.f","naplex.3.e"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-womens-derm-eye-menopause-pregnancy","title":"Menopause hormone therapy and prescribing in pregnancy and lactation","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.2.a.4","naplex.3.e"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-womens-derm-eye-mens-health","title":"Men's health: BPH, erectile dysfunction and testosterone","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d","naplex.3.e"],"objectives":3,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-womens-derm-eye-derm-eye","title":"Dermatology and eye care: acne, topical steroids, fungal infections and glaucoma","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.e","naplex.2.a.4"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":[]}]},{"id":"pd-critical","title":"Critical care and nutrition support","summary":"How to recognize and resuscitate sepsis and choose vasopressors, manage ICU pain, sedation and delirium, prevent stress ulcers and blood clots, and plan and calculate enteral and parenteral nutrition safely.","blueprint":["naplex.3.c","naplex.1.c.7"],"lessons":[{"id":"pd-critical-sepsis-vasopressors","title":"Sepsis, fluids and 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antimicrobial stewardship.","blueprint":["naplex.3.c","naplex.4.b"],"lessons":[{"id":"pd-id-spectrum-pkpd","title":"Antimicrobial spectrum and PK/PD","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.1.a.2"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":["pd-foundations-microbiology"]},{"id":"pd-id-cultures-deescalation","title":"Cultures, susceptibilities and de-escalation","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.4.b"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":["pd-id-spectrum-pkpd"]},{"id":"pd-id-syndromes-cap-uti-ssti","title":"Common syndromes I: pneumonia, urinary tract and skin infections","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.c"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":["pd-id-cultures-deescalation"]},{"id":"pd-id-syndromes-cdi-sepsis-cns-sti","title":"Common syndromes II: C. difficile, sepsis, meningitis and STIs","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.4.b"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":["pd-id-spectrum-pkpd"]},{"id":"pd-id-hiv-hep-tb-fungal","title":"HIV, viral hepatitis, tuberculosis and fungal infections","minutes":20,"level":"core","scope":"naplex","blueprint":["naplex.3.c"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-id-stewardship-allergy","title":"Antimicrobial stewardship and penicillin allergy","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.4.b","naplex.3.c"],"objectives":3,"questions":6,"status":"ai-draft","prerequisites":["pd-id-cultures-deescalation"]}]},{"id":"pd-special","title":"Special populations","summary":"Dosing and drug selection for children, older adults, pregnancy and lactation, kidney and liver impairment, dialysis, obesity and critical illness, with worked calculations.","blueprint":["naplex.3.c"],"lessons":[{"id":"pd-special-pediatrics","title":"Pediatrics: weight-based dosing, dosage forms and drugs to avoid","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.1.c.2"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"pd-special-geriatrics","title":"Older adults: Beers Criteria, anticholinergic burden, falls and deprescribing","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.3.d"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"pd-special-pregnancy-lactation","title":"Pregnancy and lactation: PLLR labeling, teratogens, LactMed and folic acid","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.2.a.4"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":[]},{"id":"pd-special-organ-impairment","title":"Kidney and liver impairment and dialysis: drugs to avoid or cap","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.c","naplex.1.c.1"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":["pd-pk-organ-function"]},{"id":"pd-special-obesity-critical-care","title":"Obesity and critical illness: choosing a dosing weight","minutes":15,"level":"advanced","scope":"naplex","blueprint":["naplex.3.c","naplex.1.c.1","naplex.1.c.9"],"objectives":3,"questions":7,"status":"ai-draft","prerequisites":["pd-pk-organ-function"]}]},{"id":"pd-selfcare","title":"Self-care, OTC products and supplements","summary":"Triage for self-care, OTC choices for common conditions, dietary supplement regulation and quality, and home tests and monitoring devices.","blueprint":["naplex.3.f","naplex.3.g"],"lessons":[{"id":"pd-selfcare-triage","title":"Self-care triage: QuEST/SCHOLAR-MAC, exclusions and referral","minutes":12,"level":"foundation","scope":"naplex","blueprint":["naplex.3.f","naplex.3.b"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":[]},{"id":"pd-selfcare-common-conditions","title":"Common OTC conditions: respiratory, pain, GI, skin, sleep, eye and ear","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.f"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":["pd-selfcare-triage"]},{"id":"pd-selfcare-supplements","title":"Dietary supplements: regulation, claims, quality marks and adulteration","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.3.f"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"pd-selfcare-home-tests","title":"Home tests and monitoring devices","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.g"],"objectives":4,"questions":8,"status":"ai-draft","prerequisites":[]}]},{"id":"pd-safety","title":"Medication reconciliation and safety","summary":"How to build an accurate medication list across transitions of care, why medication errors are usually system failures, and how reporting and quality tools turn events into safer processes.","blueprint":["naplex.3.a","naplex.4.a","naplex.5.c"],"lessons":[{"id":"pd-safety-med-rec","title":"Best possible medication history and reconciliation","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.3.a","coepa.epa.1"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":[]},{"id":"pd-safety-error-science","title":"Error science and high-alert medications","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.4.a","naplex.5.a"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-safety-reporting-quality","title":"Reporting systems and quality tools","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.4.a","naplex.5.c","coepa.epa.10"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]}]},{"id":"pd-communication","title":"Communication and counseling","summary":"Structured counseling with the prime questions and teach-back, plain language and interpreters, motivational interviewing, and clear communication with prescribers and upset patients.","blueprint":["naplex.3.e"],"lessons":[{"id":"pd-communication-counseling","title":"Counseling frameworks: prime questions, teach-back and the offer to counsel","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.3.e","naplex.3.e.2","coepa.epa.8"],"objectives":3,"questions":5,"status":"ai-draft","prerequisites":[]},{"id":"pd-communication-health-literacy","title":"Health literacy and culturally responsive care","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.3.e","acpe.sab.cultural","coepa.eo.2.3"],"objectives":3,"questions":5,"status":"ai-draft","prerequisites":[]},{"id":"pd-communication-mi","title":"Motivational interviewing","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.3.e","naplex.3.c.7","coepa.eo.2.2"],"objectives":3,"questions":5,"status":"ai-draft","prerequisites":[]},{"id":"pd-communication-interprofessional","title":"Interprofessional communication and de-escalation","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.3.e","naplex.3.d","coepa.epa.4"],"objectives":4,"questions":5,"status":"ai-draft","prerequisites":[]}]},{"id":"pd-publichealth","title":"Public health and immunization","summary":"Reading the immunization schedules as they stand in 2026, vaccine storage and administration, contraindications and adverse events, opioid stewardship and tobacco cessation, and the social drivers of health.","blueprint":["naplex.2.c","naplex.4.b","naplex.4.c"],"lessons":[{"id":"pd-publichealth-schedules","title":"Reading the immunization schedules","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.2.c.1","coepa.epa.12"],"objectives":3,"questions":5,"status":"source-checked","prerequisites":[]},{"id":"pd-publichealth-vaccine-handling","title":"Vaccine storage, handling and administration","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.2.c.3","naplex.2.c.4"],"objectives":4,"questions":5,"status":"source-checked","prerequisites":[]},{"id":"pd-publichealth-vaccine-safety","title":"Contraindications, precautions and vaccine adverse events","minutes":14,"level":"core","scope":"naplex","blueprint":["naplex.2.c.2","naplex.2.c.5","naplex.4.a"],"objectives":3,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-publichealth-opioids-tobacco","title":"Opioid stewardship, naloxone and tobacco cessation","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.4.b","naplex.3.e.1"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-publichealth-population-health","title":"Population health and social drivers of health","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.4.c","naplex.4.b","naplex.3.b"],"objectives":4,"questions":5,"status":"source-checked","prerequisites":[]}]},{"id":"pd-law","title":"Pharmacy law for pharmacists","summary":"Federal controlled-substance, FDA, compounding and privacy law at pharmacist depth, plus how state practice acts and the MPJE, Uniform MPJE and state law exams work. Current as of October 2026; always study your own state's law.","blueprint":["law"],"lessons":[{"id":"pd-law-csa-dea","title":"Controlled substances at pharmacist depth: the CSA and DEA rules","minutes":20,"level":"advanced","scope":"law","blueprint":["law"],"objectives":5,"questions":8,"status":"ai-draft","prerequisites":["tech-law-schedules","tech-law-cs-prescriptions","tech-law-cs-handling"]},{"id":"pd-law-fdca-compounding","title":"FDCA, REMS, DSCSA, compounding law and OBRA-90","minutes":18,"level":"core","scope":"law","blueprint":["law","naplex.2.a.4"],"objectives":5,"questions":7,"status":"ai-draft","prerequisites":["tech-law-other-acts","tech-law-restricted-programs","tech-law-dscsa"]},{"id":"pd-law-state-exams","title":"State practice acts and the pharmacy law exams","minutes":15,"level":"core","scope":"law","blueprint":["law"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":[]},{"id":"pd-law-hipaa","title":"HIPAA privacy for pharmacists","minutes":14,"level":"core","scope":"law","blueprint":["law"],"objectives":5,"questions":7,"status":"ai-draft","prerequisites":["tech-law-other-acts"]}]},{"id":"pd-systems","title":"Health systems, informatics and ethics","summary":"How drugs are paid for and managed in US health care, how technology helps and harms medication safety, and how pharmacists reason through ethics, lead improvement and teach.","blueprint":["naplex.5","naplex.4.d"],"lessons":[{"id":"pd-systems-payment","title":"How US drug payment works","minutes":13,"level":"core","scope":"pharmd","blueprint":["pharmd","acpe.sab.healthsystems"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-systems-operations","title":"Formulary, shortages, recalls and inventory","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.5.b","naplex.2.b"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-systems-informatics","title":"Informatics and clinical decision support safety","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.5.a"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-systems-ethics","title":"Ethics in pharmacy practice","minutes":12,"level":"core","scope":"naplex","blueprint":["naplex.4.d"],"objectives":4,"questions":6,"status":"source-checked","prerequisites":[]},{"id":"pd-systems-leadership-qi","title":"Leadership, precepting and quality improvement","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.5.c","naplex.5.d"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]}]},{"id":"pd-compounding","title":"Compounding and pharmaceutical calculations","summary":"The calculations behind compounding and IV therapy, and the USP standards for nonsterile, sterile and hazardous-drug compounding.","blueprint":["naplex.1.b","naplex.1.c"],"lessons":[{"id":"pd-compounding-calculations","title":"Core pharmaceutical calculations","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.1.c.5","naplex.1.c.6"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-compounding-pn","title":"IV and parenteral nutrition calculations","minutes":16,"level":"advanced","scope":"naplex","blueprint":["naplex.1.c.3","naplex.1.c.7"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":["pd-compounding-calculations"]},{"id":"pd-compounding-usp795","title":"USP <795>: nonsterile compounding","minutes":13,"level":"core","scope":"naplex","blueprint":["naplex.1.b.1"],"objectives":4,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-compounding-usp797","title":"USP <797>: sterile compounding","minutes":16,"level":"advanced","scope":"naplex","blueprint":["naplex.1.b.2"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":[]},{"id":"pd-compounding-usp800","title":"USP <800>: hazardous drugs","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.1.b","naplex.2.d"],"objectives":3,"questions":7,"status":"source-checked","prerequisites":[]}]},{"id":"pd-cases","title":"Patient assessment and integrated cases","summary":"The Pharmacists' Patient Care Process, lab interpretation, physical assessment, drug therapy problems and SOAP documentation, practiced on synthetic integrated cases. Simulated cases build reasoning but are not experiential training.","blueprint":["naplex.3.b","naplex.3.d"],"lessons":[{"id":"pd-cases-ppcp","title":"The Pharmacists' Patient Care Process","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.b","naplex.3.d","coepa.epa.1","coepa.epa.2","coepa.epa.3"],"objectives":3,"questions":6,"status":"ai-draft","prerequisites":[]},{"id":"pd-cases-labs","title":"Lab interpretation: BMP, CBC, LFTs, INR, A1C and lipids","minutes":18,"level":"core","scope":"naplex","blueprint":["naplex.3.b","naplex.3.d","naplex.1.c.1"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["pd-cases-ppcp"]},{"id":"pd-cases-physical-assessment","title":"Physical assessment basics for pharmacists","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.b","naplex.3.d","naplex.3.g"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["pd-cases-ppcp"]},{"id":"pd-cases-drug-therapy-problems","title":"Drug therapy problems: classify and prioritize","minutes":16,"level":"core","scope":"naplex","blueprint":["naplex.3.b","naplex.3.d","naplex.3.c.4"],"objectives":4,"questions":7,"status":"ai-draft","prerequisites":["pd-cases-ppcp","pd-cases-labs"]},{"id":"pd-cases-soap","title":"SOAP documentation and recommendations to prescribers","minutes":15,"level":"core","scope":"naplex","blueprint":["naplex.3.b","naplex.3.d","coepa.epa.4","coepa.epa.6"],"objectives":4,"questions":6,"status":"ai-draft","prerequisites":["pd-cases-ppcp","pd-cases-drug-therapy-problems"]}]}]},"herbs":[{"id":"aconite","commonName":"Aconite (monkshood)","scientificName":"Aconitum napellus L.","family":"Ranunculaceae","group":"safety","otherNames":["monkshood","wolfsbane","friar's cap","fuzi (processed root of A. carmichaelii)","chuanwu","caowu"],"summary":"Aconite (monkshood) is a blue-flowered mountain and garden plant, and one of the most poisonous plants in the world. Its alkaloids, chiefly aconitine, act on sodium channels in the heart and nerves, causing numbness, vom","hero":{"file":"media/herbs/aconite-whole.webp","thumb":"media/herbs/thumbs/aconite-whole.webp","attribution":"Photo: H. Zell, CC BY-SA 3.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1400,"height":1050},"ratings":[{"use":"Pain and neuralgia (historical tinctures and liniments)","rating":"little"},{"use":"Uses in traditional Chinese medicine formulas","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"Antiarrhythmics, digoxin and other drugs that affect cardiac conduction","mechanism":"Additive or unpredictable effects on cardiac sodium channels and rhythm","severity":"major","evidence":"theoretical","advice":"No combination is safe because aconite itself is not safe to take. In a poisoned patient, antiarrhythmic choice belongs to the treating team and toxicologist."}],"status":"source-checked","questions":4},{"id":"ashwagandha","commonName":"Ashwagandha","scientificName":"Withania somnifera (L.) Dunal","family":"Solanaceae","group":"supplement","otherNames":["Indian ginseng","winter cherry","poison gooseberry"],"summary":"Ashwagandha is a root used for centuries in Ayurvedic medicine and now one of the best-selling supplements in the US, mostly for stress and sleep. Small, short trials of specific root extracts suggest modest benefits, bu","hero":{"file":"media/herbs/ashwagandha-whole.webp","thumb":"media/herbs/thumbs/ashwagandha-whole.webp","attribution":"Photo: Biswarup Ganguly, CC BY 3.0, via Wikimedia Commons","width":1400,"height":931},"ratings":[{"use":"Stress and anxiety","rating":"some"},{"use":"Sleep and insomnia","rating":"some"},{"use":"Testosterone and sperm quality","rating":"some"},{"use":"Other uses (blood sugar, athletic performance, memory, menopause, COVID-19)","rating":"little"}],"majorInteractions":0,"interactions":[{"with":"Thyroid hormone (levothyroxine) and antithyroid drugs","mechanism":"May raise thyroid hormone levels; case reports of thyrotoxicosis","severity":"moderate","evidence":"case-reports","advice":"Avoid unless the prescriber agrees and monitors thyroid tests (TSH, free T4). Ask about new palpitations, tremor or weight loss."},{"with":"Sedatives: benzodiazepines, barbiturates, anticonvulsants, alcohol","mechanism":"Possible additive sedation; GABA-receptor effects in animal studies","severity":"moderate","evidence":"theoretical","advice":"Counsel about added drowsiness; MSK advises people on these drugs to likely avoid ashwagandha."},{"with":"Immunosuppressants (e.g., after transplant or for autoimmune disease)","mechanism":"Possible immune-stimulating effect that could work against the drug; may trigger or worsen autoimmune disease","severity":"moderate","evidence":"theoretical","advice":"Avoid in transplant recipients and autoimmune disease unless the specialist approves."},{"with":"Diabetes medicines (insulin, sulfonylureas and others)","mechanism":"Possible additive glucose lowering","severity":"minor","evidence":"theoretical","advice":"If used, monitor blood glucose more closely when starting or stopping."},{"with":"Blood pressure medicines","mechanism":"Possible additive blood pressure lowering","severity":"minor","evidence":"theoretical","advice":"Watch for dizziness; check blood pressure."}],"status":"source-checked","questions":4},{"id":"asian-ginseng","commonName":"Asian ginseng","scientificName":"Panax ginseng C.A.Mey.","family":"Araliaceae","group":"supplement","otherNames":["Korean ginseng","Chinese ginseng","ren shen","red ginseng (steamed root)","white ginseng (dried root)","Panax"],"summary":"Asian ginseng is the root of Panax ginseng, used for centuries in Chinese and Korean medicine and sold today for energy, fatigue, thinking and blood sugar. Human studies are mostly small and short, with modest or inconsi","hero":{"file":"media/herbs/asian-ginseng-whole.webp","thumb":"media/herbs/thumbs/asian-ginseng-whole.webp","attribution":"Photo: Nina Filippova (via iNaturalist), CC BY 4.0, via Wikimedia Commons","width":933,"height":1400},"ratings":[{"use":"General fatigue","rating":"some"},{"use":"Mental performance (attention, reaction time)","rating":"some"},{"use":"Blood glucose and cardiometabolic markers in prediabetes or diabetes","rating":"some"},{"use":"Erectile dysfunction","rating":"some"},{"use":"Athletic performance","rating":"against"}],"majorInteractions":0,"interactions":[{"with":"Warfarin","mechanism":"Possible faster warfarin clearance (enzyme induction proposed); ginseng may also affect platelets","severity":"moderate","evidence":"pharmacokinetic","advice":"Evidence is mixed. In a randomized trial in 20 healthy volunteers, **American** ginseng lowered peak INR and warfarin levels; in a crossover study of 12 healthy men, a ginseng product did not change warfarin levels or INR. Do not assume the American-ginseng result applies to every Asian ginseng product, but treat any start, stop or switch as a reason to check the INR more closely. The pharmacist handles this counseling; technicians flag it."},{"with":"Insulin, sulfonylureas (e.g., glipizide) and other glucose-lowering drugs","mechanism":"Additive blood-glucose lowering","severity":"moderate","evidence":"theoretical","advice":"Ginseng may lower blood glucose. Patients should check glucose more often when starting or stopping it and report lows; the prescriber may need to adjust therapy."},{"with":"MAOIs (e.g., phenelzine)","mechanism":"Unknown; manic-like symptoms reported in case reports","severity":"moderate","evidence":"case-reports","advice":"Avoid the combination; refer the patient to the pharmacist and prescriber."},{"with":"Imatinib","mechanism":"Unclear; possible additive liver injury","severity":"moderate","evidence":"case-reports","advice":"A case of liver toxicity was reported in a patient taking imatinib with ginseng. People on cancer therapy should discuss any supplement with their oncology team."}],"status":"source-checked","questions":4},{"id":"autumn-crocus","commonName":"Autumn crocus","scientificName":"Colchicum autumnale L.","family":"Colchicaceae","group":"drug-source","otherNames":["meadow saffron","naked ladies","colchicum"],"summary":"Autumn crocus is the plant behind colchicine, a drug used for gout flares, familial Mediterranean fever (FMF) and, at a low dose, cardiovascular risk reduction. Colchicine has a narrow therapeutic index: strong CYP3A4 or","hero":{"file":"media/herbs/autumn-crocus-whole.webp","thumb":"media/herbs/thumbs/autumn-crocus-whole.webp","attribution":"Photo: AnRo0002 (CC0), via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Treatment and prevention of gout flares (colchicine, the purified drug)","rating":"good"},{"use":"Familial Mediterranean fever (colchicine)","rating":"good"},{"use":"Lowering risk of heart attack, stroke and cardiovascular death in atherosclerotic disease (low-dose colchicine 0.5 mg)","rating":"some"},{"use":"Gout or any other use of the plant (corm, seed, leaf, tea, tincture)","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"Strong CYP3A4 inhibitors and P-gp inhibitors: clarithromycin, ketoconazole, itraconazole, ritonavir and other HIV protease inhibitors, cyclosporine, ranolazine","mechanism":"Blocking colchicine's metabolism (CYP3A4) and efflux (P-gp) raises its levels sharply.","severity":"major","evidence":"clinical","advice":"Fatal interactions continue to be reported. Contraindicated in kidney or liver impairment; otherwise the label requires dose reduction or avoidance. The pharmacist must review every new prescription for these drugs in a patient on colchicine."},{"with":"Moderate CYP3A4 inhibitors: verapamil, diltiazem, grapefruit juice","mechanism":"Moderate increase in colchicine exposure; verapamil and diltiazem are also linked to neuromuscular toxicity with colchicine.","severity":"moderate","evidence":"clinical","advice":"The label recommends dose adjustment; counsel patients to avoid large amounts of grapefruit juice."},{"with":"Statins and fibrates (e.g., simvastatin, atorvastatin, gemfibrozil, fenofibrate)","mechanism":"Additive muscle toxicity; myopathy and rhabdomyolysis have been reported.","severity":"moderate","evidence":"case-reports","advice":"Counsel patients to report muscle pain or weakness promptly; risk is higher in older adults and with kidney impairment."}],"status":"source-checked","questions":4},{"id":"belladonna","commonName":"Belladonna (deadly nightshade)","scientificName":"Atropa bella-donna L.","family":"Solanaceae","group":"drug-source","otherNames":["deadly nightshade","Atropa belladonna","belladonna leaf","belladonna root"],"summary":"Belladonna is a highly poisonous nightshade whose leaves and roots gave medicine the tropane alkaloids: hyoscyamine, its racemic form atropine, and smaller amounts of scopolamine. Purified atropine is still an essential ","hero":{"file":"media/herbs/belladonna-whole.webp","thumb":"media/herbs/thumbs/belladonna-whole.webp","attribution":"Photo: Krzysztof Ziarnek, Kenraiz, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1050,"height":1400},"ratings":[{"use":"Blocking dangerous muscarinic effects: symptomatic slow heart rate, organophosphate or muscarinic mushroom poisoning, and drying secretions (atropine, the purified drug)","rating":"good"},{"use":"Teething pain and other uses (homeopathic belladonna products)","rating":"little"},{"use":"Any use of raw plant, berries, tea or homemade extracts","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"Other anticholinergic drugs: diphenhydramine and other first-generation antihistamines, tricyclic antidepressants, oxybutynin, some antipsychotics","mechanism":"Additive muscarinic blockade (anticholinergic burden).","severity":"major","evidence":"theoretical","advice":"Combining belladonna alkaloids (or the plant) with other anticholinergics raises the risk of delirium, urinary retention, constipation and overheating, especially in older adults. The pharmacist reviews the full medication list, including OTC sleep aids."},{"with":"Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and other cholinergic drugs","mechanism":"Opposing effects on acetylcholine signaling.","severity":"moderate","evidence":"theoretical","advice":"Anticholinergics can cancel the intended effect of dementia drugs and vice versa; flag the combination for the pharmacist."},{"with":"Mexiletine (with atropine)","mechanism":"Atropine slows gastric emptying and decreases the absorption rate of mexiletine.","severity":"minor","evidence":"pharmacokinetic","advice":"Listed in the atropine label; usually relevant only around anesthesia."}],"status":"source-checked","questions":4},{"id":"black-cohosh","commonName":"Black cohosh","scientificName":"Actaea racemosa L.","family":"Ranunculaceae","group":"supplement","otherNames":["black snakeroot","bugbane","cimicifuga"],"summary":"Black cohosh root and rhizome extracts are used for hot flashes and other menopausal symptoms. Results are mixed: a 2012 Cochrane review and a large U.S. trial found no benefit over placebo, while a 2023 meta-analysis su","hero":{"file":"media/herbs/black-cohosh-whole.webp","thumb":"media/herbs/thumbs/black-cohosh-whole.webp","attribution":"Photo: H. Zell, CC BY-SA 3.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1053,"height":1400},"ratings":[{"use":"Hot flashes and other menopausal symptoms","rating":"some"},{"use":"Hot flashes related to breast cancer treatment","rating":"some"},{"use":"Menstrual cramps, premenstrual syndrome and labor induction","rating":"little"}],"majorInteractions":0,"interactions":[{"with":"Other drugs or supplements that can injure the liver","mechanism":"Possible additive liver injury; adverse reactions with concomitant prescription drugs most often involve abnormal liver function.","severity":"moderate","evidence":"theoretical","advice":"Refer to the pharmacist when black cohosh is combined with known hepatotoxic drugs; liver tests may be considered."},{"with":"Tamoxifen","mechanism":"Black cohosh may interfere with tamoxifen's action; clinical relevance unknown.","severity":"moderate","evidence":"theoretical","advice":"People with breast cancer should discuss any menopausal supplement with their oncology team."},{"with":"CYP3A4 substrates","mechanism":"Possible interaction with drugs metabolized by CYP3A4; clinical significance not determined.","severity":"minor","evidence":"theoretical","advice":"Flag narrow-therapeutic-index drugs for the pharmacist."}],"status":"source-checked","questions":4},{"id":"cinchona","commonName":"Cinchona (red cinchona)","scientificName":"Cinchona pubescens Vahl","family":"Rubiaceae","group":"drug-source","otherNames":["quinine tree","red cinchona","Peruvian bark","Jesuit's bark","quina","cinchona bark"],"summary":"Cinchona bark, once called \"Jesuit's bark\" or \"Peruvian bark\", was the first effective treatment for malaria, and its chief alkaloid quinine was isolated in 1820. Today quinine sulfate capsules are FDA-approved only for ","hero":{"file":"media/herbs/cinchona-whole.webp","thumb":"media/herbs/thumbs/cinchona-whole.webp","attribution":"Photo: Klockrike, CC BY-SA 3.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1400,"height":1050},"ratings":[{"use":"Uncomplicated *Plasmodium falciparum* malaria (quinine sulfate, the purified drug)","rating":"good"},{"use":"Nocturnal leg cramps (quinine drug; not an approved use)","rating":"some"},{"use":"Malaria prevention or treatment, \"fever\" or cramps (cinchona bark, teas, extracts, tonic water)","rating":"little"}],"majorInteractions":3,"interactions":[{"with":"QT-prolonging drugs (class IA and III antiarrhythmics, pimozide, others) and mefloquine (with quinine)","mechanism":"Additive QT prolongation and torsades de pointes risk; mefloquine adds cardiac and seizure risk.","severity":"major","evidence":"clinical","advice":"The label says to avoid these combinations. Technicians escalate the DUR alert to the pharmacist."},{"with":"Rifampin and other strong CYP3A4 inducers (with quinine)","mechanism":"Induction of CYP3A4 lowered median quinine AUC by 75% in patients.","severity":"major","evidence":"pharmacokinetic","advice":"Avoid; low quinine exposure risks malaria treatment failure."},{"with":"Ritonavir and other strong CYP3A4 inhibitors (with quinine)","mechanism":"Ritonavir raised quinine levels about four-fold; ketoconazole raised AUC by 45%.","severity":"major","evidence":"pharmacokinetic","advice":"The label advises avoiding ritonavir; other inhibitors need pharmacist review for toxicity and QT risk."},{"with":"Digoxin (with quinine or quinidine)","mechanism":"Quinine raised digoxin AUC by 33%; quinidine roughly doubles digoxin levels (P-gp inhibition).","severity":"moderate","evidence":"pharmacokinetic","advice":"Digoxin levels are monitored and the dose adjusted by the prescriber."},{"with":"Warfarin (with quinine)","mechanism":"Quinine may enhance the anticoagulant effect.","severity":"moderate","evidence":"case-reports","advice":"INR is monitored during and after the course."},{"with":"Aluminum- or magnesium-containing antacids (with quinine)","mechanism":"Reduced quinine absorption.","severity":"minor","evidence":"pharmacokinetic","advice":"The label advises avoiding concomitant use; separate doses if an antacid is needed and check with the pharmacist."}],"status":"source-checked","questions":4},{"id":"comfrey","commonName":"Comfrey","scientificName":"Symphytum officinale L.","family":"Boraginaceae","group":"safety","otherNames":["common comfrey","knitbone","boneset","blackwort","bruisewort","slippery root"],"summary":"Comfrey is a hairy garden and meadow plant long used on bruises, sprains and broken bones (hence \"knitbone\"). Some small trials suggest root-extract creams may ease back pain and sprains. Taken by mouth it can seriously ","hero":{"file":"media/herbs/comfrey-whole.webp","thumb":"media/herbs/thumbs/comfrey-whole.webp","attribution":"Photo: AnRo0002 (CC0), via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Back pain, sprains and muscle or joint pain (topical)","rating":"some"},{"use":"Wound healing (topical)","rating":"little"},{"use":"Ulcers, bronchitis, cancer (oral)","rating":"little"}],"majorInteractions":0,"interactions":[{"with":"Enzyme inducers (e.g., phenobarbital and other CYP inducers)","mechanism":"Induction increases conversion of PAs to toxic pyrrole metabolites","severity":"moderate","evidence":"theoretical","advice":"LiverTox notes that microsomal enzyme inducers increase PA toxicity. This adds to the reasons oral comfrey should not be used."},{"with":"Other liver-toxic drugs, herbs or supplements","mechanism":"Additive liver injury","severity":"moderate","evidence":"theoretical","advice":"Avoid combining with any hepatotoxic product; refer patients with liver disease or liver-risk medicines to the pharmacist."}],"status":"source-checked","questions":4},{"id":"cranberry","commonName":"Cranberry","scientificName":"Vaccinium macrocarpon Aiton","family":"Ericaceae","group":"supplement","otherNames":["American cranberry","large cranberry"],"summary":"Cranberry is the tart red fruit of a North American bog shrub, taken as juice or capsules mainly to help prevent repeat urinary tract infections (UTIs). A 2023 Cochrane review found it lowers the risk of symptomatic UTIs","hero":{"file":"media/herbs/cranberry-whole.webp","thumb":"media/herbs/thumbs/cranberry-whole.webp","attribution":"Photo: Kristine Paulus, CC BY 2.0, via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Preventing repeat UTIs in women with recurrent UTIs","rating":"some"},{"use":"Preventing UTIs in children","rating":"some"},{"use":"Preventing UTIs in people at risk after a medical intervention","rating":"some"},{"use":"Preventing UTIs in institutionalized older adults, pregnant women, or people with bladder-emptying problems","rating":"against"},{"use":"Treating an active UTI","rating":"little"}],"majorInteractions":0,"interactions":[{"with":"Warfarin","mechanism":"Uncertain; proposed inhibition of warfarin metabolism (CYP2C9) or other effects on clotting","severity":"moderate","evidence":"case-reports","advice":"Evidence conflicts. Case reports describe high INRs and bleeding, but a randomized, double-blind trial of 240 mL juice daily for 2 weeks in 30 patients on stable warfarin found no change in warfarin levels and no clinically meaningful INR change. MSK suggests large amounts (for example 1–2 L of juice a day, or supplements for more than 3–4 weeks) may matter. Advise keeping intake steady and checking the INR when starting, stopping or greatly increasing cranberry. The pharmacist handles this counseling."},{"with":"Tacrolimus","mechanism":"Unclear; possibly intestinal CYP3A effects","severity":"moderate","evidence":"case-reports","advice":"One kidney transplant patient had low tacrolimus levels that recovered after stopping cranberry. A trial with cyclosporine found no clinically significant effect. Transplant patients should tell their team before using cranberry products regularly."}],"status":"source-checked","questions":4},{"id":"echinacea","commonName":"Echinacea","scientificName":"Echinacea purpurea (L.) Moench","family":"Asteraceae","group":"supplement","otherNames":["purple coneflower","eastern purple coneflower","narrow-leaved coneflower (E. angustifolia)","pale purple coneflower (E. pallida)"],"summary":"Echinacea products, made from the flowering tops and/or roots of three Echinacea species, are used mainly to prevent or treat colds. Trials suggest at most a small reduction in the chance of catching a cold and no clear ","hero":{"file":"media/herbs/echinacea-whole.webp","thumb":"media/herbs/thumbs/echinacea-whole.webp","attribution":"Photo: Emőke Dénes, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1050,"height":1400},"ratings":[{"use":"Preventing the common cold","rating":"some"},{"use":"Treating a cold (shortening its duration)","rating":"some"},{"use":"Respiratory infections in children","rating":"some"}],"majorInteractions":0,"interactions":[{"with":"Immunosuppressants (for example, tacrolimus, cyclosporine, mycophenolate)","mechanism":"Echinacea is promoted to stimulate the immune system, which could oppose immunosuppression; a pemphigus vulgaris flare was reported in a patient whose disease had been controlled with immunosuppressants.","severity":"moderate","evidence":"theoretical","advice":"Transplant recipients and people with autoimmune disease should not take echinacea without the prescriber's approval. Refer to the pharmacist."},{"with":"CYP3A substrates (for example, midazolam)","mechanism":"*E. purpurea* root increased midazolam's systemic clearance by 34% but raised its oral bioavailability (0.23 to 0.33): it affected liver and gut CYP3A in opposite directions, so the net effect depends on the drug.","severity":"moderate","evidence":"pharmacokinetic","advice":"Flag combinations with narrow-therapeutic-index CYP3A substrates for the pharmacist."},{"with":"CYP1A2 substrates (for example, caffeine; by extension theophylline and tizanidine)","mechanism":"Echinacea reduced caffeine's oral clearance from 6.6 to 4.9 L/h in healthy volunteers.","severity":"minor","evidence":"pharmacokinetic","advice":"Mostly relevant for narrow-range CYP1A2 drugs such as theophylline; the extension to those drugs is theoretical. Pharmacist review."},{"with":"Chemotherapy (for example, etoposide)","mechanism":"Profound thrombocytopenia was reported with etoposide, possibly through CYP3A4 inhibition; in contrast, echinacea did not significantly change docetaxel pharmacokinetics.","severity":"moderate","evidence":"case-reports","advice":"Supplement use during cancer treatment should be cleared with the oncology team."}],"status":"source-checked","questions":4},{"id":"elderberry","commonName":"Elderberry","scientificName":"Sambucus nigra L.","family":"Viburnaceae","group":"supplement","otherNames":["European elder","black elder","black elderberry","elderflower (the flowers)"],"summary":"Elderberry is the dark purple fruit of the European elder, a common shrub. People mostly take elderberry syrups, lozenges and gummies for colds and flu, but the human studies are small and mixed, and the most recent flu ","hero":{"file":"media/herbs/elderberry-whole.webp","thumb":"media/herbs/thumbs/elderberry-whole.webp","attribution":"Photo: Ryan Hodnett, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":933,"height":1400},"ratings":[{"use":"Influenza: shortening or easing symptoms","rating":"some"},{"use":"Common cold: prevention, duration and severity","rating":"some"},{"use":"COVID-19 prevention or treatment","rating":"little"}],"majorInteractions":0,"interactions":[{"with":"Immunosuppressants (for example tacrolimus, cyclosporine, mycophenolate)","mechanism":"Lab studies show elderberry can change cytokine release, raising a theoretical concern about opposing immunosuppressant therapy","severity":"theoretical","evidence":"theoretical","advice":"No clinical cases are documented, and a 2021 systematic review found no evidence that elderberry overstimulates the immune system. Because the stakes are high for transplant recipients and people with autoimmune disease, a pharmacist should review any elderberry use with the prescriber."},{"with":"Diabetes medicines (insulin, sulfonylureas and others)","mechanism":"Possible additive glucose lowering, based on lab findings","severity":"theoretical","evidence":"theoretical","advice":"Clinical relevance is undetermined. People who check their blood glucose can watch for lower readings after starting elderberry."},{"with":"Diuretics","mechanism":"Possible additive diuretic effect","severity":"theoretical","evidence":"theoretical","advice":"Clinical relevance is undetermined; mention elderberry use when diuretic therapy is reviewed."},{"with":"Laxatives","mechanism":"Possible additive laxative effect","severity":"minor","evidence":"theoretical","advice":"Watch for loose stools if both are used."}],"status":"source-checked","questions":4},{"id":"ephedra","commonName":"Ephedra (ma huang)","scientificName":"Ephedra sinica Stapf","family":"Ephedraceae","group":"safety","otherNames":["ma huang","Chinese ephedra","ephedrae herba","joint fir"],"summary":"Ephedra (ma huang) is a leafless-looking shrub whose stems contain ephedrine and pseudoephedrine. It was sold in US weight-loss and sports supplements until FDA banned dietary supplements containing ephedrine alkaloids i","hero":{"file":"media/herbs/ephedra-whole.webp","thumb":"media/herbs/thumbs/ephedra-whole.webp","attribution":"Photo: Krzysztof Ziarnek, Kenraiz, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":933,"height":1400},"ratings":[{"use":"Weight loss","rating":"some"},{"use":"Athletic performance","rating":"little"},{"use":"Asthma, cough and nasal congestion (traditional)","rating":"little"}],"majorInteractions":2,"interactions":[{"with":"MAO inhibitors (e.g., phenelzine, tranylcypromine, selegiline, linezolid)","mechanism":"MAO inhibition blocks breakdown of the norepinephrine that ephedrine releases","severity":"major","evidence":"theoretical","advice":"Do not combine; concurrent use can cause hypertensive crisis. This mirrors the label warnings for pseudoephedrine with MAOIs."},{"with":"Caffeine and other stimulants (decongestants, ADHD stimulants, diet aids)","mechanism":"Additive sympathomimetic and CNS stimulation","severity":"major","evidence":"case-reports","advice":"Most harmful pre-ban products combined ephedra with caffeine. Avoid any combination; refer patients using stimulant products with cardiac symptoms for urgent care."},{"with":"Digoxin","mechanism":"Sympathomimetic stimulation adds to arrhythmia risk","severity":"moderate","evidence":"theoretical","advice":"Avoid; MSK warns concurrent use can cause arrhythmia."},{"with":"Antihypertensives","mechanism":"Vasoconstriction and increased heart rate oppose blood-pressure treatment","severity":"moderate","evidence":"theoretical","advice":"Ephedra can undo blood-pressure control; the pharmacist reviews any product containing ephedrine alkaloids in a hypertensive patient."}],"status":"source-checked","questions":4},{"id":"foxglove","commonName":"Foxglove","scientificName":"Digitalis purpurea L.","family":"Plantaginaceae","group":"drug-source","otherNames":["purple foxglove","common foxglove","digitalis","Withering's foxglove"],"summary":"Foxglove is the garden plant behind the digitalis heart drugs. William Withering described using its leaf for dropsy (fluid build-up from heart failure) in 1785; the purified glycosides digitoxin and digoxin followed, an","hero":{"file":"media/herbs/foxglove-whole.webp","thumb":"media/herbs/thumbs/foxglove-whole.webp","attribution":"Photo: Björn S..., CC BY-SA 2.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":933,"height":1400},"ratings":[{"use":"Heart failure with reduced ejection fraction (digoxin, the purified drug)","rating":"good"},{"use":"Resting heart-rate control in chronic atrial fibrillation (digoxin)","rating":"good"},{"use":"Heart failure, swelling or any other condition (foxglove leaf, tea, tincture or homemade preparations)","rating":"little"}],"majorInteractions":3,"interactions":[{"with":"Amiodarone, verapamil, quinidine, clarithromycin and other P-gp inhibitors (with digoxin)","mechanism":"Inhibition of P-glycoprotein reduces digoxin clearance; the label reports rises of about 70% (amiodarone), 50–75% (verapamil), about 100% (quinidine) and about 70% AUC (clarithromycin).","severity":"major","evidence":"clinical","advice":"The pharmacist flags these combinations; the prescriber may reduce the digoxin dose and check levels. Technicians escalate DUR alerts rather than overriding them."},{"with":"Drugs that lower potassium or magnesium, such as loop and thiazide diuretics (with digoxin or foxglove)","mechanism":"Low potassium and low magnesium increase the heart's sensitivity to cardiac glycosides.","severity":"major","evidence":"clinical","advice":"Electrolytes are monitored during digoxin therapy. Refer patients with new weakness, nausea or palpitations to the pharmacist."},{"with":"St. John's wort (with digoxin)","mechanism":"Induction of P-glycoprotein lowers digoxin levels.","severity":"moderate","evidence":"pharmacokinetic","advice":"Ask about supplements when digoxin control changes; the label advises measuring levels if the combination is used."},{"with":"Digoxin or any other cardiac glycoside (with foxglove plant material)","mechanism":"Additive Na+/K+-ATPase inhibition from an unmeasured glycoside dose.","severity":"major","evidence":"theoretical","advice":"There is no safe combination; any plant exposure in a patient taking digoxin is an emergency referral."}],"status":"source-checked","questions":4},{"id":"garlic","commonName":"Garlic","scientificName":"Allium sativum L.","family":"Amaryllidaceae","group":"supplement","otherNames":["ajo"],"summary":"Garlic is a common food; garlic supplements (powder tablets, aged garlic extract and oils) are taken mainly for cholesterol and blood pressure. Trials show small reductions in total and LDL cholesterol and in blood press","hero":{"file":"media/herbs/garlic-whole.webp","thumb":"media/herbs/thumbs/garlic-whole.webp","attribution":"Photo: H. Zell, CC BY-SA 3.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1050,"height":1400},"ratings":[{"use":"High total and LDL cholesterol","rating":"some"},{"use":"High blood pressure","rating":"some"},{"use":"Blood sugar in diabetes","rating":"some"},{"use":"Preventing colds (\"immune support\")","rating":"some"}],"majorInteractions":1,"interactions":[{"with":"Saquinavir and other HIV protease inhibitors (such as darunavir)","mechanism":"In 10 healthy volunteers, garlic caplets lowered saquinavir exposure (AUC) by 51%, trough levels by 49% and peak levels by 54%; after a 10-day washout levels had recovered only to 60–70% of baseline. Two patients had low darunavir levels and viral rebound with heavy garlic intake. Garlic extract induced P-glycoprotein in volunteers, one possible mechanism.","severity":"major","evidence":"clinical","advice":"Avoid garlic supplements with protease inhibitors and ask about heavy dietary use (one darunavir case involved about 15 cloves a week). Refer to the pharmacist and HIV prescriber."},{"with":"Warfarin and other anticoagulants","mechanism":"Garlic reduces platelet aggregation and increases fibrinolytic activity; the INR may rise.","severity":"moderate","evidence":"clinical","advice":"Evidence is mixed: a 12-week pilot trial of aged garlic extract in 48 closely monitored warfarin patients found no increase in bleeding, but other products and doses differ. Refer to the pharmacist; monitoring of the INR and bleeding signs may be needed."},{"with":"Antiplatelet drugs (such as aspirin and clopidogrel) and NSAIDs","mechanism":"Additive effect on platelet function.","severity":"moderate","evidence":"theoretical","advice":"Ask about garlic supplements in patients on antiplatelet therapy and before procedures."},{"with":"Insulin and other glucose-lowering drugs","mechanism":"Garlic may lower blood sugar slightly.","severity":"minor","evidence":"theoretical","advice":"Patients should monitor glucose when starting or stopping garlic supplements."}],"status":"source-checked","questions":4},{"id":"ginger","commonName":"Ginger","scientificName":"Zingiber officinale Roscoe","family":"Zingiberaceae","group":"supplement","otherNames":["ginger root","shen jiang","Zingiberis rhizoma"],"summary":"Ginger is the underground stem (rhizome) of a tropical plant, used as a spice and as a supplement mainly for nausea. Small trials suggest it can ease nausea in pregnancy and menstrual cramps, while results for chemothera","hero":{"file":"media/herbs/ginger-whole.webp","thumb":"media/herbs/thumbs/ginger-whole.webp","attribution":"Photo: ritirene, CC BY 4.0, via Wikimedia Commons","width":1400,"height":1050},"ratings":[{"use":"Nausea and vomiting of pregnancy","rating":"some"},{"use":"Menstrual cramps","rating":"some"},{"use":"Knee osteoarthritis pain","rating":"some"},{"use":"Chemotherapy-induced and postoperative nausea","rating":"some"},{"use":"Motion sickness","rating":"little"}],"majorInteractions":0,"interactions":[{"with":"Warfarin and other anticoagulants","mechanism":"Possible antiplatelet effect at supplement doses; additive bleeding risk","severity":"moderate","evidence":"case-reports","advice":"In a controlled study in 12 healthy men, usual doses of ginger did not change the INR, warfarin levels or platelet aggregation. Bleeding case reports still exist, especially in older adults. Food amounts are fine; with supplements, monitor the INR and report any unusual bleeding or bruising."},{"with":"Antiplatelet drugs and NSAIDs","mechanism":"Possible additive effect on platelets and bleeding","severity":"minor","evidence":"theoretical","advice":"Counsel about bleeding signs; avoid high-dose supplements with dual antiplatelet therapy unless the prescriber agrees."},{"with":"Insulin and other glucose-lowering drugs","mechanism":"Possible additive glucose lowering","severity":"minor","evidence":"theoretical","advice":"Clinical relevance is unknown; monitor glucose when starting supplements."},{"with":"Tacrolimus","mechanism":"Ginger supplements may increase tacrolimus blood levels","severity":"moderate","evidence":"theoretical","advice":"Transplant patients should check with their transplant team before taking ginger supplements; clinical relevance is not established."}],"status":"source-checked","questions":4},{"id":"ginkgo","commonName":"Ginkgo","scientificName":"Ginkgo biloba L.","family":"Ginkgoaceae","group":"supplement","otherNames":["maidenhair tree","ginkgo biloba","bai guo (seed, Chinese)"],"summary":"Ginkgo leaf extract is sold mainly for memory and \"brain health\". Large trials, including the 6-year Ginkgo Evaluation of Memory (GEM) study, found that it does not prevent dementia, and evidence for other uses is weak. ","hero":{"file":"media/herbs/ginkgo-whole.webp","thumb":"media/herbs/thumbs/ginkgo-whole.webp","attribution":"Photo: Marty Aligata, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1400,"height":1050},"ratings":[{"use":"Preventing dementia or Alzheimer disease","rating":"against"},{"use":"Symptoms of existing dementia","rating":"some"},{"use":"Memory or thinking in healthy people","rating":"some"},{"use":"Preventing heart disease or treating high blood pressure","rating":"against"}],"majorInteractions":1,"interactions":[{"with":"Anticoagulants (such as warfarin), antiplatelet drugs and NSAIDs","mechanism":"Possible additive effect on platelets and bleeding time. Case reports describe bleeding, but a controlled study in 12 healthy men found recommended doses of ginkgo did not change warfarin pharmacokinetics or the international normalized ratio (INR).","severity":"moderate","evidence":"case-reports","advice":"Because bleeding can be serious, refer to the pharmacist. If ginkgo is continued, the prescriber may monitor the INR and the patient should report bruising or bleeding."},{"with":"Efavirenz","mechanism":"Case reports describe lower efavirenz effect when ginkgo was added; ginkgo induces CYP3A in lab studies.","severity":"major","evidence":"case-reports","advice":"Avoid the combination. Loss of HIV control is serious; refer to the pharmacist and HIV prescriber."},{"with":"Drugs that lower the seizure threshold (for example, some antipsychotics such as prochlorperazine)","mechanism":"Case reports of seizures when ginkgo was combined with these drugs.","severity":"moderate","evidence":"case-reports","advice":"Flag for the pharmacist, especially in people with a seizure history."},{"with":"Trazodone","mechanism":"Coma was reported in a patient with Alzheimer disease taking ginkgo with trazodone.","severity":"moderate","evidence":"case-reports","advice":"Refer to the pharmacist; older adults on sedating drugs need review."},{"with":"P-glycoprotein and CYP3A substrates (for example, midazolam)","mechanism":"In healthy volunteers ginkgo inhibited P-glycoprotein and lowered midazolam levels; lab data on CYP enzymes conflict.","severity":"minor","evidence":"pharmacokinetic","advice":"Clinical relevance is uncertain; flag narrow-therapeutic-index drugs for the pharmacist."}],"status":"source-checked","questions":4},{"id":"goldenseal","commonName":"Goldenseal","scientificName":"Hydrastis canadensis L.","family":"Ranunculaceae","group":"safety","otherNames":["orangeroot","yellow root","yellow puccoon","goldenroot","eye root","turmeric root (not true turmeric)"],"summary":"Goldenseal is a North American woodland plant whose yellow rhizome is sold for colds and other infections, often combined with echinacea. There is not enough evidence that it helps any condition. Its main safety issues a","hero":{"file":"media/herbs/goldenseal-whole.webp","thumb":"media/herbs/thumbs/goldenseal-whole.webp","attribution":"Photo: Eric Hunt, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1121,"height":1400},"ratings":[{"use":"Colds and upper respiratory infections","rating":"little"},{"use":"Diarrhea and other digestive complaints","rating":"little"},{"use":"Masking illicit drugs in urine drug tests","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"CYP3A4 substrates, especially narrow-therapeutic-index drugs (e.g., midazolam, cyclosporine, tacrolimus)","mechanism":"CYP3A4 inhibition raises drug levels","severity":"major","evidence":"pharmacokinetic","advice":"In 16 healthy volunteers, 14 days of goldenseal raised oral midazolam exposure (AUC) from about 108 to 175 ng·h/mL and lengthened its half-life from about 2 to 3 hours. Avoid with narrow-therapeutic-index CYP3A4 drugs; refer any combination to the pharmacist."},{"with":"CYP2D6 substrates (e.g., dextromethorphan, metoprolol, tricyclic antidepressants)","mechanism":"CYP2D6 inhibition raises drug levels","severity":"moderate","evidence":"pharmacokinetic","advice":"Inhibition was shown in healthy volunteers. Watch for stronger effects or side effects of 2D6 drugs; refer to the pharmacist."},{"with":"Metformin","mechanism":"Altered intestinal absorption (transporter-mediated)","severity":"moderate","evidence":"pharmacokinetic","advice":"An NCCIH-funded study in healthy adults found metformin levels fell about 25%, which could weaken glucose control in type 2 diabetes. Advise against combining; the pharmacist may suggest glucose monitoring if the patient continues."},{"with":"Bosutinib (an oral kinase inhibitor)","mechanism":"CYP3A4 inhibition","severity":"moderate","evidence":"theoretical","advice":"Modeling predicts about a 2-fold increase in bosutinib exposure (the same model predicted no change for imatinib). Patients on oral cancer drugs should avoid goldenseal unless the oncology team approves."}],"status":"source-checked","questions":4},{"id":"green-tea","commonName":"Green tea","scientificName":"Camellia sinensis (L.) Kuntze","family":"Theaceae","group":"supplement","otherNames":["tea plant","Chinese tea","green tea extract (GTE)","EGCG"],"summary":"Green tea is made from young leaves of the tea plant that are heated soon after picking so they do not oxidize. Brewed tea is a safe everyday drink for most adults, while concentrated green tea extract is sold for weight","hero":{"file":"media/herbs/green-tea-whole.webp","thumb":"media/herbs/thumbs/green-tea-whole.webp","attribution":"Photo: Chamara Ratnaweera (Public domain), via Wikimedia Commons","width":1400,"height":1039},"ratings":[{"use":"External genital and perianal warts","rating":"good"},{"use":"Lowering LDL cholesterol","rating":"some"},{"use":"Weight loss","rating":"some"},{"use":"Cancer prevention","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"Nadolol","mechanism":"Green tea inhibits intestinal uptake of nadolol through the OATP1A2 transporter. In 10 healthy volunteers, 700 mL/day of green tea for 14 days lowered nadolol peak level and AUC by about 85% and blunted its blood-pressure effect","severity":"major","evidence":"clinical","advice":"Ask patients on nadolol about tea intake. Regular green tea drinking can make nadolol much less effective; the prescriber should be told, and a relapse of rhythm problems has been reported."},{"with":"Warfarin","mechanism":"Dry tea leaf contains vitamin K, which opposes warfarin; brewed tea contains very little, but very large intakes may matter","severity":"moderate","evidence":"case-reports","advice":"Moderate brewed tea is unlikely to matter. Advise consistent intake and telling the anticoagulation clinic about big changes. A patient drinking 0.5–1 gallon a day had his INR fall from 3.79 to 1.37. Whole-leaf powders such as matcha deliver the leaf itself and may supply more vitamin K."},{"with":"Statins (atorvastatin, rosuvastatin)","mechanism":"Green tea extract lowered atorvastatin levels (NCCIH) and lowered rosuvastatin exposure in healthy volunteers","severity":"moderate","evidence":"pharmacokinetic","advice":"Tell the prescriber if a patient starts an extract; watch lipid response."},{"with":"Raloxifene","mechanism":"Green tea lowered raloxifene exposure in a study of healthy adults","severity":"moderate","evidence":"pharmacokinetic","advice":"Discuss green tea supplements with the prescriber."},{"with":"Bortezomib and other boronic-acid proteasome inhibitors","mechanism":"EGCG and other polyphenols blocked the effect of these drugs in lab studies","severity":"theoretical","evidence":"theoretical","advice":"Patients on bortezomib should avoid green tea extract supplements unless the oncology team approves."},{"with":"Stimulants and other caffeine sources","mechanism":"Additive caffeine effects","severity":"minor","evidence":"theoretical","advice":"Count total caffeine from tea, coffee, energy drinks and weight-loss products."},{"with":"Iron supplements","mechanism":"Tea polyphenols can reduce iron absorption","severity":"minor","evidence":"theoretical","advice":"Separate iron doses from tea."}],"status":"source-checked","questions":4},{"id":"kava","commonName":"Kava","scientificName":"Piper methysticum G.Forst.","family":"Piperaceae","group":"safety","otherNames":["kava kava","'awa","ava","yaqona","kawa","intoxicating pepper"],"summary":"Kava is a Pacific island plant whose root is made into a relaxing ceremonial drink and into supplements for anxiety. Short-term trials of some extracts suggested modest anxiety relief, but a large 16-week trial in genera","hero":{"file":"media/herbs/kava-whole.webp","thumb":"media/herbs/thumbs/kava-whole.webp","attribution":"Photo: Forest and Kim Starr, CC BY 3.0 us, via Wikimedia Commons","width":1400,"height":1050},"ratings":[{"use":"Anxiety (short-term)","rating":"some"},{"use":"Generalized anxiety disorder","rating":"against"},{"use":"Insomnia, stress and other uses","rating":"little"}],"majorInteractions":2,"interactions":[{"with":"Alcohol","mechanism":"Additive CNS depression; alcohol is also a suspected co-factor in kava liver injury","severity":"major","evidence":"case-reports","advice":"Advise not to combine. Sedation adds up, and alcohol use is common in reported liver-injury cases."},{"with":"Benzodiazepines, barbiturates, opioids and other sedatives","mechanism":"Additive CNS depression (GABA-A potentiation)","severity":"major","evidence":"case-reports","advice":"Avoid the combination. Excess sedation can impair breathing and driving."},{"with":"Liver-toxic drugs (e.g., acetaminophen at high doses, other hepatotoxic medicines or supplements)","mechanism":"Possible additive liver injury; lab data show enhanced acetaminophen toxicity in liver cells","severity":"moderate","evidence":"theoretical","advice":"Avoid combining. Refer patients with liver-risk drugs to the pharmacist before any kava use."},{"with":"CYP2E1 substrates (e.g., chlorzoxazone)","mechanism":"Modest CYP2E1 inhibition in human studies","severity":"minor","evidence":"pharmacokinetic","advice":"Effect is modest; kava did not change midazolam (CYP3A) exposure in a human study. Flag for pharmacist review rather than assume no effect."}],"status":"source-checked","questions":4},{"id":"kratom","commonName":"Kratom","scientificName":"Mitragyna speciosa Korth.","family":"Rubiaceae","group":"safety","otherNames":["ketum","biak"],"summary":"Kratom is the leaf of a Southeast Asian tree whose alkaloids act on the same brain receptors as opioids. People use it for pain, energy or to self-manage opioid withdrawal, but it is not approved or shown to be safe and ","hero":{"file":"media/herbs/kratom-whole.webp","thumb":"media/herbs/thumbs/kratom-whole.webp","attribution":"Photo: ThorPorre, CC BY 3.0, via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Pain relief","rating":"little"},{"use":"Self-treatment of opioid withdrawal or opioid use disorder","rating":"little"},{"use":"Energy and alertness","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"Opioids, benzodiazepines, alcohol, gabapentinoids and other CNS depressants","mechanism":"Additive opioid-like sedation and respiratory depression","severity":"major","evidence":"case-reports","advice":"Most kratom-associated deaths involved other drugs, especially fentanyl. Counsel against combining. If an overdose is suspected, call 911 and give naloxone if available."},{"with":"Drugs metabolized by CYP3A (for example midazolam and many opioids, benzodiazepines and other narrow-margin drugs)","mechanism":"Kratom inhibits intestinal CYP3A: one low-dose kratom tea raised midazolam AUC by about 40% and peak level by about 50% in 12 healthy adults; mitragynine is a time-dependent CYP3A inhibitor","severity":"moderate","evidence":"pharmacokinetic","advice":"Ask about kratom when reviewing CYP3A substrates; higher or repeated kratom use may have larger effects than the single low dose studied."},{"with":"CYP2D6 substrates (for example dextromethorphan)","mechanism":"In vitro inhibition, but a single low-dose kratom tea did not change dextromethorphan levels","severity":"theoretical","evidence":"pharmacokinetic","advice":"No clinical effect shown at low dose; effects with heavier use are unknown."}],"status":"source-checked","questions":4},{"id":"licorice","commonName":"Licorice","scientificName":"Glycyrrhiza glabra L.","family":"Fabaceae","group":"safety","otherNames":["liquorice","licorice root","sweet root","glycyrrhiza","gan cao (Chinese licorice, G. uralensis)"],"summary":"Licorice root is a sweet-tasting herb used in candy, teas, flavorings and herbal remedies, most often for sore throat, mouth ulcers and digestive complaints. Evidence for benefit is limited and mostly topical or local (g","hero":{"file":"media/herbs/licorice-whole.webp","thumb":"media/herbs/thumbs/licorice-whole.webp","attribution":"Photo: Krzysztof Ziarnek, Kenraiz, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":932,"height":1400},"ratings":[{"use":"Sore throat after intubation for surgery","rating":"some"},{"use":"Canker sores (aphthous ulcers)","rating":"some"},{"use":"Eczema and burns (topical)","rating":"little"},{"use":"Indigestion, ulcers and other digestive symptoms","rating":"little"},{"use":"COVID-19","rating":"little"}],"majorInteractions":2,"interactions":[{"with":"Loop and thiazide diuretics (e.g., furosemide, hydrochlorothiazide)","mechanism":"Additive potassium loss","severity":"major","evidence":"case-reports","advice":"Avoid regular licorice candy, teas and supplements. Ask about licorice when a patient on a diuretic has unexplained hypokalemia or rising blood pressure."},{"with":"Digoxin and other cardiac glycosides","mechanism":"Licorice-induced hypokalemia increases digoxin toxicity","severity":"major","evidence":"theoretical","advice":"Avoid. Low potassium makes digoxin arrhythmias more likely, especially if a diuretic is also taken."},{"with":"Antihypertensives","mechanism":"Mineralocorticoid excess raises blood pressure","severity":"moderate","evidence":"clinical","advice":"Licorice can undo blood-pressure control. Patients with hypertension should avoid regular glycyrrhizin intake."},{"with":"Corticosteroids (e.g., hydrocortisone, prednisolone)","mechanism":"11-beta-HSD inhibition increases corticosteroid activity","severity":"moderate","evidence":"pharmacokinetic","advice":"Interactions have been reported; refer to the pharmacist, especially for patients on replacement steroids (e.g., Addison's disease)."},{"with":"QT-prolonging drugs","mechanism":"Hypokalemia increases the risk of torsades de pointes","severity":"moderate","evidence":"theoretical","advice":"Avoid regular licorice; low potassium compounds the risk from drugs that prolong the QT interval."},{"with":"Warfarin and other coumarin anticoagulants","mechanism":"May increase warfarin metabolism and clearance","severity":"moderate","evidence":"case-reports","advice":"Clinical relevance is uncertain, but MSK reports a sudden INR drop in a patient taking phenprocoumon (a related coumarin). Mention any regular licorice use to the anticoagulation pharmacist."}],"status":"source-checked","questions":4},{"id":"madagascar-periwinkle","commonName":"Madagascar periwinkle","scientificName":"Catharanthus roseus (L.) G.Don","family":"Apocynaceae","group":"drug-source","otherNames":["rosy periwinkle","vinca","bright eyes"],"summary":"Madagascar periwinkle is the source of the vinca alkaloids vinblastine and vincristine, extracted from its leaves and still essential in chemotherapy, especially for childhood leukemia; vinorelbine is a semisynthetic rel","hero":{"file":"media/herbs/madagascar-periwinkle-whole.webp","thumb":"media/herbs/thumbs/madagascar-periwinkle-whole.webp","attribution":"Photo: imbeaul, CC BY 4.0, via Wikimedia Commons","width":1400,"height":1050},"ratings":[{"use":"Acute leukemia, lymphomas and childhood solid tumors (vincristine, the purified drug)","rating":"good"},{"use":"Diabetes (leaf tea or homemade extracts)","rating":"little"},{"use":"Self-treatment of cancer (plant material)","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"Azole antifungals and other strong CYP3A inhibitors (e.g., itraconazole) with vincristine","mechanism":"CYP3A inhibition reduces vincristine metabolism; itraconazole and fluconazole have been associated with earlier and more severe neuromuscular toxicity.","severity":"major","evidence":"clinical","advice":"The label advises avoiding strong CYP3A inhibitors and monitoring closely with moderate ones such as fluconazole. Antifungal orders for patients on vincristine go to the pharmacist for review."},{"with":"P-glycoprotein inhibitors or inducers with vincristine","mechanism":"Altered P-gp transport changes vincristine exposure.","severity":"moderate","evidence":"pharmacokinetic","advice":"Avoid the combination when possible; the oncology pharmacist reviews the regimen."},{"with":"St. John's wort and other strong CYP3A inducers with vincristine","mechanism":"Induction of CYP3A can lower vincristine levels and effectiveness.","severity":"moderate","evidence":"pharmacokinetic","advice":"Ask patients receiving chemotherapy about supplements; the label advises avoiding strong CYP3A inducers."}],"status":"source-checked","questions":4},{"id":"milk-thistle","commonName":"Milk thistle","scientificName":"Silybum marianum (L.) Gaertn.","family":"Asteraceae","group":"supplement","otherNames":["Marian thistle","St. Mary's thistle","blessed milk thistle"],"summary":"Milk thistle fruit (\"seed\") extract, called silymarin, is promoted for liver health. Despite long traditional use, controlled trials in liver disease are conflicting or negative, including an NIH-funded trial in chronic ","hero":{"file":"media/herbs/milk-thistle-whole.webp","thumb":"media/herbs/thumbs/milk-thistle-whole.webp","attribution":"Photo: Harry Rose from South West Rocks, Australia, CC BY 2.0, via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Chronic hepatitis C","rating":"against"},{"use":"Other liver diseases (alcohol-related, fatty liver, drug- or toxin-related)","rating":"some"},{"use":"Blood sugar in type 2 diabetes","rating":"some"},{"use":"Increasing breast milk supply","rating":"some"}],"majorInteractions":0,"interactions":[{"with":"Insulin and other glucose-lowering drugs","mechanism":"Milk thistle may lower blood sugar, which could add to these drugs' effects.","severity":"moderate","evidence":"theoretical","advice":"Refer to the pharmacist; patients should monitor blood glucose when starting or stopping milk thistle."},{"with":"Warfarin","mechanism":"The INR rose from 2.64 to 4.12 in a man taking a liver-cleanse supplement containing milk thistle (with other ingredients) and normalized after he stopped it.","severity":"moderate","evidence":"case-reports","advice":"Flag for the pharmacist; the prescriber may check the INR after any new supplement."},{"with":"CYP3A4 substrates","mechanism":"Milk thistle inhibits CYP3A4 in vitro, but human data conflict; it did not lower levels of the HIV drug indinavir.","severity":"minor","evidence":"pharmacokinetic","advice":"Clinical relevance is uncertain; flag narrow-therapeutic-index drugs for the pharmacist."}],"status":"source-checked","questions":4},{"id":"opium-poppy","commonName":"Opium poppy","scientificName":"Papaver somniferum L.","family":"Papaveraceae","group":"drug-source","otherNames":["breadseed poppy","poppy seed plant","Papaver"],"summary":"The opium poppy is the only commercial source of morphine and codeine, and of thebaine, which industry converts into drugs such as oxycodone and the overdose-reversal drug naloxone. The alkaloids are concentrated in the ","hero":{"file":"media/herbs/opium-poppy-whole.webp","thumb":"media/herbs/thumbs/opium-poppy-whole.webp","attribution":"Photo: Ryan Hodnett, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":933,"height":1400},"ratings":[{"use":"Severe pain needing an opioid when alternatives are inadequate (morphine, the purified drug)","rating":"good"},{"use":"Pain, sleep, cough, anxiety or any other use (poppy-seed tea, pod tea, homemade opium preparations)","rating":"little"}],"majorInteractions":2,"interactions":[{"with":"Benzodiazepines, alcohol and other CNS depressants (with morphine, other opioids or poppy teas)","mechanism":"Additive central nervous system and respiratory depression.","severity":"major","evidence":"clinical","advice":"Boxed warning on opioid labels. The pharmacist reviews every opioid-plus-sedative combination; a fatal case involved poppy-seed tea with the benzodiazepine phenazepam."},{"with":"MAOIs (with morphine)","mechanism":"Possible serotonin syndrome or opioid toxicity.","severity":"major","evidence":"case-reports","advice":"Morphine is contraindicated with MAOIs or within 14 days of stopping one; escalate to the pharmacist."},{"with":"Buprenorphine, butorphanol, nalbuphine, pentazocine (with morphine)","mechanism":"Mixed agonist-antagonist and partial agonist opioids can reduce analgesia or precipitate withdrawal.","severity":"moderate","evidence":"clinical","advice":"Avoid the combination unless the prescriber intends it; flag for the pharmacist."},{"with":"P-glycoprotein inhibitors such as quinidine (with morphine)","mechanism":"Reduced efflux can roughly double morphine exposure.","severity":"moderate","evidence":"pharmacokinetic","advice":"Monitor for sedation and slowed breathing; the pharmacist decides whether the prescriber needs to be contacted."},{"with":"Urine opiate drug screens (dietary poppy seeds)","mechanism":"Morphine and codeine residue on food poppy seeds is absorbed and excreted in urine.","severity":"moderate","evidence":"clinical","advice":"A positive opiate screen after eating poppy seeds is possible; confirmatory testing and review by the ordering clinician or a medical review officer interpret the result. Patients in monitored programs may be told to avoid poppy seeds."}],"status":"source-checked","questions":4},{"id":"pacific-yew","commonName":"Pacific yew","scientificName":"Taxus brevifolia Nutt.","family":"Taxaceae","group":"drug-source","otherNames":["western yew"],"summary":"Pacific yew is the tree whose bark gave us paclitaxel (Taxol), a cornerstone chemotherapy drug for ovarian, breast and lung cancers. Stripping the bark killed slow-growing trees, so today paclitaxel and its relative doce","hero":{"file":"media/herbs/pacific-yew-whole.webp","thumb":"media/herbs/thumbs/pacific-yew-whole.webp","attribution":"Photo: Walter Siegmund, CC BY 2.5, via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Ovarian, breast and non-small cell lung cancer and AIDS-related Kaposi sarcoma (paclitaxel, the purified drug)","rating":"good"},{"use":"Cancer or any other condition (yew needles, bark, tea or homemade extracts)","rating":"little"}],"majorInteractions":1,"interactions":[{"with":"Cisplatin (with paclitaxel; order of administration)","mechanism":"When paclitaxel was given after cisplatin, its clearance fell by about 33% and myelosuppression was more profound.","severity":"major","evidence":"clinical","advice":"Paclitaxel is given before cisplatin in combination regimens. Pharmacy staff preparing and labeling infusions follow the protocol sequence and flag discrepancies to the pharmacist."},{"with":"Strong CYP2C8 or CYP3A4 inhibitors and inducers (e.g., ketoconazole, ritonavir, rifampin)","mechanism":"Paclitaxel is metabolized by CYP2C8 and CYP3A4; inhibitors may raise levels and toxicity, inducers may lower them.","severity":"moderate","evidence":"pharmacokinetic","advice":"The oncology pharmacist reviews the full medication list, including supplements such as St. John's wort, before each cycle."},{"with":"Doxorubicin (with paclitaxel)","mechanism":"Plasma levels of doxorubicin and its active metabolite may rise when the two are combined.","severity":"moderate","evidence":"pharmacokinetic","advice":"Combination regimens are protocol-driven and monitored by the oncology team."}],"status":"source-checked","questions":4},{"id":"psyllium","commonName":"Psyllium","scientificName":"Plantago ovata Forssk.","family":"Plantaginaceae","group":"supplement","otherNames":["blond psyllium","Indian psyllium","ispaghula","isabgol","desert Indianwheat"],"summary":"Psyllium is the seed husk of Plantago ovata, a small desert plantain. It is the active ingredient in many OTC bulk-forming fiber laxatives, and taken regularly it modestly lowers LDL cholesterol; the FDA authorizes a hea","hero":{"file":"media/herbs/psyllium-whole.webp","thumb":"media/herbs/thumbs/psyllium-whole.webp","attribution":"Photo: S. Rae from Scotland, UK, CC BY 2.0, via Wikimedia Commons","width":1400,"height":1083},"ratings":[{"use":"Constipation","rating":"good"},{"use":"Lowering LDL cholesterol","rating":"good"},{"use":"Blood glucose control in type 2 diabetes","rating":"some"}],"majorInteractions":0,"interactions":[{"with":"Other medicines taken by mouth (general)","mechanism":"The gel can bind drugs or slow their absorption","severity":"moderate","evidence":"theoretical","advice":"OTC labels state that bulk-forming fiber may affect how well other medicines work and direct taking psyllium **at least 2 hours before or 2 hours after** a prescription medicine taken by mouth. Pharmacists check timing when a patient on narrow-therapeutic-index drugs starts daily fiber."},{"with":"Levothyroxine","mechanism":"Dietary fiber can bind levothyroxine and lower its absorption","severity":"moderate","evidence":"pharmacokinetic","advice":"The levothyroxine label lists dietary fiber among foods that decrease absorption. Keep levothyroxine at its usual time on an empty stomach and take psyllium at a different time of day, consistently. The prescriber may recheck thyroid tests if a patient starts or stops daily fiber."},{"with":"Diabetes medicines (insulin, sulfonylureas and others)","mechanism":"Additive glucose lowering; psyllium blunts after-meal glucose rises","severity":"moderate","evidence":"theoretical","advice":"Psyllium lowered fasting glucose in people treated for type 2 diabetes. Patients on insulin or sulfonylureas who start regular psyllium can monitor glucose more closely; refer dose questions to the pharmacist or prescriber."}],"status":"source-checked","questions":4},{"id":"saw-palmetto","commonName":"Saw palmetto","scientificName":"Serenoa repens (W.Bartram) Small","family":"Arecaceae","group":"supplement","otherNames":["American dwarf palm","sabal"],"summary":"Saw palmetto berry extract is the best-known herbal product for urinary symptoms of an enlarged prostate (benign prostatic hyperplasia, BPH). Well-designed trials and a 2023 Cochrane review found it works no better than ","hero":{"file":"media/herbs/saw-palmetto-whole.webp","thumb":"media/herbs/thumbs/saw-palmetto-whole.webp","attribution":"Photo: Mjrmtg, CC BY 4.0, via Wikimedia Commons","width":1400,"height":933},"ratings":[{"use":"Urinary symptoms of benign prostatic hyperplasia (BPH)","rating":"against"},{"use":"BPH symptoms with combination herbal products","rating":"some"},{"use":"Male-pattern hair loss","rating":"some"}],"majorInteractions":0,"interactions":[{"with":"Anticoagulants and antiplatelet drugs (for example, warfarin, rivaroxaban, aspirin, clopidogrel)","mechanism":"Possible additive effect on bleeding; case reports include bleeding during surgery, hematuria with coagulopathy, and hemopericardium in a man taking rivaroxaban.","severity":"moderate","evidence":"case-reports","advice":"Refer to the pharmacist; tell the surgical team about saw palmetto before procedures."},{"with":"NSAIDs","mechanism":"A case report suggests an increased risk of side effects (bleeding) when combined.","severity":"minor","evidence":"case-reports","advice":"Ask about NSAID use when saw palmetto is taken with other bleeding-risk drugs."},{"with":"5-alpha-reductase inhibitors (finasteride, dutasteride)","mechanism":"Overlapping lab mechanism; no evidence that adding saw palmetto improves outcomes.","severity":"theoretical","evidence":"theoretical","advice":"No proven benefit from combining. Patients should tell their urologist about any supplements."},{"with":"Hormonal medicines (for example, oral contraceptives and estrogen therapy)","mechanism":"Antiandrogenic and antiestrogenic activity in lab studies could, in theory, alter effects.","severity":"theoretical","evidence":"theoretical","advice":"Women, especially if pregnant or using hormonal therapy, should not use saw palmetto without advice."}],"status":"source-checked","questions":4},{"id":"st-johns-wort","commonName":"St. John's wort","scientificName":"Hypericum perforatum L.","family":"Hypericaceae","group":"safety","otherNames":["hypericum","Klamath weed","goatweed","Saint John's wort"],"summary":"St. John's wort is a yellow-flowered plant sold mainly for low mood and depression. Standardized extracts helped mild to moderate depression in many short trials. Its biggest danger is drug interactions: it speeds the br","hero":{"file":"media/herbs/st-johns-wort-whole.webp","thumb":"media/herbs/thumbs/st-johns-wort-whole.webp","attribution":"Photo: AnRo0002 (CC0), via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Mild to moderate depression","rating":"some"},{"use":"Severe depression, or use longer than 12 weeks","rating":"little"},{"use":"Menopausal hot flashes","rating":"some"},{"use":"ADHD in children and adolescents","rating":"against"},{"use":"Other uses studied (IBS, OCD, PMS, smoking cessation, wound healing)","rating":"little"}],"majorInteractions":6,"interactions":[{"with":"Cyclosporine, tacrolimus (transplant immunosuppressants)","mechanism":"CYP3A4 and P-gp induction lowers drug levels","severity":"major","evidence":"clinical","advice":"Avoid the combination. MSK reports an average 49% fall in cyclosporine trough levels across 45 patients, with acute rejection in case reports. If a patient already takes both, do not stop the herb abruptly without the prescriber: drug levels climb as induction wears off, so levels need monitoring."},{"with":"Hormonal birth control pills","mechanism":"Enzyme induction speeds hormone metabolism","severity":"major","evidence":"clinical","advice":"Can cause breakthrough bleeding and unintended pregnancy. Advise avoiding St. John's wort; the pharmacist discusses backup or alternative contraception. The same induction concern applies to other hormonal contraceptives."},{"with":"HIV antiretrovirals (e.g., indinavir, ritonavir, nevirapine)","mechanism":"CYP3A4/P-gp induction lowers antiretroviral levels","severity":"major","evidence":"pharmacokinetic","advice":"Avoid. Lower drug levels risk treatment failure and viral resistance."},{"with":"Cancer drugs (e.g., irinotecan, imatinib, docetaxel)","mechanism":"Induction increases clearance of the drug or its active metabolite","severity":"major","evidence":"pharmacokinetic","advice":"Avoid during cancer treatment. MSK reports SN-38 (irinotecan's active metabolite) levels lowered by as much as 40%, an effect lasting up to 3 weeks after the herb was stopped."},{"with":"Warfarin","mechanism":"Induction usually increases warfarin metabolism","severity":"major","evidence":"clinical","advice":"Avoid. Starting or stopping the herb can shift the INR; if a patient has been taking both, the pharmacist arranges closer INR monitoring."},{"with":"SSRIs, SNRIs, tricyclics, triptans and other serotonergic drugs","mechanism":"Additive serotonergic effects","severity":"major","evidence":"case-reports","advice":"Do not combine. Serotonin syndrome (agitation, tremor, sweating, fast heart rate, fever) has been reported. Switching between St. John's wort and an antidepressant should be planned by the prescriber."},{"with":"Digoxin","mechanism":"Intestinal P-gp induction reduces absorption","severity":"moderate","evidence":"pharmacokinetic","advice":"Avoid; lower digoxin levels can mean loss of rate or symptom control."},{"with":"Other CYP3A4/P-gp substrates (e.g., simvastatin, phenytoin, carbamazepine, ivabradine, oxycodone, zolpidem)","mechanism":"Induction increases clearance","severity":"moderate","evidence":"pharmacokinetic","advice":"Expect reduced effect. Ask about the herb whenever one of these drugs seems to stop working, and refer to the pharmacist."}],"status":"source-checked","questions":5},{"id":"sweet-wormwood","commonName":"Sweet wormwood","scientificName":"Artemisia annua L.","family":"Asteraceae","group":"drug-source","otherNames":["sweet annie","annual wormwood","qinghao","Chinese wormwood","artemisia"],"summary":"Sweet wormwood is the source of artemisinin, whose derivatives (artesunate, artemether and dihydroartemisinin) are the backbone of today's WHO-recommended malaria treatments. The discovery by Tu Youyou's team in the 1970","hero":{"file":"media/herbs/sweet-wormwood-whole.webp","thumb":"media/herbs/thumbs/sweet-wormwood-whole.webp","attribution":"Photo: Stefan.lefnaer, CC BY-SA 4.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1050,"height":1400},"ratings":[{"use":"Uncomplicated *P. falciparum* malaria (artemisinin-based combination therapy such as artemether-lumefantrine)","rating":"good"},{"use":"Severe malaria (IV artesunate)","rating":"good"},{"use":"Malaria prevention or treatment (*A. annua* tea, dried-leaf powder, capsules)","rating":"little"},{"use":"Cancer (artesunate or dihydroartemisinin; investigational)","rating":"little"}],"majorInteractions":2,"interactions":[{"with":"Rifampin, carbamazepine, phenytoin, St. John's wort (with artemether-lumefantrine)","mechanism":"Strong CYP3A4 induction markedly lowers artemether and lumefantrine exposure.","severity":"major","evidence":"pharmacokinetic","advice":"Contraindicated in the label because treatment can fail. Technicians flag the DUR alert for the pharmacist."},{"with":"QT-prolonging drugs, including quinine, quinidine and halofantrine (with artemether-lumefantrine)","mechanism":"Additive QT prolongation; lumefantrine's 3–6 day half-life extends the risk window.","severity":"major","evidence":"clinical","advice":"Avoid halofantrine within one month and use other QT-prolonging drugs cautiously; pharmacist review required."},{"with":"Hormonal contraceptives (with artemether-lumefantrine)","mechanism":"Reduced contraceptive hormone exposure.","severity":"moderate","evidence":"pharmacokinetic","advice":"The label advises an additional non-hormonal or barrier method; the pharmacist counsels."},{"with":"Drugs metabolized by CYP2B6 or CYP3A4 (with *A. annua* plant extracts)","mechanism":"Extracts induced these enzymes in laboratory studies.","severity":"theoretical","evidence":"theoretical","advice":"Clinical relevance is unknown; ask about herbal products, especially in patients on narrow-margin drugs."}],"status":"source-checked","questions":4},{"id":"turmeric","commonName":"Turmeric","scientificName":"Curcuma longa L.","family":"Zingiberaceae","group":"supplement","otherNames":["Indian saffron","haldi","turmeric root"],"summary":"Turmeric is the orange rhizome of a ginger-family plant. It is a common spice and is sold as turmeric or curcumin supplements, mostly for joint pain and \"inflammation\". Human evidence is preliminary for every use. Key ca","hero":{"file":"media/herbs/turmeric-whole.webp","thumb":"media/herbs/thumbs/turmeric-whole.webp","attribution":"Photo: Manojk, CC BY-SA 3.0, via Wikimedia Commons. Adapted versions are shared under the same license.","width":1400,"height":1050},"ratings":[{"use":"Knee osteoarthritis pain and function","rating":"some"},{"use":"Nonalcoholic fatty liver disease (NAFLD)","rating":"some"},{"use":"Oral mucositis from cancer treatment","rating":"some"}],"majorInteractions":0,"interactions":[{"with":"Anticoagulants (such as warfarin) and antiplatelet drugs","mechanism":"Curcumin inhibits platelet aggregation in lab studies, so bleeding risk may add up.","severity":"moderate","evidence":"case-reports","advice":"Ask about turmeric and curcumin use. The pharmacist decides whether extra monitoring is needed (for warfarin, the international normalized ratio, INR) and reviews any unusual bruising or bleeding."},{"with":"Tacrolimus","mechanism":"Turmeric raised tacrolimus levels in an animal study; acute calcineurin-inhibitor kidney toxicity was reported in a liver-transplant patient taking large amounts of turmeric.","severity":"moderate","evidence":"case-reports","advice":"Transplant recipients should not start turmeric supplements without the transplant team. Refer to the pharmacist; drug levels and kidney function may need checking."},{"with":"Paclitaxel","mechanism":"In 60 patients with breast cancer, turmeric 2 g/day caused only small changes in paclitaxel pharmacokinetics that were judged clinically irrelevant; one case report of toxicity involved several supplements.","severity":"minor","evidence":"pharmacokinetic","advice":"Supplement use during chemotherapy should be cleared with the oncology team."},{"with":"Drugs metabolized by CYP3A4, CYP1A2 or CYP2D6","mechanism":"Curcumin inhibits these cytochrome P450 enzymes in vitro, but a short-term study in healthy volunteers found no clinically relevant CYP3A4 interaction.","severity":"theoretical","evidence":"theoretical","advice":"Clinical relevance is unknown. Flag use with narrow-therapeutic-index drugs for the pharmacist."}],"status":"source-checked","questions":4},{"id":"valerian","commonName":"Valerian","scientificName":"Valeriana officinalis L.","family":"Caprifoliaceae","group":"supplement","otherNames":["garden heliotrope","all-heal","common valerian"],"summary":"Valerian root is the most common herbal sleep aid. Evidence is inconsistent: some people report better sleep quality, but reviews find no clear effect on insomnia, and the American Academy of Sleep Medicine (AASM) recomm","hero":{"file":"media/herbs/valerian-whole.webp","thumb":"media/herbs/thumbs/valerian-whole.webp","attribution":"Photo: AnRo0002 (CC0), via Wikimedia Commons","width":1050,"height":1400},"ratings":[{"use":"Insomnia and sleep quality","rating":"some"},{"use":"Menopausal hot flashes","rating":"some"},{"use":"Anxiety, depression, stress, premenstrual syndrome or menstrual cramps","rating":"some"}],"majorInteractions":0,"interactions":[{"with":"Alcohol, benzodiazepines, Z-drugs, opioids, barbiturates and other CNS depressants","mechanism":"Possible additive sedation; valerian prolonged barbiturate-induced sleep in animals, and an animal study and a case report suggest synergy with benzodiazepines.","severity":"moderate","evidence":"case-reports","advice":"Refer to the pharmacist. Warn about drowsiness, next-day impairment and driving; older adults are at particular risk."},{"with":"Anesthesia (surgery)","mechanism":"Possible interaction with anesthetic agents and benzodiazepine-like withdrawal if stopped abruptly.","severity":"moderate","evidence":"theoretical","advice":"Tell the surgical team; MSK advises stopping at least 1 week before surgery, tapering if used long term."},{"with":"CYP3A4 and CYP2D6 substrates","mechanism":"Valerian inhibits these enzymes in some lab studies, but in vivo and human studies suggest CYP-mediated interactions are unlikely.","severity":"minor","evidence":"pharmacokinetic","advice":"Low concern; flag narrow-therapeutic-index drugs for the pharmacist."}],"status":"source-checked","questions":4},{"id":"white-willow","commonName":"White willow","scientificName":"Salix alba L.","family":"Salicaceae","group":"drug-source","otherNames":["willow bark","European willow","Salicis cortex"],"summary":"White willow is the tree behind the aspirin story: its bark contains salicin, which the body converts to salicylic acid, and chemists later turned salicylic acid into acetylsalicylic acid (aspirin). Willow bark extracts ","hero":{"file":"media/herbs/white-willow-whole.webp","thumb":"media/herbs/thumbs/white-willow-whole.webp","attribution":"Photo: AnRo0002 (CC0), via Wikimedia Commons","width":1400,"height":1050},"ratings":[{"use":"Pain, fever, and prevention of heart attack and stroke in selected patients (aspirin, the synthetic derivative)","rating":"good"},{"use":"Acute flare-ups of chronic low back pain (standardized willow bark extract)","rating":"some"},{"use":"Osteoarthritis and rheumatoid arthritis (willow bark extract)","rating":"some"},{"use":"Replacing low-dose aspirin for heart or stroke protection (willow bark)","rating":"little"}],"majorInteractions":0,"interactions":[{"with":"Warfarin, other anticoagulants and antiplatelet drugs","mechanism":"Salicylates may add to bleeding risk; willow's platelet effect is weaker than aspirin's but not zero.","severity":"moderate","evidence":"theoretical","advice":"Refer to the pharmacist before use; people on blood thinners should avoid willow bark unless their prescriber agrees."},{"with":"NSAIDs (ibuprofen, naproxen) and aspirin","mechanism":"Overlapping anti-inflammatory and salicylate effects can increase stomach and intestinal irritation and bleeding.","severity":"moderate","evidence":"theoretical","advice":"Avoid stacking pain relievers. The pharmacist reviews all analgesics the person takes."},{"with":"Other salicylate-containing products (bismuth subsalicylate, methyl salicylate rubs, salicylate combination products)","mechanism":"Duplicate salicylate exposure.","severity":"moderate","evidence":"theoretical","advice":"Technicians can flag hidden salicylates on the profile or at the counter for the pharmacist's review."}],"status":"source-checked","questions":4},{"id":"yohimbe","commonName":"Yohimbe","scientificName":"Corynanthe johimbe K.Schum.","family":"Rubiaceae","group":"safety","otherNames":["yohimbe bark","johimbe","Pausinystalia yohimbe","yohimbine (the alkaloid)"],"summary":"Yohimbe is a West and Central African tree whose bark contains yohimbine, an alpha-2 adrenergic blocker. The bark is sold in supplements for sexual performance, workouts and weight loss, but there is very little evidence","hero":{"file":"media/herbs/yohimbe-leaf.webp","thumb":"media/herbs/thumbs/yohimbe-leaf.webp","attribution":"Photo: Naturalis Biodiversity Center (specimen collected by G.A. Zenker) (CC0), via Wikimedia Commons","width":977,"height":1400},"ratings":[{"use":"Erectile dysfunction (yohimbe bark supplements)","rating":"little"},{"use":"Athletic performance and weight loss","rating":"little"}],"majorInteractions":4,"interactions":[{"with":"MAO inhibitors (e.g., phenelzine, tranylcypromine)","mechanism":"Added noradrenergic stimulation with impaired norepinephrine breakdown","severity":"major","evidence":"theoretical","advice":"Do not combine. NCCIH lists MAOIs as drugs not to use with yohimbe; dangerous blood-pressure rises are the concern."},{"with":"Tricyclic antidepressants (e.g., amitriptyline, nortriptyline)","mechanism":"Additive noradrenergic effects","severity":"major","evidence":"theoretical","advice":"Do not combine (NCCIH). Risk of hypertension and arrhythmia."},{"with":"Bupropion","mechanism":"Additive noradrenergic and seizure-threshold effects","severity":"major","evidence":"case-reports","advice":"Avoid; co-ingestion has caused toxic effects. Both lower the seizure threshold."},{"with":"Stimulants, decongestants and diet aids (e.g., caffeine, pseudoephedrine, phenylephrine)","mechanism":"Additive sympathomimetic stimulation","severity":"major","evidence":"theoretical","advice":"Avoid. Many pre-workout and fat-loss products already combine yohimbe with stimulants, so read the full ingredient list."},{"with":"Antihypertensives, including clonidine","mechanism":"Opposing effects; yohimbine blocks the alpha-2 receptors that clonidine stimulates","severity":"moderate","evidence":"theoretical","advice":"Yohimbe may undo blood-pressure control; refer to the pharmacist."},{"with":"Opioids","mechanism":"Increased noradrenergic activity","severity":"moderate","evidence":"theoretical","advice":"MSK reports yohimbine may induce withdrawal-like and anxiety symptoms in people taking opioids. Refer to the pharmacist."}],"status":"source-checked","questions":5}],"counts":{"units":31,"lessons":158,"herbs":33,"images":130,"questions":1165,"legacyQuestions":100,"drugs":219},"contentVersion":"6c4a11a88cd8","builtAt":"2026-10-30T00:59:50.646Z","corrections":11}