Ginkgo (Ginkgo biloba L.)
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| Ginkgo |
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Ginkgo biloba has been used medicinally for thousands of
years. Today, it is one of the top selling herbs in the United States.
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Ginkgo is used for the treatment of numerous conditions, many which are under
scientific investigation. Available evidence demonstrates ginkgo's efficacy in
the management of intermittent claudication, Alzheimer's/multi-infarct
dementia, and "cerebral insufficiency" (a syndrome thought to be
secondary to atherosclerotic disease, characterized by impaired concentration,
confusion, decreased physical performance, fatigue, headache, dizziness,
depression, and anxiety).
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Although not definitive, there is promising early evidence favoring use of
ginkgo for memory enhancement in healthy subjects, altitude (mountain)
sickness, symptoms of premenstrual syndrome (PMS), and reduction of
chemotherapy-induced end-organ vascular damage.
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Although still controversial, a recent large trial has shifted the evidence
against the use of ginkgo for tinnitus.
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The herb is generally well tolerated, but due to multiple case reports of
bleeding, should be used cautiously in patients on anti-coagulant therapy,
with known coagulopathy, or prior to some surgical or dental procedures.
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Arbre aux quarante écus, adiantifolia, baiguo, bai guo ye, BN-52063, duck
foot tree, EGb, EGb 761, Elefantenohr, Eun-haeng, facherblattbaum, Fossil
tree, GBE, GBE 24, GBX, ginan, gin-nan, Ginkgoaceae (family), ginkgo balm,
ginkgoblätter, Ginkgo biloba blätter, Ginkgo folium,
ginkgogink, ginkgold, ginkgopower, ginkyo, icho, ityo, Japanbaum, Japanese
silver apricot, kew tree, kung sun shu, LI 1370, maidenhair tree, noyer du
Japon, oriental plum tree, pei kuo, pei-wen, Pterophyllus, Pterophyllus
salisburiensis, Rokan, salisburia, Salisburia adiantifolia ,
Salisburia macrophylla , silver apricot, sophium, tanakan,
tanakene, tebofortan, tebonin, tempeltrae, temple balm, tramisal, valverde,
vasan, vital, ya chio, yin-guo, yin-hsing.
These uses have been tested in humans or animals. Safety
and effectiveness have not always been proven. Some of these conditions are
potentially serious, and should be evaluated by a qualified healthcare provider.
| Uses based on scientific evidence |
Grade* |
| Claudication (painful legs from clogged arteries)
Numerous studies suggest that Ginkgo biloba taken by
mouth causes small improvements in claudication symptoms (leg pain with
exercise or at rest due to clogged arteries). However, ginkgo may not be
as helpful for this condition as exercise therapy or prescription drugs.
Additional evidence is needed.
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A |
| Dementia (multi-infarct and Alzheimer's type)
The scientific literature overall does suggest that ginkgo benefits
people with early stage Alzheimer's disease and multi-infarct dementia,
and may be as helpful as acetylcholinesterase inhibitor drugs such as
donepezil (Aricept®). Well-designed research comparing ginkgo to
prescription drug therapies is needed.
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A |
| Cerebral insufficiency
Multiple clinical trials have evaluated ginkgo for a syndrome called
"cerebral insufficiency." This condition, more commonly
diagnosed in Europe than the United States, may include poor
concentration, confusion, absent-mindedness, decreased physical
performance, fatigue, headache, dizziness, depression, and anxiety. It
is believed that cerebral insufficiency is caused by decreased blood
flow to the brain due to clogged blood vessels. Some research reports
benefits of ginkgo in patients with these symptoms, but most have been
poorly designed without reliable results. Better studies are needed
before a strong recommendation can be made.
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B |
| Acute hemorrhoidal attacks
In early study ginkgo was shown to be effective in the treatment of
patients with acute hemorrhoidal attacks. Further research is needed to
confirm these results.
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C |
| Age-associated memory impairment (AAMI)
Age-associated memory impairment (AAMI) is a non-specific syndrome,
which may be caused by early Alzheimer's disease or multi-infarct
dementia (conditions for which ginkgo has been shown to have benefit).
There is preliminary research showing small improvements in memory and
other brain functions in patients with AAMI, although some studies
disagree. Overall, there is currently not enough clear evidence to
recommend for or against ginkgo for this condition.
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C |
| Altitude (mountain) sickness
A small amount of poorly designed research reports benefits of ginkgo
for the treatment of altitude (mountain) sickness. Additional study is
needed before a recommendation can be made.
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C |
| Chemotherapy side effects reduction
In limited human study, ginkgo has been examined in addition to
5-fluorouracil (5-FU) in the treatment of pancreatic and colorectal
cancer, to measure possible benefits on side effects. At this time,
there is not conclusive evidence in this area.
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C |
| Deafness (cochlear)
Preliminary clinical study has been conducted on the effect of ginkgo in
chronic cochleovestibular disorders. Further research is needed before a
recommendation can be made.
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C |
| Depression and seasonal affective disorder (SAD)
Preliminary study of seasonal affective disorder (SAD) suggests that
ginkgo is not effective in preventing the development of winter
depression. Other research in elderly patients with depression shows
possible minor benefits. Overall, there is not enough evidence to form a
clear conclusion.
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C |
| Gastric cancer
Ginkgo biloba exocarp polysaccharides (GBEP) capsule
preparation has been studied for upper digestive tract malignant tumors
of middle and late stage with positive results. However, further
research is needed before a recommendation can be made.
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C |
| Glaucoma
Several small human studies report ginkgo may be associated with mild
increases in blood flow to the eyes, vision and intraocular pressure.
Well-designed research is needed before a recommendation can be made.
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C |
| Macular degeneration
Preliminary research suggests that ginkgo may improve eye blood flow,
although it remains unclear if macular degeneration is significantly
affected by ginkgo. More research is needed in this area before a
conclusion can be drawn.
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C |
| Memory enhancement (in healthy people)
It remains unclear if ginkgo is effective. Further well-designed
research is needed as existing study results conflict.
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C |
| Multiple sclerosis
Based on laboratory study, it has been suggested that ginkgo may provide
benefit in multiple sclerosis (MS). Human research is limited to several
small studies, which have not found consistent benefit. Additional
research is needed before a recommendation can be made.
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C |
| Premenstrual syndrome (PMS)
Initial study in women with premenstrual syndrome or breast discomfort
suggests that ginkgo may relieve symptoms including emotional upset.
Further well-designed research is needed before a recommendation can be
made.
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C |
| Pulmonary interstitial fibrosis
Based on early study, ginkgo may be effective in treating pulmonary
interstitial fibrosis. Further research is needed to confirm these
results.
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C |
| Quality of life
Early studies suggest that ginkgo may aid in quality of life. More
randomized controlled trials are needed before a conclusion can be made.
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C |
| Raynaud's disease
Results from one clinical trial suggest that Ginkgo biloba may
be effective in reducing the number of Raynaud's attacks in patients
suffering from Raynaud's disease. In order to confirm these results,
further clinical trials are required.
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C |
| Retinopathy (diabetes mellitus type II)
Early study suggests Ginkgo biloba extract may offer
benefit to individuals with retinopathy. Further clinical trials are
required to determine efficacy.
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C |
| Ringing in the ears (tinnitus)
There is conflicting research regarding the use of ginkgo for tinnitus.
Additional well-designed research is needed in order to resolve this
controversy.
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C |
| Sexual dysfunction
Ginkgo has been used and studied for the treatment of sexual dysfunction
in men and women. In general, studies are small and not well designed.
Additional research is needed before a recommendation can be made.
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C |
| Stroke
Laboratory studies suggest that ginkgo may be helpful immediately
following strokes because of possible antioxidant or blood vessel
effects. However, initial study of ginkgo in people having strokes found
no benefits. Further research is needed in this area.
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C |
| Vertigo
A small amount of poorly designed research reports benefits of ginkgo
for the treatment of vertigo. Additional study is needed before a
recommendation can be made.
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C |
| Vitiligo
Early study using oral Ginkgo biloba extract reports
that ginkgo appears to arrest the progression of this disease.
Better-designed studies are needed to confirm these results.
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C |
| Cocaine dependence
One small study reports no benefit of ginkgo for cocaine independence.
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D |
| Mental performance (after eating)
The results of one study investigating the effect of Ginkgo
biloba on post-prandial mental alertness are unclear. Ginkgo
may benefit some but not all endpoints. Further clinical trials are
required before recommendations can be made.
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D |
| Mood and cognition in post-menopausal women
Based on early study of chronic administration, Gincosan appears to have
no beneficial effects on mood, anxiety, or sleepiness in post-menopausal
women.
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D |
*Key to grades
A: Strong scientific evidence for this use;
B: Good scientific evidence for this use;
C: Unclear scientific evidence for this use;
D: Fair scientific evidence against this use;
F: Strong scientific evidence against this use.
Grading rationale
Uses based on tradition or theory
The below uses are based on tradition or scientific theories. They often
have not been thoroughly tested in humans, and safety and effectiveness have
not always been proven. Some of these conditions are potentially serious, and
should be evaluated by a qualified healthcare provider.
Acidosis, acute cerebral infarction, aging, alcoholism, allergies, angina,
anti-bacterial, anti-fungal, antioxidant, anti-parasitic, anti-rheumatic,
anti-tumor, anxiety, asthma, atherosclerosis (clogged arteries), attention
deficit hyperactivity disorder, autoimmune disorders, blood vessel disorders,
blood clots, breast disease, breast tenderness, bronchial asthma, bronchitis,
cancer, cardiac rhythm abnormalities, cataracts, chilblains (inflammation of
toes, fingers, ears, or face with exposure to cold), chronic rhinitis,
congestive heart failure, coronary heart disease, cough, dermatitis, diabetes,
diabetic nerve damage (neuropathy), diabetic eye disease, diabetic peripheral
neuropathy, digestion, dysentery (bloody diarrhea), eczema, enhancing learning,
enhancing memory, enhancement of female sexual function, fatigue, filariasis,
freckle-removing, genitourinary disorders, heart disease, heart attack,
headache, hepatitis B, high cholesterol, high blood pressure, hypoxia (lack of
oxygen), immunomodulator, insomnia, labor induction, menstrual pain, migraine,
mood disturbances, oral cavity cancer, respiratory tract illnesses, scabies
(ginkgo cream), schizophrenia, seizures, sepsis, skin sores (ginkgo cream),
swelling, traumatic brain injury, ulcerative colitis, varicose veins.
The below doses are based on scientific research,
publications, traditional use, or expert opinion. Many herbs and supplements
have not been thoroughly tested, and safety and effectiveness may not be proven.
Brands may be made differently, with variable ingredients, even within the same
brand. The below doses may not apply to all products. You should read product
labels, and discuss doses with a qualified healthcare provider before starting
therapy.
Adults (18 years and older)
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80-240 milligrams of a 50:1 standardized leaf extract taken daily by mouth in
two to three divided doses has been used and studied (standardized to 24% to
25% ginkgo flavone glycosides and 6% terpine lactones). Other forms used
include tea (bags usually contain 30 milligrams of extract), 3 to 6
milliliters of 40 milligrams per milliliter extract daily in three divided
doses, and "fortified" foods. Ginkgo seeds are potentially toxic and
should be avoided. The German ginkgo product Tebonin®, given through veins
(IV), was removed from the German market due to significant side effects.
Children (younger than 18 years)
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There is not enough scientific evidence to recommend use of ginkgo in
children.
The U.S. Food and Drug Administration does not strictly
regulate herbs and supplements. There is no guarantee of strength, purity or
safety of products, and effects may vary. You should always read product labels.
If you have a medical condition, or are taking other drugs, herbs, or
supplements, you should speak with a qualified healthcare provider before
starting a new therapy. Consult a healthcare provider immediately if you
experience side effects.
Allergies
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Allergy/hypersensitivity to Ginkgo biloba or members of the
Ginkgoaceae family may occur. A severe reaction called Stevens-Johnson
syndrome, which includes skin blistering and sloughing-off, has been reported
with use of a combination product. There may be cross-sensitivity to ginkgo in
people allergic to urusiols (mango rind, sumac, poison ivy, poison oak,
cashews), and an allergic cross-reaction has been reported in a person
allergic to poison ivy.
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If administered into a vein (IV), ginkgo may cause a skin allergy, blood
vessel irritation and damage. Ginkgo fruit or pulp has caused strong allergic
reactions after skin contact, and severe skin reactions and intestinal spasms
have occurred after direct contact with fleshy fruit pulp.
Side Effects and Warnings
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Overall, ginkgo leaf extract (used in most commercial products) appears to be
well tolerated in most healthy adults at recommended doses for up to six
months. Minor symptoms including headache, nausea, and intestinal complaints
have been reported.
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Bleeding has been associated with the use of ginkgo taken by mouth, and
caution is advised in patients with bleeding disorders or taking
drugs/herbs/supplements that may increase the risk of bleeding. Dosing
adjustments may be necessary. Ginkgo should be stopped prior to some surgical
or dental procedures. Reports of bleeding range from nose bleeds to
life-threatening bleeding in several case reports. In some of these reports,
ginkgo has been used with other agents that may also cause bleeding.
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Eating the seeds is potentially deadly, due to risk of tonic-clonic seizures
and loss of consciousness.
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Based on human study, ginkgo may theoretically affect insulin and blood sugar
levels. Caution is advised in patients with diabetes or hypoglycemia, and in
those taking drugs, herbs, or supplements that affect blood sugar. Serum
glucose levels may need to be monitored by a healthcare professional, and
medication adjustments may be necessary.
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There have been uncommon reports of headache, dizziness, stomach upset,
nausea, diarrhea, vomiting, muscle weakness, loss of muscle tone,
restlessness, heart racing, rash, and irritation around the mouth with the use
of ginkgo. There is a case report of "coma" in an elderly
Alzheimer's patient taking trazodone and ginkgo, although it is not clear that
ginkgo was the cause. Based on laboratory and human research, ginkgo may
decrease blood pressure, although there is one report of ginkgo possibly
raising blood pressure in a person taking a thiazide diuretic ("water
pill"). Based on theory, high concentrations of ginkgo may reduce male
and female fertility. Contamination with the drug colchicine has been found in
commercial preparations of Ginkgo biloba.
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Ginkgo may affect the outcome of electroconsulvie therapy (ECT). Adverse
effects on the eyes have also been reported.
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Another study reported vomiting and convulsions from large quantities of MPN
(4-O-methylpyridoxine), which is contained in Ginkgo biloba
seeds.
Pregnancy and Breastfeeding
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Use of ginkgo is not recommended during pregnancy and breastfeeding due to
lack of reliable scientific study in this area. The risk of bleeding
associated with ginkgo may be dangerous during pregnancy.
Most herbs and supplements have not been thoroughly
tested for interactions with other herbs, supplements, drugs, or foods. The
interactions listed below are based on reports in scientific publications,
laboratory experiments, or traditional use. You should always read product
labels. If you have a medical condition, or are taking other drugs, herbs, or
supplements, you should speak with a qualified healthcare provider before
starting a new therapy.
Interactions with Drugs
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Overall, controlled trials of ginkgo report few adverse effects and good
tolerance, with rates of complications similar to placebo. However, use of
ginkgo with drugs that may cause bleeding may further increase the risk of
bleeding, based on multiple case reports of spontaneous bleeding in patients
using ginkgo alone, with warfarin (Coumadin®), or with aspirin. One case
report documents a possible increase in bleeding risk with ticlodipine (Ticlid®)
and ginkgo. Examples of drugs that may increase the risk of bleeding include
aspirin, anticoagulants ("blood thinners") such as warfarin (Coumadin®)
or heparin, anti-platelet drugs such as clopidogrel (Plavix®), and
non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin®, Advil®) or
naproxen (Naprosyn®, Aleve®). However, not all studies agree with the
existence of this risk, and it is not clear if particular types of patients
may be at greater risk.
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Based on preliminary research, ginkgo may affect insulin and blood sugar
levels. Caution is advised when using medications that may also lower blood
sugar. Patients taking drugs for diabetes by mouth or insulin should be
monitored closely by a qualified healthcare professional. Medication
adjustments may be necessary.
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Ginkgo has been found to decrease blood pressure in healthy volunteers,
although some studies disagree. Theoretically, ginkgo may add to the effects
of medications that also lower blood pressure, although raised blood pressure
has been reported in a patient taking a thiazide diuretic ("water
pill") with ginkgo. It has been suggested that Ginkgo biloba
leaf extract (GBE) and nifedipine should not be ingested at the same time.
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Monoamine oxidase (MAO) inhibition by ginkgo was reported in one animal study,
but has not been confirmed in humans. In theory, if taken with MAOI drugs,
such as isocarboxazid (Marplan®), phenelzine (Nardil®), or tranylcypromine (Parnate®),
additive effects and side effects may occur. Based on laboratory research,
ginkgo may also add to the effects of SSRI antidepressants such as sertraline
(Zoloft®), with an increased risk of causing serotonin syndrome, a condition
characterized by stiff muscles, fast heart rate, hyperthermia, restlessness,
and sweating.
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Based on human use, ginkgo may decrease side effects of antipsychotic drugs,
although scientific information in this area is limited. There is a case
report of "coma" in an elderly Alzheimer's patient taking trazodone
and ginkgo, although it is not clear that this reaction was due to ginkgo. In
theory, ginkgo may increase the actions of drugs used for erectile dysfunction
such as sildenafil (Viagra®).
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There may be a risk of seizure when taking ginkgo, particularly in people with
a history of seizure disorder. Although most reports of seizures have been due
to eating ginkgo seeds (not leaf extract which is found in most products), an
animal study found that the anti-seizure properties of sodium valproate or
carbamazepine were reduced by giving ginkgo. In theory, drugs such as
donepezil (Aricept®) and tacrine (Cognex®) may have an additive effect when
used at the same time as ginkgo, potentially increasing cholinergic effects
(such as salivation and urination).
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5-fluorouracil induced side effects and cyclosporine kidney toxicity may in
theory be improved by ginkgo, although evidence is not conclusive in these
areas. Colchicine has been found in commercial preparations of ginkgo, and may
increase blood concentrations in patients using colchicine.
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Gingko may alter the way the liver breaks down certain drugs.
Interactions with Herbs and Dietary Supplements
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Use of ginkgo with herbs or supplements that may cause bleeding may increase
the risk of bleeding, although some studies disagree. Several cases of
bleeding have been reported with the use of garlic, and two cases with saw
palmetto. Numerous other agents may theoretically increase the risk of
bleeding, although this has not been proven in most cases.
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Ginkgo has been found to decrease blood pressure in healthy volunteers,
although some studies disagree. Theoretically, ginkgo may have additive
effects when used with herbs or supplements that also decrease blood pressure.
However, high blood pressure was reported in a patient taking a thiazide
diuretic ("water pill") plus ginkgo. Although it remains unclear if
ginkgo has clinically significant effects on blood pressure, caution may be
warranted when ginkgo is used with other agents that affect blood pressure.
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Based on human study, ginkgo may theoretically affect insulin and lower blood
sugar levels. Caution is advised when using herbs or supplements that may also
affect blood sugar. Blood glucose levels may require monitoring, and doses may
need adjustment.
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Effects on monoamine oxidase (inhibition) by ginkgo are reported in animals
but not confirmed in humans. In theory, ginkgo may add to the side effects of
herbs or supplements that also inhibit monoamine oxidase, such as 5-HTP
(5-Hydroxytryptophan).
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Based on laboratory research, ginkgo may add to the effects of herbs or
supplements that affect levels of serotonin in the blood or brain, and could
increase the risk of serotonin syndrome (a condition characterized by muscle
stiffness, increased heart rate, hyperthermia, restlessness, and sweating).
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Ginkgo may alter the way the liver breaks down herbs and supplements.