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Application of Tonga

Scientific Name: Kava-Kava

Other Names: Awa, Kava, Kawa, Kew, Piper methysticum, Tonga, Yagona

Who is this for?

Note: In March 2002, the U.S. Food and Drug Administration (FDA) issued a warning that taking kava has been associated with cases of liver damage. The FDA recommends that individuals — especially those with liver diseases or those taking medications that might impair liver function — discuss the use of kava with a healthcare professional before they begin taking it.

Britain, Canada, and the countries of the European Union have prohibited the sale of all kava products due to their potentially severe side effects, as well as to the likelihood that kava interacts with numerous other substances. Since the ban went into effect, however, some countries have resumed limited sales of kava. Other countries, including the United States, are considering whether or not to take it off the market. Currently, the World Health Organization (WHO) is re-considering the safety of kava.

In Western cultures, kava most often has been used to reduce anxiety and treat insomnia. It contains chemicals known as kava lactones (also called kava pyrones) that appear to have several calming effects on the central nervous system. However, unlike some other antianxiety and sedative drugs, the chemicals in kava do not seem to interfere with blood pressure, breathing, heart rate, or thinking. Kava lactones may affect the amounts certain neurotransmitters in the blood. Neurotransmitters are chemicals that carry messages from nerve cells to other cells. Taking kava may keep the body from re-absorbing one neurotransmitter known as norepinephrine. The resulting increased blood levels of norepinephrine may be associated with lessened anxiety and relaxed mood. The lactones in kava may also cause the body to produce more attachment sites for another neurotransmitter, gamma aminobutyric acid (GABA). More GABA sites may mean more GABA activity, which promotes sedation. Other ways that kava might work are to block the action of an enzyme known as monoamine oxidase-B (MAO-B) and to affect levels of a fourth neurotransmitter, dopamine, but in unpredictable ways. Although both MAO-B and dopamine play roles in emotional balance, the results of kava’s effects on them are unclear.

Its calming effects have made kava a subject of laboratory studies for various other types of central nervous system (CNS) conditions including attention deficit activity disorder (ADHD), depression, epilepsy, and psychoses. However, no major human studies are underway, and not enough is known about kava’s activity in any of these CNS disorders to recommend its use. Presently, the FDA advises consumers that the risk of severe side effects, although very small, outweighs the possible benefits of taking kava for any reason.

When should I be careful taking it?

Individuals who have liver conditions should avoid taking kava because it may cause liver damage.

Individuals with Parkinson's disease usually have low levels of the neurotransmitter dopamine. Kava may increase or decrease amounts of dopamine in the body, possibly worsening Parkinson's symptoms.

Pregnant and breast-feeding women should not take kava because neither its immediate nor its long-term effects on developing babies and infants are known.

Precautions

Individuals who take kava may need to have their liver function monitored.

Taking kava may cause daytime drowsiness, so individuals who need to drive or perform other tasks that require alertness should avoid its use.

What side effects should I watch for?

Multiple documented cases of liver damage have been attributed to taking kava. While individuals with previous liver conditions appear to be at highest risk; cases of cirrhosis, hepatitis, liver damage, liver failure, and death have occurred in individuals with no history of liver diseases. In addition, the dose and duration of kava use do not appear to be factors in the development of liver problems. Symptoms of liver damage may include:

  • Excessive fatigue
  • Extreme widespread itchiness
  • Nausea, vomiting or diarrhea
  • Pain or swelling in the upper right part of the abdomen
  • Yellowing of the skin or the white parts of the eyes

The unpredictable effect that kava may have on dopamine levels may result in rare cases of uncontrollable movements of the head, mouth, neck, or tongue.

Chronic use of more than 400 mg of kava-lactones per day for extended periods of time has resulted in:

  • Blood in the urine
  • Decreased numbers of platelets
  • Decreased numbers of white blood cells
  • Increased numbers of red blood cells
  • Loss of body protein
  • Underweight

Side effects that were seen in a study of individuals who consumed approximately 200,000 mg (200 grams) of kava included:

  • Inability to control muscle movements
  • Shaking
  • Twitches of the eyes

Less Severe Side Effects

Kava has been known to cause upset stomach. Individuals taking kava have also reported central nervous system side effects such as dizziness and headaches.

A skin reaction known as "kawaism" has occurred in individuals who consumed large amounts of the kava beverage for extended periods of time. Symptoms of kawaism include dry, rough, yellowish colored skin and red, irritated eyes.

Kava can cause daytime drowsiness, so individuals who need to drive or perform other tasks that require alertness should avoid its use.

Chewing kava root or drinking kava tea may cause the mouth to become numb.

What interactions should I watch for?

Prescription Drugs

Taking some prescription drugs may increase the risk of liver damage. If kava, which may also result in liver damage, is taken at the same time as a potentially liver-damaging drug, the risk of potentially life threatening liver damage may increase even more. Drugs that may possibly damage the liver include:

  • Anticonvulsants such as carbamazepine (Tegretol) and valproic acid (Depakene)
  • Antifungal drugs such as itraconazole (Sporanox), ketoconazole (Nizoral), and terbinafine (Lamisil)
  • Antiviral drugs such as nevirapine (Viramune) and ritonavir (Norvir)
  • Arava
  • azathioprine
  • Cholesterol-lowering drugs (fibric acid derivatives) such as fenofibrate (Tricor) and gemfibrozil (Lopid)
  • Cholesterol-lowering drugs (statins) such as atorvastatin (Lipitor), lovastatin (Mevacor), pravastatin (Pravachol), and Zocor
  • Cognex
  • isoniazid
  • methotrexate
  • Oral drugs for diabetes (glitazones) such as pioglitazone (Actos) and rosiglitazone (Avandia)
  • Precose
  • rifampin
  • tamoxifen (Nolvadex)

When kava is used with prescription drugs that promote sleepiness, the effects of the drug may be exaggerated, resulting in sedation or mental impairment. Prescription drugs that can cause sleepiness include:

  • Anticonvulsants such as carbamazepine, phenytoin and valproic acid
  • Barbiturates such as phenobarbital
  • Benzodiazepines such as alprazolam and diazepam
  • Drugs for insomnia such as zaleplon and zolpidem
  • Tricyclic antidepressants such as amitriptyline, amoxapine, doxepin and nortriptyline

In laboratory studies, kava has been shown to increase the time blood needs to clot. When it is taken with antiplatelet or anticoagulant drugs, the effect of the drug may be increased, possibly resulting in uncontrolled bleeding.

  • Antiplatelets include Plavix and Ticlid
  • Anticoagulants include heparin and warfarin

Because it is broken down by certain enzymes in the liver, kava may possibly interfere with the use of prescription drugs that are processed by the same enzymes. Some of these drugs are:

  • Allergy drugs like fexofenadine (Allegra)
  • Antifungal drugs like itraconazole (Sporanox) and ketoconazole (Nizoral)
  • Cancer drugs like etoposide, paclitaxel, vinblastine, or vincristine
  • Drugs for high cholesterol like lovastatin
  • Oral contraceptives

Kava's potential to alter dopamine levels may interfere with the effectiveness of drugs such as carbidopa-levodopa (Sinemet), levodopa (Dopar), Mirapex, Requip, and selegiline (Eldepryl), which mainly are used to treat Parkinson's disease.

Non-prescription Drugs

Rarely, some drugs that are sold without a prescription may cause damage to the liver. If these drugs are taken at the same time as kava, the risk of liver damage may increase. Non-prescription drugs that may be associated with liver damage include niacin (vitamin B-3) and antifungal drugs such as ketoconazole (Nizoral) and terbinafine (Lamisil).

The sleep-producing effects of over-the-counter products containing diphenhydramine may be enhanced by taking kava at the same time. Diphenhydramine is contained in many non-prescription sleeping pills as well as in some cough and cold products, therefore caution should be used when taking these medications with kava because excessive drowsiness may result.

Kava may affect the ability of blood to clot after an injury. Aspirin can also delay clotting, so kava should not be taken orally at the same time as aspirin.

Herbal Products

If it is taken at the same time as other herbal products or dietary supplements that could affect liver function, kava might increase the chance of liver problems. Other herbs and supplements that may affect liver function include:

  • Borage
  • Comfrey
  • DHEA
  • Pennyroyal Oil
  • Scullcap
  • Uva Ursi
  • Valerian

Kava may cause excessive sedation if it is taken with other potentially sedating herbs or supplements such as:

  • Catnip
  • Hops
  • St. John's Wort
  • Tryptophan
  • Valerian

Theoretically, if kava is used with other herbs that affect blood clotting, bleeding may occur. Some of the most common herbal products that might inhibit blood clotting are:

  • Danshen
  • Devil's Claw
  • Eleuthero
  • Garlic
  • Ginger (in high amounts)
  • Ginkgo
  • Horse Chestnut
  • Panax Ginseng
  • Papain

Foods

Drinking alcohol at the same time as using kava by mouth may result in increased drowsiness.

Some interactions between herbal products and medications can be more severe than others. The best way for you to avoid harmful interactions is to tell your doctor and/or pharmacist what medications you are currently taking, including any over-the-counter products, vitamins, and herbals.

Should I take it?

Kava is a member of the pepper family of plants that grows mainly in the tropical climate of islands in the South Pacific Ocean. Traditionally, it has been used to prepare a ceremonial drink that promotes feelings of well-being — much as alcoholic beverages are used in social settings.

Kava plants grow as tall perennial bushes with broad, flat heart-shaped leaves. Although the plants produce small flowers, they do not produce seeds that will sprout. They spread by sending out rhizomes — fleshy extensions of their stems that run just under the ground and produce new plants. Generally, the roots of kava plants that are 3 to 4 years old are harvested to make the traditional beverage as well as for medicine. For farming, cuttings are taken of the kava stems when the roots are dug up. One kava stem may produce several new plants. Young kava plants need protection from the sun and the wind, so they are often planted between rows of taller plants such as banana trees or sweet potatoes.

In the South Pacific, the kava beverage traditionally was prepared in a formalized ritual similar to the Japanese tea-preparation ceremony. Although the details of the ceremonies may differ by region, a typical process involves chewing kava or wrapping dried and shredded kava root into a cloth "ball" which is dipped into a container of water until it is thoroughly waterlogged. Then, the water is squeezed out of the ball back into the container. The whole dunking and squeezing process is repeated until the water assumes a slightly thick, cloudy appearance — a few minutes to about half an hour depending on the location. The resulting beverage has a taste said to be slightly bitter and peppery. In some parts of the area, only certain individuals were allowed to make the drink. Now, although traditional ways are still observed in some places, kava beverages are often made in electric blenders.

Dosage and Administration

Until re-evaluations of kava's safety are completed by the FDA and the WHO, the use of kava is not recommended.

Note: As treatment for anxiety, kava may take up to 2 months to reach maximum effectiveness.

Note: Many of the human studies of kava used a preparation that was standardized to contain 70% kava lactones. This strength is approximately twice as concentrated as the kava products that were on the market before they were recalled. Standardization by the manufacturer should assure the same amount of active ingredient in every batch of the commercial preparation. Standardization of herbal products is not required by the U.S. Food and Drug Administration (FDA), so not every kava product that was previously available contained the same amounts of active ingredients.

Summary

Due to its association with cases of liver damage, the use of kava is discouraged.

Risks

Because it may worsen liver conditions and Parkinson's disease, kava should be avoided by individuals with those conditions. Pregnant and breast-feeding women should not take it because its possible effects in developing babies and infants are not known.

Side Effects

Deaths and serious liver damage have been attributed to taking kava. It is also thought to cause rare instances of changes in blood cell numbers, loss of weight, shaking in the hands, and uncontrollable body movements. A characteristic skin condition known as kawaism may result from large doses of kava taken for long periods of time. Kava has also been associated with dizziness, drowsiness, headaches, stomach upset, and numbness of the mouth.

Interactions

Potentially, kava may interact with alcohol and many drugs or herbals that affect liver function, promote sleep, lessen blood clotting, treat Parkinson's disease, or break down in the liver.

Last Revised September 8, 2004

References

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(Note: The above information is not intended to replace the advice of your physician, pharmacist, or other healthcare professional. It is not meant to indicate that the use of the product is safe, appropriate, or effective for you.)

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