What to Combine Ginkgo Biloba With

Ginkgo biloba extract is popular for circulation and memory, and it often appears in multi-ingredient 'brain' formulas. Whether a combination makes sense depends on what each ingredient adds and on how they interact. Our editorial team looks at reasonable pairings, combinations with little evidence and those that may be risky.

What ginkgo extract does

Standardised ginkgo extracts, such as EGb 761, are made from the leaves of the Ginkgo biloba tree. They typically contain around 24% flavone glycosides and 6% terpene lactones, including ginkgolides and bilobalide, with ginkgolic acids reduced to very low levels because they can be allergenic.

The extract is thought to improve microcirculation, act as an antioxidant and influence platelet-activating factor, a molecule involved in blood clotting. Those last properties are important when considering combinations, because they may add to the effects of other substances that affect bleeding.

Clinical evidence is mixed. Some trials in people with dementia have shown modest benefits with EGb 761, whereas the large GEM study found ginkgo did not prevent dementia in older adults. Evidence for improving memory in healthy young people is weak.

In the UK, ginkgo products may be registered under the MHRA's Traditional Herbal Registration scheme or sold as food supplements. THR products carry a patient leaflet listing known interactions, which is helpful when planning combinations.

Reasonable combinations

Ginkgo is frequently paired with nutrients that have independent roles in brain health. B vitamins, including B6, B12 and folate, are involved in homocysteine metabolism, and correcting a deficiency is useful in its own right. Adding them does not interfere with ginkgo.

Omega-3 fatty acids from oily fish or supplements are another common pairing. DHA is a structural component of brain cell membranes. However, high-dose omega-3s can have a mild antiplatelet effect, so people combining them with ginkgo should be aware of a theoretical additive effect on bleeding.

Caffeine and L-theanine are often found alongside ginkgo in focus products. There is no strong evidence of a harmful interaction, but nor is there good evidence that ginkgo adds much to the alertness benefits of caffeine.

Ginkgo with ginseng and other herbs

The combination of ginkgo with Panax ginseng has been tested in a handful of small, short-term studies on memory and attention. Results were inconsistent, and the combination increases the potential for side effects such as insomnia or headache that each herb can cause.

Several other herbs, including garlic, ginger, turmeric and feverfew, may also affect platelets. Combining many of them in one regime, as some 'circulation' products do, could theoretically raise bleeding risk, even if each is modest on its own.

St John's wort is a special case because it strongly induces liver enzymes and alters levels of many medicines. Combining it with ginkgo is not known to be specifically dangerous, but anyone taking prescription medicines should avoid St John's wort without advice.

The general principle is simple: the more ingredients in a combination, the harder it becomes to know what is responsible for any effect or side effect. Simpler regimes are easier to evaluate and safer.

Combinations to avoid or discuss with a doctor

Anticoagulants and antiplatelet drugs top the list. Case reports describe bleeding events, including brain haemorrhage, in people taking ginkgo, sometimes alongside warfarin or aspirin. Controlled studies have not always confirmed a significant interaction, but the potential consequences are serious enough to warrant caution.

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Non-steroidal anti-inflammatory drugs such as ibuprofen also affect platelets and the stomach lining. A case report described fatal bleeding in a patient taking ginkgo and ibuprofen; while a single case cannot prove causation, regular NSAID users should discuss ginkgo with a pharmacist.

Ginkgo seeds contain a toxin that can provoke seizures, and some reports raise concerns about extracts in people with epilepsy. Interactions with certain anticonvulsants, such as valproate, have been suggested. People with epilepsy should avoid ginkgo unless their neurologist agrees.

• Warfarin, apixaban, rivaroxaban and other anticoagulants.
• Aspirin, clopidogrel and other antiplatelet agents.
• Regular NSAIDs such as ibuprofen or naproxen.
• Antiepileptic medicines.
• Some antidepressants and diabetes medicines, where interactions have been suggested.

Practical tips for safer use

Choose a standardised extract that states its flavone glycoside and terpene lactone content and has low ginkgolic acid. Avoid eating raw or roasted ginkgo seeds, which are sometimes used in traditional cooking and can be toxic.

Studies have commonly used 120–240 mg of standardised extract per day in divided doses. Higher doses are not necessarily more effective, and the potential for side effects such as headache, stomach upset and dizziness increases.

Stop taking ginkgo at least two weeks before planned surgery or dental procedures, and tell your surgeon or dentist. Many anaesthetists ask specifically about herbal products for this reason.

If you take several supplements, bring them to a pharmacist for a medicine review. Pharmacists in the UK are well placed to check interactions with prescription drugs, and this service is often free.

Editorial conclusions

Ginkgo combines reasonably with B vitamins and, with some caution, omega-3s; evidence for added benefit from ginseng or caffeine pairings is limited.

Combinations with anticoagulants, antiplatelet drugs, NSAIDs and antiepileptic medicines need medical advice because of bleeding and seizure concerns.

Simple, standardised products and a pharmacist review are the safest approach.

Our editorial team suggests reading next about omega-3 supplements and bleeding risk, herbal products before surgery and what the evidence says about nootropics.

References

1. DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008;300(19):2253–2262.
2. Bent S, Goldberg H, Padula A, Avins AL. Spontaneous bleeding associated with ginkgo biloba: a case report and systematic review of the literature. J Gen Intern Med. 2005;20(7):657–661.
3. Meisel C, Johne A, Roots I. Fatal intracerebral mass bleeding associated with Ginkgo biloba and ibuprofen. Atherosclerosis. 2003;167(2):367.
4. Kellermann AJ, Kloft C. Is there a risk of bleeding associated with standardized Ginkgo biloba extract therapy? A systematic review and meta-analysis. Pharmacotherapy. 2011;31(5):490–502.
5. Birks J, Grimley Evans J. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev. 2009;(1):CD003120.
6. Kennedy DO, Scholey AB, Wesnes KA. The dose-dependent cognitive effects of acute administration of Ginkgo biloba to healthy young volunteers. Psychopharmacology (Berl). 2000;151(4):416–423.
7. https://anabolizantes-espana.com/producto/winstrol-oral-estanozolol-50/