What to combine Ginkgo biloba with

Ginkgo biloba is rarely sold on its own in the sports segment: it is added to "nootropic" mixes, pre-workout complexes, "for vessels" formulas. The question of combination is therefore quite practical. The editorial team examines which supplements ginkgo is most often combined with, what is known about these combinations from studies and which combinations may be dangerous.

Principles of safe combination

When we evaluate any combination of supplements, we ask three questions. Do the components have a common goal that makes sense? Are there data specifically on the combination, and not just on each component separately? And do the risks not add up — primarily the effect on blood clotting and on liver enzymes?

In the case of ginkgo, the third question is the most important. Ginkgolide B inhibits the action of platelet-activating factor, and although the meta-analysis by Kellermann and Kloft found no significant increase in the risk of bleeding in randomized studies, in clinical cases of bleeding ginkgo was often combined with other substances with a similar action.

The second potential problem is the effect on cytochrome P450 enzymes. For most supplements this is not critical, but in combination with medications it can change their concentration.

Finally, multi-component mixes often contain each ingredient in an understated dose. Therefore the effect of the combination may be smaller than that of a single well-dosed component, while the risk of unpredictable interactions is higher.

Ginkgo and ginseng

Combining ginkgo with true ginseng (Panax ginseng) is one of the few combinations that has been studied directly. In the work by Kennedy, Scholey and Wesnes in 2002, young healthy volunteers received single doses of ginkgo, ginseng and their combination in a placebo-controlled crossover design.

The authors reported that the individual components and the combination affected different cognitive indicators differently: for the combination an improvement in memory-quality indicators was recorded, whereas some attention indicators responded to the individual extracts. The effects were moderate and depended on the time of measurement.

These data are interesting, but they concern single doses in a small group. Conclusions about a long-term benefit of the combination for athletes cannot be drawn on their basis.

As for safety: ginseng can also affect blood clotting and interact with warfarin, so for people on anticoagulants such a combination is not suitable without a doctor's agreement. For some people ginseng worsens sleep, so it is better to take it in the first half of the day.

Other popular combinations

Most other combinations with ginkgo do not have direct studies. Below we summarize what is known about each pair, relying on data about the individual components.

Combinations with caffeine and creatine are probably safe for healthy people, since these substances act through completely different mechanisms. However, no one has proven an additional benefit of ginkgo in such stacks either: the main effect of a pre-workout complex is provided by caffeine.

The combination with bacopa monnieri is popular in "nootropic" formulas. Both plants have moderate evidence of cognitive effects, but we did not find studies of their combined intake with a proper design. Moreover, bacopa acts slowly and requires weeks of intake, so the logic of a "single dose before training" does not work here.

Omega-3 in ordinary dietary doses probably does not create problems, but high doses of fish oil together with ginkgo, garlic or curcumin theoretically enhance the effect on platelets. People prone to bruising or preparing for surgery should avoid such combinations.

What to avoid categorically

The editorial team considers some combinations of ginkgo with medications unacceptable without medical supervision. Here the risks outweigh any theoretical benefit.

• Anticoagulants (warfarin, direct oral anticoagulants).
• Antiplatelet agents (aspirin in cardiac doses, clopidogrel).
• Regular intake of non-steroidal anti-inflammatory drugs after injuries.
• Antiepileptic drugs — only by a neurologist's decision.
• Antiretroviral agents, in particular efavirenz.
• Antidepressants and other psychotropic medications — after consulting a doctor.

A review of ginkgo's pharmacokinetic interactions (Unger, 2013) shows that most interactions in humans are weakly expressed, but for individual drugs, in particular omeprazole, a change in concentrations was recorded. It is impossible to predict the individual reaction, so caution here is justified.

Athletes who systematically take painkillers after injuries should remember that the combination of NSAIDs with ginkgo is one of the most common and at the same time least recognized.

How to compose a sensible regimen

If you still want to include ginkgo in your supplement program, we advise following a few simple rules.

1. First, define a specific goal and check whether there are at least some data on ginkgo for it.
2. Add one new component at a time to assess tolerability and effect.
3. Choose a standardized extract in doses that were used in studies, not token amounts from complexes.
4. Do not combine several supplements with antiplatelet action without need.
5. Inform your doctor about all supplements, especially before surgery and when new medications are prescribed.

For most athletes, ginkgo is not a mandatory element of the program. Sleep, diet, sufficient hydration, creatine and caffeine have a far more convincing evidence base for performance.

Simplicity of the regimen is also a matter of safety: the fewer the components, the easier it is to understand what exactly caused an adverse reaction.

Editorial conclusions

Direct data on combining ginkgo biloba with other supplements are limited: the best-studied combination is with ginseng, but even it was studied mainly in single doses.

With creatine and caffeine, ginkgo is most likely combined safely, although an additional benefit has not been proven. Combinations with high doses of omega-3, garlic, curcumin, ginseng require caution due to a possible cumulative effect on blood clotting.

Combining with anticoagulants, antiplatelet agents, NSAIDs and a number of other medications is allowed only by a doctor's decision.

We also advise reading "Who should not take Ginkgo biloba", "Side effects of Ginkgo biloba" and "Bacopa monnieri: what it is and how it works".

References

1. Kennedy DO, Scholey AB, Wesnes KA. Modulation of cognition and mood following administration of single doses of Ginkgo biloba, ginseng, and a ginkgo/ginseng combination to healthy young adults. Physiol Behav. 2002;75(5):739–751.
2. 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.
3. 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.
4. 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.
5. Unger M. Pharmacokinetic drug interactions involving Ginkgo biloba. Drug Metab Rev. 2013;45(3):353–385.
6. European Medicines Agency, Committee on Herbal Medicinal Products (HMPC). European Union herbal monograph on Ginkgo biloba L., folium. London: EMA; 2015.