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Zhang Y, Wang G, Li Q, Jiang Y, Chen W, Zhao M, Liang G, Miao Q

This allows these toxins to get back into the bloodstream, where they can cause problems such as estrogen dominance disorders (8)

Furthermore, their quinidinelike effect on cardiac conduction, which can prolong the QTc interval, necessitates careful cardiovascular screening and often precludes their use in elderly patients or those with preexisting heart disease, frequently positioning them as a secondary choice after SNRIs or gabapentinoids [45, 336, 368, 369]

These include older anti-seizure medications (such as phenytoin, phenobarbital, and carbamazepine) [79, 80, 81, 82]