Herb Update Final09 B

Copyright J Klemens 2008, 2009Copyright J Klemens 2008, 2009

What You Need to Know What You Need to Know About Herbs & About Herbs & SupplementsSupplements

Jonathan Klemens, B.S. Bio, BS Pharm, MSLBE

““The Herbs and The Herbs and Supplements that Supplements that your Patients are your Patients are Talking about”Talking about”

PHARMACIST OBJECTIVES Review Herb & Supplement Market Discuss Herb & Supplement Safety &

Regulations Identify Herbs & Supplements of

Choice Discuss Indications, Major Side Effects & Interactions Identify Herbs & Supplements Under

Study Identify Resources for Information

TECHNICIAN OBJECTIVES Define Scope of Herbal /

Supplement Market Discuss Importance of Herb &

Supplement Safety & Regulations Identify Herbs & Supplements of

Choice Define Technician’s Role in Use of

Herbs & Supplements Identify Herbs & Supplements

Under Study

Small Print Legal StuffSmall Print Legal Stuff

■ This presentation may discuss therapeutic products that have not been approved by the US FDA & off-label uses of approved products.

■ This information is not all-inclusive and is not meant to replace the diagnosis, advice, treatment, & judgment of medical professionals.

■ Please verify all information and data and review updates before treating patients, employing any therapies, or recommending any herbs or supplements.

■ These views do not reflect the views of the Jefferson Regional Medical Center.

“ “ I really didn’t say everything I I really didn’t say everything I said”said”

- Yoga Berra- Yoga Berra

I have an earache: 2000 B.C. - Here, eat this root.1000 A.D. - That root is heathen, say this prayer.1850 A.D. - That prayer is superstition, drink this potion.1940 A.D. - That potion is snake oil, swallow this pill.1985 A.D. - That pill is ineffective, take this antibiotic.2000 A.D. - That antibiotic is artificial. Here, eat this root.

"A Brief History Of Medicine" Posted by Thunderbird

November - 1998November - 1998

HERBSHERBS

Aromatic ● Savory ● Medicinal

Between 1991 – 1997, the use of herbals in USA rose by 380% (JAMA, 1998).

Annual sales of herbals in USA approx. $2.7 billion - $23.2 billion world market, $5 trillion by 2050.

1994 – Passage of Dietary Supplement Health and Education Act (DSHEA).

“ Phytomedicinals” are classified as “dietary supplements.”

Claims are limited to product’s role in “affecting structure or function” or to maintain health.

Allows a product to remain on market as long as NOT proven to be unsafe.

There are NO There are NO safety controls safety controls for herbs and for herbs and supplements supplements like those for like those for prescription or prescription or OTC drugsOTC drugs

Vioxx (9/04)Vioxx (9/04)

AARP / NCCAM SURVEYAARP / NCCAM SURVEY 1,559 individuals age 50 and older surveyed in the spring of 2006

63 % reported having used one or more CAM therapies

42 percent used herbal/dietary supplements

1998 JAMA STUDY– ONLY 4% 1998 JAMA STUDY– ONLY 4% USED CAM ALONE USED CAM ALONE

↓↓ INTEGRATIVE MEDICINE INTEGRATIVE MEDICINE

INTEGRATIVE HEALTHINTEGRATIVE HEALTH

More than 95 of nation’s 125 More than 95 of nation’s 125 medical schools (76%) require medical schools (76%) require

Some CAM coursework.Some CAM coursework.

Why do people use Why do people use products that have products that have

not been proven safe not been proven safe and effective?and effective?

Perceived lower healthcare costs Control over own health Prevention of disease / condition Diseases without cure Fear of surgery Decreased side effects? Popular and expert advocates

▪ ▪ Dr. Andrew Weil, founder - Program in Integrative Medicine, & Weil Lifestyle, at University of Arizona

▪ Degrees in biology and medicine (Harvard)

▪ Author of numerous articles and 7 books

Holistic – Natural Approach – Drugless? Perception that NATURAL = SAFE (Arsenic & Cyanide)

Recommendations - family & friends Will not affect insurability Dissatisfaction with provider /

therapy → internet search → sales pitch → perceptions from misinformation

Precarious SituationPrecarious Situation

THESE ARE DEFINITELY DRUGS! Drug usage is a Balancing of Risks and

Benefits Not FDA approved, Claims and NOT

Indications (Evidence Based?) Lack of standardization, spice v. med –

optimal dose ? They do not work for everyone to same

extent OTC, Unregulated Distribution, Good Profit

Margin, Online Sales

Contaminated (Chinese, Ayurvedic – lead, mercury, arsenic etc.)

Contraindications, Consumer Confusion, Drug/Food Interactions, SE, Allergies / Sensitivities, Perioperative Cautions

Synergy – Beneficial or Harmful Share Decision with Provider(s) and

Pharmacist(s) Cultural Transformation & Patient’s

Rights

Side Effects & Side Effects & InteractionsInteractions

Allergic reactions & Sensitivities Increase/decrease bleeding

tendency Increase/decrease blood sugar Aggravate hypertension May effect organ systems or

disease states

New England Journal of MedicineNew England Journal of Medicine suggests that repeated topical use suggests that repeated topical use of products containing lavender oil of products containing lavender oil and/or tea tree oil may cause and/or tea tree oil may cause prepubertal gynecomastia, a rare prepubertal gynecomastia, a rare condition resulting in enlarged condition resulting in enlarged breast tissue in boys prior to breast tissue in boys prior to puberty … (01/31/07)puberty … (01/31/07)

Inhibit key metabolic enzymes (CYP isoenzymes): Additive/inhibitory effect on medication and supplements

Negative perioperative effects Discontinue 3 weeks Discontinue 3 weeks

prior to surgeryprior to surgery

Interactions between drugs and supplements: pharmacokinetic and pharmacodynamic.

The CYP system is involved in the oxidative metabolism of drugs. The human body has over 30 CYP enzymes, but only six of them are known to be relevant for interactions.

Over 90% of oxidative drug metabolism occurs via 6 CYP enzymes:

1A2, 2C19, 2E1, 2C9, 2D6, 3A4

CYP 3A4CYP 3A4 The CYP 3A4 enzyme is involved in the metabolism

of over 50% of all drugs. Supplements such as St. John's Wort, garlic, DHEA and others that alter this

enzyme can interact with a very long list of medications.

St. John's Wort INDUCES CYP3A4 and therefore usually REDUCES activity of drugs metabolized by this enzyme.

EXCEPTION: Clopidogrel (Plavix) is a pro-drug. It needs to be metabolized by CYP3A4 to become active. Taking clopidogrel with St. John's wort actually INCREASES the activity of clopidogrel.13038

Most Popular HerbsMost Popular Herbs

1. Ginkgo Biloba (oldest?)2. St. John’s Wort (6/24)3. Ginseng 4. Garlic5. Echinacea6. Saw Palmetto7. Kava

Survey – Drug Store NewsSurvey – Drug Store News

8. Soy 9. Valerian 10. Evening Primrose11. Grape Seed12. Milk Thistle 13. Bilberry14. Black Cohosh 15. Pycnogenol

Ginkgo -Ginkgo - Antioxidant, > blood flow, memory. SE: > bleeding tendency, monitor Type I induces P450 2C19 but inhibits other P450 enzymes

St. John’s Wort (6/24) –St. John’s Wort (6/24) – Antidepressant. SE: > effects of many drugs (P450), warfarin, HIV meds, OC. May > activity of clopidogrel, > photosensitivity, mania, withdrawal

Ginseng (Wild: $400) {Asian, American, Ginseng (Wild: $400) {Asian, American, Siberian} -Siberian} - Fatigue, weakness, ED. SE: May > bleeding (check INR with 2 weeks), insomnia, mania, may prolong QT interval, may < blood sugar. Vitamin C can interfere with absorption

Garlic -Garlic - < BP, < cholesterol. SE: > bleeding with warfarin, ASA, NSAIDS, < OC, may induce or inhibit CYP450 enzymes

Echinacea -Echinacea - Colds and respiratory infections. SE: may augment hepatotoxicity/nephrotoxicity with other hepatotoxic drugs, Contra in progressive systemic diseases and immune disorders, Inhibits CYP3A4 isoenzymes

Saw Palmetto -Saw Palmetto - Enlarged prostate. SE: < OC and hormone therapy, > bleeding

Kava -Kava - Sedative, sleep aid. SE: Very hepatotoxic, exacerbates hepatitis and may cause a progressive form of Parkinsonism, may cause severe liver damage resulting in transplant, yellowing of skin, inhibits a variety of P450 enzymes, has caused coma with alprazolam

Soy (Phytoestrogens) -Soy (Phytoestrogens) - Menopausal symptoms. SE: Cross allergy to peanuts, may interact with warfarin causing sub-therapeutic INR, may worsen hypothyroidism, may > certain cancers

Valerian (5%) -Valerian (5%) - Anxiety, sleep aid. SE: May > effects of anti-seizure meds and sedatives, long term may be hepatotoxic, may inhibit CYP3A4 enzymes, withdrawal symptoms

Evening Primrose (GLA) -Evening Primrose (GLA) - Inflammation, PMS, menopause, immune disorders, MS, rosacea/ eczema / acne. SE: < bleeding tendency, may exacerbate temporal lobe epilepsy. Contra schizophrenia

Grape Seed Extract (OPCGrape Seed Extract (OPC - oligomeric oligomeric proanthocyanidinsproanthocyanidins) - Antioxidant, allergies. SE: May < plasma levels of certain drugs, > effect of warfarin

OPC’sOPC’s

Unique flavonoids 50X more powerful than vitamin

E & 20X more powerful than vitamin C in terms of antioxidant activity

Strengthen/repair connective tissue, moderate allergies and inflammation

Milk Thistle -Milk Thistle - Liver disease, liver protection, hangovers? SE: > drug levels by inhibiting CYP3A4/CYP2C9 enzymes, Contra in progressive systemic diseases and immune disorders

Bilberry (Huckleberry) -Bilberry (Huckleberry) - Eye disorders. SE: may < blood sugar, and inhibit platelet aggregation, interferes with iron absorption

Black Cohosh -Black Cohosh - PMS, menopause, menstrual disorders. SE: May be hepatotoxic, may > metastasis of breast cancer, may > toxicity of certain chemo agents but < cytotoxic effects of cisplatin

Pycnogenol (OPC) -Pycnogenol (OPC) - Antioxidant, poor circulation, immunity. SE: May interfere with immunosuppressant therapy, avoid in autoimmune patients

Tea Tree oil - antifungal, antifungal, antibacterial, antiviralantibacterial, antiviral

Green Tea - antioxidant, < antioxidant, < cholesterol, ant-cancer activity?cholesterol, ant-cancer activity?

Goji Juice (Lycium) - WolfberryWolfberry Guarana - guaranine ?, caffeine guaranine ?, caffeine Goldenseal - wounds, mucus wounds, mucus

membrane infections, cold/flu, membrane infections, cold/flu, mask drugsmask drugs

Medical Mushrooms (200/700) - adaptogens, Reishi – Maitake – adaptogens, Reishi – Maitake – ShitakeShitake

Yerba Mate - 196 active 196 active compounds! (cancers?)compounds! (cancers?)

Salvia divinorum - (“Diviner’s Sage” (“Diviner’s Sage”

hallucinogen, the “new hallucinogen, the “new marijuana”?)marijuana”?)

ACAI BERRIESACAI BERRIES

The açaí berry The açaí berry comes from the comes from the Brazilian Açaí Brazilian Açaí palm.palm.

Referred to as Referred to as “The Tree of “The Tree of Life,” by the Life,” by the Yanomami Yanomami Indians.Indians.

Flavor that faintly resembles Flavor that faintly resembles raspberries and chocolateraspberries and chocolate

10 times more antioxidants than red 10 times more antioxidants than red grapes and 10 to 30 times more than grapes and 10 to 30 times more than the artery-protective flavonoids of the artery-protective flavonoids of red wine. red wine.

Seems to inhibit key enzymes that Seems to inhibit key enzymes that may reduce inflammation. may reduce inflammation.

Helps in loosing weightHelps in loosing weight One 60-capsule supply runs about One 60-capsule supply runs about

$19.95 for a two-week dose.$19.95 for a two-week dose.

SPECIFIC SPECIFIC CONDITIONSCONDITIONS

DIABETESDIABETESCinnamonCinnamon

●● Journal of Diabetes Care (01/09/2008)

● ● Hartford Hospital – “Meta-analysis” of 5 studies, 282 type 1 or type 2 diabetics cinnamon (cassia) or placebo for up to 16 weeks, 1-6 g daily

● ● No significant change in HgbA1c, FBS, or lipid parameters

Supplements with Claims Supplements with Claims to Lower Blood Sugarto Lower Blood Sugar

Cinnamon Bark, Ginseng, Neem, Banaba, Jambolan,, Kudzu,, Milk Thistle, Aloe Vera, Soy, Bilberry, Stevia, Pterocarpus marsupium (Indian Kino Tree), Holy Basil, Devil’s Claw, Jackfruit, Gulvel, Pycnogenol, Vanadyl Sulfate, Black/GreenTea

Gymnema Slyvestre, Bitter Melon (Balsam Pear), Agaricus Mushroom, Alpha Lipoic Acid, GTF, GingerXanthan Gum, Blond Psyllium, Guar Gum, Glucomannan (Konjac), Beta-glucan, Fenugreek, Oats, Prickly Pear Cactus (Nopal), Vitamin D-3, Niacinamide, Salsalate

GlucobeticGlucobetic® (Atrium)® (Atrium) Normalize Elevated Blood Sugar Normalize Elevated Blood Sugar

LevelsLevels Zinc GluconateZinc Gluconate 15 mg 15 mg Chromium GTFChromium GTF 240 mg240 mg Vanadyl SulfateVanadyl Sulfate 10 mg 10 mg Gymnema Sylvestre Extr.Gymnema Sylvestre Extr. 200 mg200 mg Bitter Melon ExtractBitter Melon Extract 200 mg200 mg Fenugreek ExtractFenugreek Extract 100 mg100 mg Bilberry ExtractBilberry Extract 40 mg 40 mg Cinnamon ExtractCinnamon Extract 30 mg 30 mg JambolanJambolan 75 mg 75 mg Pterocarpus MarsupiumPterocarpus Marsupium 200 mg200 mg Gulvel Gulvel 50 mg 50 mg

WEIGHT CONTROLWEIGHT CONTROL Hoodia Gordonii (Trim-Fast™) Glucomannan (2 hrs) Chitosan Fish Oil Ephedra Ginger ? Acai Berries Misc: Lipozene™ (Latin American

Yam, Green Tea), Banatol™

ENERGYENERGY

CaffeineCaffeine Guarana (Fiber-Bound Guarana (Fiber-Bound

Caffeine)Caffeine) Yerba MateYerba Mate GinsengGinseng Ginkgo BilobaGinkgo Biloba

CHOL / TRIGCHOL / TRIG Red Yeast Rice Fish Oil, Krill Oil

(48X) Flax Seed Glucomannan (2 hrs) Sitostanol Guar Gum Alfalfa Turmeric Avocado

Chitosan Oats Olive Oil / Safflower

Oil Nuts

(Walnuts/Almonds/Pecans/ Pistachios/Macadamia)

Nopal (Prickly Pear) Aloe Vera ?

Red Yeast RiceRed Yeast Rice Red yeast rice is rice that has been

fermented by the red yeast, Monascus purpureus.

Used in China for over 1,000 years for medicinal purposes. Claims: useful for improving blood circulation, indigestion and diarrhea.

Claimed to lower cholesterol and triglycerides. Monacolin K/Lovastatin (low levels).

Caution: Citrinic acid concentrations.

Monacolin, most important ingredient in red yeast rice extract, varies considerably.

One study of different brands of red yeast rice supplements: monacolin ranged from 0% to 0.58%.

In 2000, the 10th U.S. Circuit Court of Appeals ruled that red yeast rice IS subject to FDA regulation. FDA has aggressively gone after companies selling red rice yeast containing lovastatin.

Essentially, supplements containing appreciable amounts of monacolin have disappeared from retail stores.

EDED L-Arginine – Increase Nitric oxide

concentration Cnidium Monnier (fruit) Also called “Snake

Bed” – induces nitric oxide, inhibits PDE-5 Epimedium Extract, “Horny Goat Weed”-

inhibits acetylcholinesterase (Yohimbe) Panax Ginseng Ashwaganda Ginkgo

SIGRASIGRA®®(Alpha Pharmaceuticals - (Alpha Pharmaceuticals -

Holland)Holland) Cnidium Monnier (fruit) – induces

nitric oxide, inhibits PDE-5 Xanthoparmelia Scabrosa (lichen) –

smooth muscle relaxation, increases blood flow

Epimedium Extract, “Horny Goat Weed” (leaves, stems) – inhibits acetylcholinesterase

Cistanches (root) – ↑ blood circulation L-arginine, Gamma Amino Butyric Acid

HYPERTENSIONHYPERTENSION(one class of flavonoids, the flavanols, is

receiving increasing attention)

Garlic Co-Q 10 Fish Oil PycnogenolPycnogenol CacaoCacao Green TeaGreen Tea

PomegranatePomegranate Arginine Magnesium Grape seedGrape seed Blond

Psyllium

ALLERGIESALLERGIES

Quercetin Butterbur Stinging Nettle

MEMORYMEMORY Phosphatidyl Choline Phosphatidyl Serine (PS) Huperzine – (Chinese club moss)

Alzheimer's, Memory loss Ginkgo ? Turmeric? Vitamin D3? (Obtain level first)

MIGRAINESMIGRAINES

Butterbur Feverfew Burdock Chicory Devil’s Claw Elder

Ginkgo Ginseng Ginger C0-Q10 Arginine SAMe

INSOMNIAINSOMNIA

Melatonin Lemon Balm Hops L-tryptophan Valerian

ARTHRITIS / JOINT PAIN / ARTHRITIS / JOINT PAIN / INFLAMMATIONINFLAMMATION

Glucosamine – Chrondrotin

Turmeric Ginger SAMe Beta-Carotene Avocado Bromelain Boswillia Devil’s Claw

Fish Oil Hyaluronic Acid

/Hyaluronan (Baxyl®)

MSM (Methylsulfonylmethane)

Rutin Vitamin E Evening Primrose Oil

UTIUTI

Cranberries Vitamin C

Herbs with Negative Herbs with Negative Perioperative EffectPerioperative Effect

Discontinue at least 3 weeks prior Discontinue at least 3 weeks prior to surgery:to surgery:

Evening Primrose Oil, Saw Palmetto; Echinacea, Ephedra,

Feverfew,Garlic, Ginkgo Biloba, Ginseng,

Kava Kava, St. John’s Wort, Valerian

(JAMA 2001;286:208-216)Chamomile, Licorice, Ginger,

Turmeric,Willow Bar, Policosanol, Bitter

Orange, Guarana, L-Tryptophan

The Dirty DozenThe Dirty Dozen

Bitter Orange Chaparral Comfry Germander Groundsel Kava

Lobelia Margosa Oil Pennyroyal Oil Sassafras Skullcap Yohimbe

SPECIAL SPECIAL SUPPLEMENTSSUPPLEMENTS

Annual sales of supplements in USA ~ $8.8 billion

Surveys indicate that over 50% of adults use supplements

- Improve health and well-being - Increase muscle mass, maintain desired weight - Antioxidant effects - Feel better SAFE OR EFFECTIVE???

Most Popular Most Popular SupplementsSupplements

Glucosamine / Chrondrotin

(Joint Juice - 1500mg)(Joint Juice - 1500mg)

Co-Enzyme Q10 Melatonin Amino Acids Fish Oil (Omega 3

FA) - Drug Store News Survey, 2000

▪ ▪ Alpha Lipoic Acid (Thiotic Acid, 1951) Universal Antioxidant

▪ Bee Hive Products: “Apitherapy” - Pollen /

Propylis / Royal Jelly / Bee Venom

▪ Creatine Monohydrate

Emu Oil SAME-e (S-adenosyl-

methionine) Shark Oil, Cartilage Vanadyl Sulfate (V2G) GTF (chromium)

NutraceuticalsNutraceuticals Coined in 1989:

Foundation for Innovation in Medicine

Foods with therapeutic claims –

““Functional Functional

Foods” Foods” Special benefits

►► “Functional” dark chocolate bar, 50-60% (CocoaVia ™)

►3 oz/day/ 500 cal►60-61% Cacao –

“Semisweet”►70-72% -

“Bittersweet”►Unsweetened baking

chocolate – 100% Cacao

Probiotics (1965)Probiotics (1965)

GI tract: 400 strains of bacteria – Probiotics – beneficial strains that help maintain microflora balance, homeostasis, promote overall immunity.

Bifidobacterium longum, B. bifdum, Lactobacillus bulgaricus, L. acidophilus, Saccharomyces boulardii

Low levels of Low levels of probiotics can cause:probiotics can cause:

● Constipation, diarrhea, Crohn’s Disease, ulcerative colitis, IBS (10- 20% of adults in U.S.).● Also implicated in jock itch, vaginitis, and

yeast infections (Candida albicans), gingivitis, psoriasis, eczema, migraines,

UTIs, chronic fatigue syndrome.

The independent lab. ConsumerLab.com, tested 26

probiotic supplements and found that only 8 of the products

contained less than 1% of the claimed number of live bacteria or the expected minimum of 1

billion organisms

Class Action LitigationClass Action Litigation

Activia®Activia®

Activa Activa Lite® Lite®

and and

DanActive®DanActive®

Get Some Culture!Get Some Culture!

Yogurt Kefir (ke-fir′) Cottage cheese Buttermilk Sauerkraut / Kimchi (Korea) Acidophilus fortified milk

Influenza Influenza

Prevention/TreatmentPrevention/Treatment

Seasonal Flu (44%), Avian Flu (H5N1)Seasonal Flu (44%), Avian Flu (H5N1) TAMIFLU – Chinese Star Anise (+ other

sources) RESVERATROL – Grapes, raisins, peanuts SAMBUCOL – Black elderberries IMMUNE BOOSTING MUSHROOMS (e.g.Maitake, Shiitake, Reishi,

Agaricus) ASTRAGALUS

ECHINACEA, GARLIC, GINSENG KIMCHI, SAUERKRAUT, KEFIR,

YOGURT CARROTS – LETTUCE – CELERY

(Alkaline) OSCILLOCOCCINUM – Homeopathic

Remedy

Beware of potential Beware of potential “Cytokine “Cytokine Storm”Storm”

The Search for The Search for Clinical EvidenceClinical Evidence

http://nccam.nih.gov/http://nccam.nih.gov/clinicaltrials/alltrials.htmclinicaltrials/alltrials.htm

NATIONAL CENTER FOR NATIONAL CENTER FOR CAMCAM

AcupunctureAcupunctureArthritisArthritisBlack CohoshBlack CohoshCancerCancerChelationChelationChiropracticChiropracticChondroitinChondroitinDepressionDepressionDietary SupplementsDietary Supplements

EchinaceaEchinaceaEphedraEphedraGinkgoGinkgoGinsengGinsengGlucosamineGlucosamineHerbs at a GlanceHerbs at a GlanceHomeopathyHomeopathyMenopauseMenopauseSt. John's WortSt. John's Wort

NCCAM ( NIH ) Clinical NCCAM ( NIH ) Clinical TrialsTrials

Screening Herbs for Drug Interactions

Herb-Opioid Interactions Extract of Ginkgo and Vascular

Function Effects of Selected

Vegetable/Herb Mix on Advanced Non-Small Cell Ling Cancer

Hawthorn Extract Randomized Blinded Chronic Heart Failure Trial

Evaluation of Interaction between Herbal Products and Anticoagulants

Treatment of Major Depression with St. John’s Wort (Hypericum)

Effects of Dark Chocolate on Insulin Sensitivity in Hypertensive Patients

Ginkgo Biloba: Antidepressant-Induced Sexual Dysfunction

Herbal Alternatives for Menopause Symptoms

Ginger Control of Chemotherapy Induced Nausea and Vomiting

Therapeutic Effect of Chinese Herbal Medicine on Food Allergy

Salsalate: NSAID in treating diabetes

Favorite PicksFavorite Picks Alpha Lipoic Acid Coenzyme Q10 Grape Seed

Extract Green Tea Omega 3 (Fish

Oil, Flax Seed) Phosphatidyl

Serine (PS)

Probiotics Pycnogenol Resveratrol Turmeric Vitamin D3

(get level first)

I heartily encourage all of you to I heartily encourage all of you to further study the integration of further study the integration of

herbs herbs and supplements into our healthcare and supplements into our healthcare to better understand, and perhaps to better understand, and perhaps improve, the health of our patientsimprove, the health of our patients

in body, mind, and spirit. in body, mind, and spirit.

NATIONAL CENTER FOR CAM (NIH)NATIONAL CENTER FOR CAM (NIH) http://nccam.nih.gov/ NATURAL MEDICINES COMPREHENSIVENATURAL MEDICINES COMPREHENSIVE

DATABASE (Compiled : Editors of DATABASE (Compiled : Editors of Pharmacist’s Letter & Prescriber’s Pharmacist’s Letter & Prescriber’s Letter)Letter) http://www.naturaldatabase.com/(S(ufdxlkr1tbjogim02tqapj3k))/home.aspx?cs=&s=ND

NATURAL STANDARD – THE AUTHORITY NATURAL STANDARD – THE AUTHORITY ON INTEGRATIVE MEDICINEON INTEGRATIVE MEDICINE

(Compiled: International Board of (Compiled: International Board of Editors)Editors) http://www.naturalstandard.com/index.asphttp://www.naturalstandard.com/index.asp

Copyright J Klemens 2008, 2009Copyright J Klemens 2008, 2009

http://jksamurai.googlepages.com/

[email protected]

Dedicated to your Health in Dedicated to your Health in Body, Mind, and SpiritBody, Mind, and Spirit

Copyright Copyright ©©J Klemens 2008, 2009J Klemens 2008, 2009