Herbs Talk

8/12/2019 Herbs Talk

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Herbs and Medicine

(Herbs - theyre not just for Red

Beans and Rice any more)

Rick Streiffer, MDTulane University Health Sciences Center

Department of Family and Community Medicine


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Thyme Heals AllWounds!


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COMPLEMENTARYALTERNATIVE MEDICINE

A group of diverse medical and health caresystems, practices, and products that are notpresently considered to be part ofconventional medicine.

While some scientific evidence exists regardingsome CAM therapies, for most there are keyquestions that are yet to be answeredthrough well-designed scientific studies. - NCCAM

Are they safe? Do they work?


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Definition 2

Complementary medicine - used togetherwith conventional medicine.

Example - aromatherapy to help lessen a patient's

discomfort following surgery.

Alternative medicine - used in place ofconventional medicine.

Example - a special diet to treat cancer insteadofundergoing surgery, radiation, or chemotherapyrecommended by a conventional doctor.


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5 main types of CAM:

(1)Alternative medical systems -

eg, Homeopathy, Naturopathy

(2) Mind-body interventions -

eg hypnosis, imagery, support groups

(3) Biologically-based treatments -

eg, Herbal, dietary treatment,

(4) Manipulative and body-based methods -

eg, chiropractic, acupressure, osteopathy

(5) Energy therapies -

eg, magnets, therapeutic touch


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Objectives

Increase awareness of use of herbs

Know about some benefits and risksbased on recent evidence

Be aware of useful resources


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Why learn about Herbal Medicine?

Your patients are taking herbs


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Your patients are taking drugs!

81% US adults take 1+ med/week JAMA Jan 16,2002

7 of 10 US adults regularly take vitamin,mineral, herb or supplement Harris Poll 2002

Rates and numbers of meds increase withage


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YOU are trying CAM, too!

60% of US physicians recommended CAM atleast once (1994)

47% of physicians reported using alternativetherapies themselves

- NCCAM


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Your patients are taking herbsMany drugs came from plants

So, why shouldnt there be potential forefficacy of herbs?


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Herbs have pharmacological propertiesincluding side effects, interactions


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Herbs have pharmacological propertiesincluding side effects, interactions

Suggestive evidence exists on efficacy


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PROBLEMS: Regulatory Issues

1906 Food and Drug Act - Accurate labeling, purity required

1962 Kefauver-Harris Amendment -Safe & Effectiverequired

1994 Dietary Supplement Health and Education Act

FDA lost authority over Herbs, Vitamins unless proven to

be unsafeBecame Nutritionals


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Problems with Herbal Medicine - 1

REGULATORY:Unmonitored, uncontrolled, non-uniform products

No standards of bioequivalence between brands, orbetween lots

Ingredients not required to be completely listed

Producers do not need to prove safety or efficacy

Adulteration has commonly been described


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Problems with Herbal Medicine -2

Many touted for prevention - hard to evaluate

Placebo effect is strong

Quality of science varies

Much of the research is not in English


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NCCAM

The Federal Government created the National Centerfor Complementary and Alternative Medicine (NCCAM) as a

response to this accelerating interest by the American

people in the healing possibi lit ies of CAM. NCCAM'smission, in its simplest terms, is to assure our cit izens,

through the use of excellent science, that CAM procedures

and products do what they purport to do.

http://nccam.nih.gov/


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A Brief Review of

Common Used Herbs


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Saw Palmetto

Traditional use: stomach ache, dysentery, diuretic,

sexual tonic, urinary disorders (in USP in early 1900s)

Commission E: Urination problems in BPH stages 1,2

Evidence: Numerous RCTs, systematic review~ equal to finasteride (Proscar) in improving flow, lowering

nocturia

90% lower side effects; less ED; no reduction of gland size;

Safety:

Infrequent GI problems; no interactions known


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Ginger root

Traditional use: stimulant, diuretic, antiemetic, insecticide

Commission E: Dyspepsia, prevention of motion sickness

Evidence: RCTs

> placebo in postop nausea, similar to metoclopramide (Reglan)

> placebo in seasickness (Naval cadets)

Safety:

low toxicity; no side effects;platelet changes;

not recommended by Comm E during pregnancy, but US

version disagrees


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Horse Chestnut Seed Extract

Traditional use: arthrit is/rheumatism; congestion (leaves);

Commission E: pathological conditions of veins (CVI)

Evidence: Numerous RCTs, systematic review

superior to placebo, reduced edema, leg circumference;

better compliance than compression hose;

improved pain, fatigue, itching, leg tension (observational)

Safety:

No Contraindications; mild and rare adverse effect (occais.

pruritis, nausea, GI c/o); no restrictions in pregnancy;

NOTE: whole seed is toxic.


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Black CohoshMay relieve menopausal symptoms (mood,

flushes, sleep)

ACOG - OK for up to 6 months

No evidence of other protection benefits ofestrogen

Safe - - no drug-herb interactions

Possible interaction with tamoxifen


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FeverfewPrevention of migraines

Cochrane review, 2003:3 of 4 trial suggest beneficial effect;

1 showed no difference vs placebo

Conclusion: Suggestive, but efficacy notestablished beyond a doubt

Avoid:

In pregnancy, W/antiplatelet agents

Sudden discontinuance


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Herbs I Might

Tolerate or Discourage

Are they safe? Do they work?


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Ginko Biloba

Traditional use: memory, circulation, asthma, digestion

Commission E: symptomatic Rx of disturbed performancein OBS; claudication; vertigo/tinnitus

Evidence: RCTs

Apparent benefit in dementia similar to tacrine (Cognex ) Improvement in pain-free walking distance

Possibly for ED secondary to SSRIs

Provides no measurable benefit in memory, cognitive functionto adults w/healthy cognitive function. (JAMA. 2002;288:835-840)

Safety: usually mild side effect eg, GI upset;

Anti-platelet effect - use with caution w other agents


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Echinacea

Wide variability in products, adulterationPositive and negative results have beenreported:

Poor evidence for prevention of URIs, flu Possible mild decrease in length/severity

Appears generally safe

Avoid in HIV, immunocompromised pts,longer then 8-10 weeks

DARE 2003, on 13 RCTs


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St. Johns Wort

Traditional use: native to Europe, N. Africa, western Asia; use

dates to Greeks; used for psychiatric disorder since 16th century;Commission E: Psychovegetative disturbances, depressive

moods, anxiety, nervous unrest

Evidence: >30 controlled trials, DARE review (2003) confirmantidepressant effect in mild-mod depression (1.5 x placebo) in

short term treatment, similar to low-dose tricycl ics

SJW could provide bridge to tx for pts that decline

conventional antidepressant medication - DARE

Safety:

Drug Interactions


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Garlic Conclusions from AHRQ Insufficient data on clinical CV outcomes (claudication

and MI)Possible small, positive, short-term effects on lipids

Inconsistent reductions in blood pressure

Promising but inconclusive on antithrombotic activity.Use < 3 to 5 years not associated with decreased risks

of breast, lung, gastric, colon, or rectal cancer.

Cautions: Problems with standardizationWatch in combination with anti-platelet agents

Bottom line - should not replace standard therapy

Evidence Report/Technology Assessment # 20, Garlic: October

2000 www.ahrq.gov/clinic/epcsums/garlicsum.htm


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A Few Cautions!


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Ginseng

Use: For invigoration, fortification; fatigue; improve

capacity for work, concentration; colds and flu; diabetes;immune support; herpes; general well being; stress; malesexual function; sports performance

DARE (2003): efficacy is not established for anyoutcomes

Concerns:Adulteration is common

ExpensiveAnti-platelet properties

Insomnia, diarrhea, vaginal bleeding, H/As, SJ syndr


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Kava Kava Traditional use: S. Pacific ritual, relaxation, UTIs, asthma

Commission E: Nervous anxiety, stress, restlessness

Evidence: Cochrane Review 2003

appears to be an effective symptomatic treatment option foranxiety; relatively safe fir short-term Tx.

Many European RCTs: safe,effective for S&S anxiety, musclerelaxation, w/out depressing cognit ive functions

Safety: regarded as safe, until recently reports of Liver toxicity

Potentiation of, interaction w/ CNS drugs, EtOH;

Dystonic reactions

Prolonged/heavy use: yellow discoloration of skin, nails

Avoid in pregnancy


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Ephedra / Ma-Huang

Use promotes modest short term weightloss (stat signif vs placebo)

Associated with 2-3x increases in nausea,

vomiting, psychiatric sympts, palpitations,autonomic hyperactivity vs placebo.

Adverse events: 5 deaths, 5 MIs, 11CVAs, 4 seizures, 8 psych cases


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No Evidence Yet

Cochrane Review 2003:No firm evidence of efficacy for any

medicinal herbs for Hepatitis C infection

Some herbs may work in Chronic Hep B, butevidence is too weak to recommend any


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Herb-drug interactions - 1

St. Johns Wort

With SSRIs - Seratonin Syndrome

With other drugs, due to Cytochrome P450:

Cyclosporine, antiretrovirals, digoxin, warfarin,

theophylline, chemotherapy, oral contraceptives,nifedipine, diltiazem, alcohol, tamoxifen


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ASA, warfarin

Garlic

Ginger

Ginko

Ginseng

Feverfew

Clove oil


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Hypertension

Ma Huang

Licorice

Yohimbe

Ginseng

Hypoglycemia

Ginseng


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Talking with patients

Ask every pt about herbs and supplements

Address natural must mean safe

If it sounds too good to be true, it probably is

Avoid preparations with >1 herb

Avoid switching brands frequently

Buy packaged products with

name/address of manufacturer, batch/lot number

common and scientif ic name, standardization when possible

dosing guidelines, side effects


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Resources - Web sites American Botanical Council: http://www.herbalgram.org

NIH National Center for Complementary and AlternativeMedicine: http://nccam.nih.gov/

Sloan Kettering Cancer CntrInformation About Herbswww.mskcc.org/aboutherbs

MEDLINEplus http://medlineplus.gov/ then search Herbs

Office of Dietary Supplements (NIH) http://ods.od.nih.gov/

iHerb www.iherb.com/health.html , then use The NaturalPharmacy and Commission E Monographs

ClinicalTrials.gov http://clinicaltrials.gov/ then type in Herbs

FDA Safety and Adverse Reporting Programhttp://www.fda.gov/medwatch For warnings on dietary supplementsee also http://www.cfsan.fda.gov/%7Edms/ds-warn.html


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Resources - Books, Articles

Herbal Medicine: Expanded Comission E Monographs. BlumenthalM., ed. American Botanical Council; 2000 (US update of CommissionE; $40 on Amazon.com)

Guide to Popular Natural Products, Dermarderosian, A., ed. Facts &Comparisons, 1999 (pocket size, handy, $29.95 at Amazon.com)

The Desktop Guide to complementary and Alternative Medicine an

evidence-based approach, Ernst, E. ed. 2001, Mosby

Integrative Medicine, Rakel, D ed. 2002, Saunders

Herbal Remedies - DeSmet NEJM Dec 19, 2002

The Risk-Benefit Profile of Commonly Used Herbal Therapies -Ernst Ann Int Med Jan 2002

A Review of Herb-Drug Interaction by Jason E. Lambrecht, Pharm.Dfound at http://www.uspharmacist.com/oldformat.asp?url=newlook/files/comp/aug00alt.htm

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