Monika Nuffer, PharmD Skaggs School of Pharmacy · 2. Identify which herbal supplements are currently selling on the market and evaluate if you would recommend them to a patient 3.

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Popular Herbal Therapies:

Stock Em’ or Knock Em’

Monika Nuffer, PharmD

Skaggs School of Pharmacy

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Learning Objectives

1. Define Integrative Health and

Medicine (IHM)

2. Identify which herbal supplements

are currently selling on the market

and evaluate if you would

recommend them to a patient

3. Compare and contrast the safety

and efficacy of various herbal

supplements

Definition Integrative Health and

Medicine

• Healing-oriented practice that incorporates the relationship between the provider and whole person (mind, body, and spirit).

• It emphasizes the evidence and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.

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IHM Statistics

Utilization

• Adult American population 33.2%

• Children American population 11.6%

• Women more then men

• Patient with higher education and income

• 72 % patients didn’t report IHM use to health care provider *

Cost in 2016

• $ 7.452 billion US dollars

• Estimated $115 billion globally by 2020

Why People Use IHM ?

Dissatisfied with the results of

conventional therapy

Lack of disease curing of

conventional therapy

Dramatic reports from media

Patient empowerment

Focused on spiritual and emotional

wellbeing

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What Patients Believe…

Natural is better then synthetic

Patient don’t consider herbs as

“drugs”

Herbs don’t have side effects

Herbs are regulated, standardized,

and safe

Used for thousands of years

Supplement References

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Safety Rating per Natural Medicine

LIKELY SAFE: Products are generally considered

appropriate to recommend

POSSIBLY SAFE: Products appear to be safe, but

do not have enough high-quality evidence to

recommend for most people

POSSIBLY UNSAFE: Patients should be advised

NOT to take products

LIKELY UNSAFE/ UNSAFE: Patients should be

discouraged from taking products

INSUFFICIENT EVIDENCE: Not enough reliable

scientific evidence

Efficacy Rating per Natural MedicineEFFECTIVE: Products

are generally considered

appropriate to

recommend

LIKELY EFFECTIVE:

Products are generally

considered appropriate

to recommend

POSSIBLY EFFECTIVE:

Products might be

beneficial, but do not

have enough high-quality

evidence to recommend

for most people

POSSIBLY INEFFECTIVE:

Patients should be advised NOT

to take products

LIKELY INEFFECTIVE: People

should be discouraged from

taking products

INEFFECTIVE: People should

be discouraged from taking

products

INSUFFICIENT EVIDENCE:

Not enough reliable scientific

evidence to provide rating

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Sprouts Supplements

Coconut oil (Cocos nucifera)

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Coconut oil (Cocos nucifera)

Indication: weight loss, DM, CV, DL,

IBS, CFS & energy

Safety: Likely Safe

Efficacy: Insufficient Evidence

Adverse reactions: well-tolerated,

increase cholesterol

Drug interactions: blond psyllium

Dosage: 10 ml tid of virgin oil

Clinical Pearl: large fat content

Coenzyme Q10

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Indication: CHF, HTN, DM & CFS

Safety: Likely Safe

Efficacy: Possibly Effective

Adverse reactions: GI upset,

heartburn & appetite loss

Drug interactions: antihypertensive

Dosage: 100 mg tid

Clinical Pearl: take with a fatty meal

Coenzyme Q10

Fish Oil / Omega 3 … 6/9

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Fish Oil / Omega 3…6/9 Indications: DL, CHD, HTN, RA,

UC, hypertriglyceridemia, depression, osteoporosis & etc.

Safety: Likely Safe

Efficacy: Effective

Adverse reactions: fishy taste

Drug interactions: HTN

Dosage: 1 - 4 g daily EPA/DHA

Clinical Pearl: omega 3 & GRAS

Prenatal Multivitamin

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Indication: essential vitamins &

minerals during pregnancy

Safety: Likely Safe

Efficacy: Likely Effective

Adverse reactions: well tolerated

& increase appetite

Drug Interactions: none*

Dosage: 1 tablet TID

Clinical Pearl: with or without food

Prenatal Multivitamin

Homeopathic Medicine

How does it work?

• The principle of

similar

• “Like cures like”

• The principle of

dilutions

• “Law of minimum

doses”

Utilization in 2007

• Adults 3.9 million

• Children 900,000

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Chestal Honey

Chestal Honey

Indication: chest congestion &

dry/productive cough

Safety: Likely Unsafe

Efficacy: Insufficient Reliable info

Adverse reactions: abuse of ipecac

Drug Interactions: activated

charcoal, digoxin & diuretics

Dosage: 10 ml q2h

Clinical Pearl: avoid in patients

under 2 years of age

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Stock Em’ or Knock Em’?

Sprouts Supplements

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Walgreens Supplements

SAMe (S-adenosyl-L-methionine)

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SAMe (S-adenosyl-L-methionine)

Indication: Depression, Anxiety, Dementia, CFS & Fibromyalgia

Safety: Likely Safe

Efficacy: Likely Effective

Adverse reactions: GI, dry mouth, HA, insomnia, sweating & anorexia

Interactions: antidepressant & MAOIs

Dosage: 800 mg BID empty stomach

Clinical Pearl:salt forms & self

diagnosing

Glucosamine Hydrochloride

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Indications: RA, TMJ, Glaucoma,

& Osteoarthritis

Safety: Possible Safe

Efficacy: Insufficient Reliable

Adverse reactions: GI

Interactions: warfarin & asthma

Dosage: 500 mg tid

Clinical pearls: different salt form

that are not interchangeable

Glucosamine Hydrochloride

Alpha Lipoic Acid

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Indications: DM, neuropathy, CFS, cataracts & glaucoma

Safety: Possibly Safe

Efficacy: Possible Effective

Adverse reactions: GI & vertigo

Drug Interactions: thyroid hormone

Dosage: 300 – 1,800 mg daily

Clinical pearls: topical used for

wrinkles & sun damage

Alpha Lipoic Acid

CholestOff

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Indication: CAD, DL & BPH

Safety: Likely Safe

Efficacy: Possible Effective

Adverse reactions: GI

Drug Interactions: Anticoagulants

Dosage: 2-3 g daily with food

Clinical Pearl: take 2 - 3 weeks to

work. Once discontinued levels

return to baseline.

CholestOff

Stock Em’ or Knock Em’?

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Walgreens Supplements

GNC Supplements

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Bilberry Extract & Lutein

Indication: age related macular

degeneration, cataracts & Parkinson

Safety: Likely Safe

Efficacy: Possible Effective

Adverse reactions: none (up 20mg)

Drug Interactions: none known

Dosage: 6 mg daily

Clinical Pearl: food as medicine

Bilberry Extract & Lutein

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Grape Seed Extract

Indication: Cardio, chronic venous

insufficiency, HTN, PVD, MI, DM & mild

laxative

Safety: Likely Safe

Efficacy: Possible Effective

Adverse reactions: HTN & rash

Drug Interactions: CYP 1A2 &

lactobacillus acidophilus

Dosage: 360-720 mg daily

Clinical Pearl: GRAS

Grape Seed Extract (Vitis vinifera)

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Milk Thistle (Silybum marianum)

Indication: Liver disorders, DM &

Dyspepsia

Safety: Likely Safe

Efficacy: Insufficient reliable

Adverse reactions: GI, HA & rash

Drug Interactions: CYP 2C9,

Antidiabetic & Sirolimus

Dosage: 140 mg tid & Standardized 70-80% silymarin

Clinical Pearl: tea form not as effective

Milk Thistle (Silybum marianum)

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Stock Em’ or Knock Em’?

GNC Supplements

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Dr. Oz Show

Raspberry Ketones

Indication: Weight loss

Safety: Insufficient Reliable information

Efficacy: Insufficient Reliable Evidence

Adverse reactions: shakiness & heart

palpitations

Drug Interactions: none

Dosage: 200 mg with Vitamin C 1200 mg

daily

Clinical Pearl: 90% eliminated in urine

within 24hrs

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Green Coffee

Indication: Weight loss, T2DM

HTN, Alzheimer & Inflammation

Safety: Possibly Safe

Efficacy: Insufficient Reliable evidence

Adverse reactions: similar to caffeine

stimulate

Drug Interaction: DM, HTN & Ephedra

Dosage: 200 mg bid & standardized to

30.9-54 % chlorogenic acids

Stock Em’ or Knock Em’?

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Dr. Oz Show

Unsafe Supplements

• What is the difference between

food, spice, herb & medicine?

– Food as medicine (GRAS)

• We need to practice patient

management verse population

management

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Top 9 common supplementsSupplement Indication Safety Efficacy

O3FA / Fish oil Hypertriglyceridemia Likely Safe Effective

Glucosamine Sulfate Osteoarthritis Possibly

Safe

Insufficient

Evidence

Echinacea

(Echinacea angustifolia)

Common cold Likely Safe Possibly Effective

Flax Seed

(Linum usitatissimum)

Hyperlipidemia Likely Safe Possible Effective

Ginseng

(Panax ginseng)

Diabetes Likely Safe Insufficient

Evidence

Ginkgo

(Ginkgo biloba)

Dementia Likely Safe Possibly Effective

Chondroitin Osteoarthritis Likely Safe Possibly Effective

Garlic

(Allium sativum)

Hypertension

Dyslipidemia

Likely Safe

Likely Safe

Possibly Effective

Possibly Effective

Coenzyme Q-10 Congestive heart

failure

Likely Safe Possibly Effective

Top 9 common supplementsSupplement Indication Safety Efficacy

O3FA / Fish oil Hypertriglyceridemia Likely Safe Effective

Glucosamine Sulfate Osteoarthritis Possibly

Safe

Insufficient

Evidence

Echinacea

(Echinacea angustifolia)

Common cold Likely Safe Possibly Effective

Flax Seed

(Linum usitatissimum)

Hyperlipidemia Likely Safe Possible Effective

Ginseng

(Panax ginseng)

Diabetes Likely Safe Insufficient

Evidence

Ginkgo

(Ginkgo biloba)

Dementia Likely Safe Possibly Effective

Chondroitin Osteoarthritis Likely Safe Possibly Effective

Garlic

(Allium sativum)

Hypertension

Dyslipidemia

Likely Safe

Likely Safe

Possibly Effective

Possibly Effective

Coenzyme Q-10 Congestive heart

failure

Likely Safe Possibly Effective

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Online resourcesTitle Location (Access)

Natural Medicine http://www.naturaldatabase.com

National Center for Complementary and

Integrative Health (NCCIH)

https://nccih.nih.gov/

Florence G. Strauss-Leonard A. Wisneski

Indigenous and Integrative Medicine

Collection

http://hslibrary.ucdenver.edu/strau

ss

American Botanical Council http://herbalgram.org/

Herb Research Foundation http://herbs.org/

American Herbalist Guild http://www.americanherbalistsguil

d.com/

United Plant Savers http://www.unitedplantsavers.org

University of Colorado Integrative Health and

Medicine Certificate Programwww.ucdenver.edu/integrativehe

alth

UCHealth Integrative Medicine Center https://www.uchealth.org/location

s/uchealth-center-for-integrative-

medicine/

Online resourcesTitle Location (Access)

Micromedex www.micromedex.com

UpToDate www.uptodate.com

PubMed www.ncbi.nlm.nih.gov/pubmed

Cochrane Collaboration www.cochrane.org

Office of Dietary Supplements www.ods.od.nih.gov

Mayo Clinic http://www.mayoclinic.com/health/drug-

information/DrugHerbIndex

Memorial Sloan-Kettering

Cancer Center

http://www.mskcc.org/mskcc/html/11570.cfm

NOAH: New York Online

Access to Healthhttp://noah-

health.org/en/alternative/healing/herbal.html

Medline Plus http://www.nlm.nih.gov/medlineplus/druginfo/her

b_All.html

Food and Drug Administration www.fda.gov

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Conclusions

IHM is defined as “complementary

and alternative medicine”

• The use of IHM is very prevalent in today’s

society

• Providers should include IHM when

obtaining a medication history and

providing treatment recommendations

New IHM products will continue to

show up on pharmacy shelves

• “Do no harm” approach

• Recognize potential benefits for patients

Conclusions

As pharmacist…know the

information or know where to find it,

regardless of personal belief on

supplements or modality

• Patients may be “mistrustful” and expect

negative responses

• Importance of summarizing risks/benefits

Pharmacists must stay informed on

IHM information

• Patient marketing will generate questions

• Good amount of “misinformation”

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References Xue C,Zhang A, Liv V, Da Costa C, Story D.

Complementary and alternative medicine use in Australia: a national population-based survey. J Altern.Complement. Med. 13(6), 643-650 (2007).

Eiseberg D, Davis R, Ettner S et al. Trends in alternative medicine use in the United States, 1990-1997. Results of a follow-up national survey. JAMA 280 (18), 1569-1575 (1998).

Eisenberg DM, Kessler Rc, Van Rompay MI et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results form a national survey. Ann Intern Med. 2001;135:344-51.

Adapted from patient education found in the Natural Medicines www.naturaldatabe.com. Accessed December 2017.

Van Dam M, Stalenhoef AFH, Wittekoek J. Efficacy of concentrated n-3 fatty acids in hypertriglyceridaemia: a comparison with gemfibrozil.

References Jeon H, Jang IJ, Lee S, et al. Apple juice greatly reduces

systemic exposure to atenolol. Br J Clin Pharmacol 2012 May 11. doi: 10.1111/j.1365-2125.2012.04324.x. [Epub ahead of print].

Koitabashi Y, Kumai T, Matsumoto N, et al. Orange juice increased the bioavailability of pravastatin, 3-hydroxy-3-methylglutaryl CoA reductase inhibitor, in rats and healthy human subjects. Life Sci 2006;78:2852-9.

Vickers AJ, Smith C. Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes. Cochrane Database Syst Rev 2000;(2):CD001957.

Vickers AJ, Smith C. Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes. Cochrane Database Syst Rev 2006;(3):CD001957.

Vinson JA, Burnham BR, Nagendran MV. Randomized, double-blind, placebo-controlled, linear dose, crossover study to evaluate the efficacy and safety of a green coffee bean extract in overweight subjects. Diabetes Metab Syndr Obes 2012;5:21-7.

Douglas RM, Chalker EB, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2000;(2):CD000980.

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QUESTIONS ?