Herbs M2 by anGlUa37

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									Herbs and Health:
Real World Basics
 Sara L. Warber, MD
 Co-Director, UM Integrative Medicine
 Assist Prof, Dept of Family Medicine
Context
Historical Context

   Physical evidence dates
    back 60,000 years
   All cultures have traditions
    of herb use for healing
   2000 BC - First known
    materia medica in Sumeria
   1st Century AD - Chinese
    Materia Medica
Cultural Context
   In China, 40-50% of meds used are
    traditional herbs
   In Africa, 80% of population uses herbal
    medicine for primary care
   In Germany, 90% of adults use herbs in
    lifetime
   Ethnic populations in US very likely to be
    using herbs
   25% of prescription drugs from plants
Pediatric Herbal Remedies

   Aloe vera     43%                      Goldenseal       7%
   Chamomile tea 29%                      Ginseng          5%
   Echinacea     28%                      Ginkgo biloba    4%
   Garlic        11%                      St John’s wort   4%
   Ginger        11%                      Feverfew         4%
   Tea tree oil  8%


Ottolini MC. Ambulatory Peds Mar-Apr 2001
Asking about herbs
Do we really need to ask?

   458 VA patients (Pittsburgh, LA)
   43% taking herbs/supplements plus
    medications
   2% at risk for serious adverse event
   42-48% at risk for minor adverse events
   59-88% never asked by physicians about
    use



Glassman P. quoted in Family Practice News. June 15, 2000.
Regulations

   Federal Trade Commission (FTC)
   Food & Drug Administration (FDA)
Role of FTC

   FTC governs the advertising and
    promotion of herbs and dietary
    supplements. It can:
    – Outlaw unfair or deceptive practices
    – Stop unsubstantiated advertising
    – Investigate complaints and seek civil
      penalties for violations of trade
      regulations
Role of FDA
   Stop the marketing of toxic or unsanitary
    products
   Stop the marketing of products with false or
    unsubstantiated claims
   Take action against a product which poses “ a
    significant unreasonable risk of illness or
    injury”
   Prohibit claims that a product cures or treats
    a disease
   Stop the marketing of a new (post 1994)
    dietary ingredient if safety data is lacking
Case study: Ephedra

   Ephedra HWLDS - 0.95 kg lost/mo
   Ephedrine alone - 0.5 kg lost/mo
   Ephedrine/caffeine combo - 1.0 kg
    lost/mo

   Ephedrine/caffeine modest dose
    response effect over multiple trials
                                  Rand Meta-analysis
Ephedra/Ephedrine Safety

   RCTs - no serious adverse effects
   Sentinel events: MI, CVA, seizures, &
    psychiatric cases.
   Adverse events reports
    – Ephedra - 21 sentinel serious adverse
      events (including 2 deaths)
    – Ephedrine - 11 sentinel events (including
      3 deaths)
                                     Rand Meta-analysis
Expertise – Who has it?
   Consumer/patient
   Clerk in store
   Herbalist – what tradition? How certified?
   Chiropractor (DC)
   Nutritionist (RD)
   Pharmacist (PharmD, PhD)
   Naturopathic Doctor (ND)
   Board Certified Holistic Physician (MD, DO)
   Fellowship-trained Integrative Physician
Evidence

   Traditional use
   Basic science
   Clinical science
Traditional use
   Often based on
    hundreds to thousands
    of years of observation
   60-70% of traditionally
    used herbs are
    pharmacologically
    active
   German Commission E
Traditional
preparations


   Infusion - flowers and leaves steeped
    in hot water, ie, teas
   Decoction - bark, roots or seeds boiled
    in water
   Tincture – extraction with alcohol or
    vinegar or glycerin and water
More preparations
   Capsules
    – dried and ground herbs in a gelatin or
      vegetable capsule
    – dried extract of plant part
   Salve - an oil and beeswax/lanolin
    mixture used topically
Basic Science

   Mechanism of action
   Pharmacokinetics, etc
   Toxicity



   Often done AFTER clinical studies
Clinical Science
Federally funded studies
1.    Echinacea       19
2.    Ginseng         22
3.    Gingko biloba   8
4.    Garlic          48
5.    SJW             28
6.    Peppermint      0
7.    Ginger          9
8.    Soy             >200
9.    Chamomile       1
10.   Kava kava       6
Problems

   Toxicity
   Interactions
   Adverse reactions
Toxicity

   Renal toxicity      Yohimbe
    – Stephania
      (Fang ji)         Liver toxicity
    – Aristolochia        – Chaparral
      (Fang chi)          – Comfrey
                          – Germander
   Lobelia               – Jin Bu Huan
Physician Actions

   Avoid products with multiple herbs
   Consider following LFT’s, BUN, Cr
   Consider herbs in differential
   Obtain samples when problems
    suspected
   Report to MedWatch 1-800-332-1088
Interactions

   St John’s wort
    – Studies - digoxin,
      protease inhibitors,
      TCAs
    – Case reports -
      cyclosporine, warfarin,
      oral contraceptives,
      theophylline, SSRIs
    – Theoretical - iron
Adverse Reactions

   52 y.o. male for R knee replacement
   Surgery went well, some oozing of
    blood
   Continued bleeding post operatively
   Smart medical student saves the day
    – Ginkgo biloba, garlic, green tea
Product Quality

   Genetics, growing conditions,
    harvest time, product preparation

   Misidentification, contamination,
    adulteration
Quality Solutions

 Standardization
 Independent testing
    – www.consumerlab.com
    – www.nsf.org
Searching for answers:
real world work
Health Professional’s Actions

   Honor your patients reasons for usage
   Encourage open communication
   Read about herbal remedies
   Be honest about what you learn
   Avoid criticism
   List herbal remedies in the patient
    chart
    Weigand JM et al, FP Recertification, 22(9):45-62

								
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