Integrative_Medicine_for_the_Office - PowerPoint

Document Sample
Integrative_Medicine_for_the_Office - PowerPoint Powered By Docstoc
					UTMB’s Alternative and Integrative Health Care Program Website
http://atc.utmb.edu/altmed

Integrative Medicine
Using Complementary and Alternative Therapies in Office Practice

Victor S. Sierpina, M.D.
Associate Professor Family Medicine University of Texas Medical Branch

Trends in Alternative Medicine Use in the United States, 1990-1997, Eisenberg, et al, JAMA, Nov 11, 1998; 280 (18); 1569-1575
  

Use of AT in past year now 42% compared to 1990, 34% Seeing an AT practitioner increased to 46% in 1997 from 36% in 1990 Out of pocket expense for all AT $27 billion (same as for all US physician services) in 1997. Comparable figure was $13 billion in 1990

Trends in Alternative Medicine Use in the United States, 1990-1997, Eisenberg, et al, JAMA, Nov 11, 1998; 280 (18); 1569-1575






Number of visits to AT practitioners exceed primary care physician visits 629 million vs. 386 million Biggest increase in use of herbs, massage, megavitamins, self-help groups, folk remedies, energy healing, homeopathy Chronic conditions, back, anxiety, depression, headaches most likely dx’s

National Institutes of Health: National Center for Complementary and Alternative Medicine (NCCAM)



  

Biological Therapies: Nutrition and Lifestyle/Herbal Medicine Mind-Body Therapies Manual Therapies Alternative Systems of Care Bioenergetic Medicine

Basics Every Doc Ought to Learn and Use
  

Mind-Body Therapies

Herbal Medicine
Nutritional therapy and supplements

My Favorite Therapies—stuff you can use every day
 


 



Glucosamine sulfate 1500 mg/d Ginkgo 120-240 mg/d St. John’s Wort 300 mg tid Echinacea 300 mg tid Horse Chestnut 35-70 mg/d aescin Saw Palmetto 160 mg bid

My Favorite Therapies—stuff you can use every day
 





Relaxation therapies Magnets Anti-oxidants Vitamins C (1 gram/d), E 800 IU/d), high intakes (5-7 servings/d) of fruits and vegetables Chromium 200-400 mcg/d

My Favorite Therapies—stuff you can use every day
 


 

Vitamin B6 50-100 mg/d Zinc 15-45 mg/d Magnesium 300-500 mg/d Coenzyme Q10 50-300 mg/d Ginger

Don’t forget the basics
  

Prayer Social support Caring

Some useful referrals
   

Acupuncture Massage Therapy Chiropractic Osteopathic manipulation

  

Biofeedback Hypnosis

Cognitive behavioral therapy

The Relaxation Response
  

A mental focusing device A passive attitude to distracting thoughts Deep, relaxed, abdominal breathing

BREATHE

FOCUS

Basic Steps to Elicit the Relaxation Response
1. Focus word 2. Sit quietly in comfortable position 3. Close your eyes 4. Relax muscles 5. Breath slowly, naturally, repeat focus word 6. Assume passive attitude 7. Continue 10-20 minutes 8. Daily practice 9. When distracting thoughts occur, return to focus word, breathing

Integrative Healthcare: Complementary and Alternative Therapies for the Whole Person

By: Victor S. Sierpina, MD FA Davis Philadelphia, 2001 www.B&N.com www.amazon.com

And for more FUN and Relaxation…..


BIODOT International P.O. Box 2245 Indianapolis, IN 46206 1-800-272-2340  About a dime apiece

The Wellness Book, H. Benson, E. Stuart, Simon and Schuster, 1992

Mind-Body Medicine—A Clinician’s Guide to Psychoneuroimmunology, Watkins, A. Churchill Livingstone, 1997

“Let me through, please— I’m an herbalist!”

Remember


 

FDA neither establishes nor regularly enforces any standards of quality for herbs or other dietary supplements Herbs are technically unapproved drugs, in an OTC limbo Best advice: obtain a standardized extract marketed by a reputable firm

Ginkgo biloba: Dose is 120-240 mg daily
taken in 2-3 doses, 0.5ml tid of extract
Gingkgold/Nature’s Way; Ginkoba/Pharmaton Quanterra/Warner Lambert; Ginkai/Lichtwer

Ginkgo





WHO (1993) Policy Statement--historic use of an herbal is valid form of information on safety and efficacy in the absence of scientific evidence to the contrary Over 120 published studies RDBPC found beneficial effect of Ginkgo Biloba Extract in slowing progression of dementia in Alzheimer’s patients*

*Le Bars PL. et al. JAMA. 1997;278(16):1327-1332

And what about some more science? Studies on Ginkgo


 

Meta-analyses of 100 articles found significant improvement in age-related cognitive function in Alzheimer’s* RDBPC found GB NOT effective in improving sx of mild-mod dementia** Meta-analysis concluded GB is effective for intermittent claudication***

*Kleijnen J. Pharm Weekbl Sci. 1992; 14(6):316-320 and Oken BS. Arch Neurol.1998;55(11):1409-1415 **van Dongen, MCJM. et al. J Am Geriatric Soc., 2000; 48:1183-94 ***Pittler & Ernst, Am J Med. 2000; 108:276-281

St. John’s Wort: Dose 300 mg tid std
extract (0.3%), 3-4 ml tid tincture
Jarsin/Lichter Pharma; Quanterra Emotional Balance/Warner Lambert; Perika/Nature’s Way; Movana/Pharmaton

Studies on St. John’s Wort



Ongoing study at Duke comparing SJW with SSRI’s Cochrane Collaboration review concluded SJW superior to placebo. Could not conclude it was as effective as TCA therapy*

*Linde K, Murrow CD. The Cochrane Library. 4/2000. Oxford: Update Software

Studies on SJW


SJW and fluoxetine equipotent in mildmoderate depression. Much lower sideeffect profile with SJW* SJW found NOT effective in major depression**



*Schrader E. Int Clin Psychopharmacol. 2000;15(23):61-8 **Shelton, R.C. et al. JAMA, 2001;285(15)1978-1986

Echinacea: Dose 300 mg tid, tincture
15-30 gtts qid, or 3-4 cups of tea qd
Echinagard/Nature’s Way

Studies on Echinacea


Review of 26 controlled clinical trials concluded that published clinical studies provide evidence that some preparations can be efficacious as immunomodulators*
9 treatment and 4 prevention RPC trials found Echinacea may be beneficial (dosage and preparation issues?), non-continuous use**



*Melchart D, Linde K. et al. Phytomed. 1994;1:245-254 **Barrett B, Vohmann C. et al. J Fam Pract. 1999;48(8):628-635

Saw palmetto Dosage is 160 mg capsule
bid, 15 gtts of extract bid
Elusan Prostate/Plantes&Medicines ProstActive/Nature’s Way

Studies on Saw Palmetto


Meta-analysis of 7 PC trials showed increase in peak urinary flow and decrease nocturia in BPH over a 3 month period* Compared to finasteride, a 6 month DBPCRCT, 1098 pts showed equally improved BPH sx score and peak urinary flow**



*Lowe F, Robertson C. et al. J Urol. 1998;159:257 (Abstract 986) **Carraro JC, Raynaud JP. et al. Prostate. 1996;29(4):231-240

Horse Chestnut 35-70 mg
aescin/d; Venastat/Pharmaton

Studies on Horse Chestnut


Systematic review of 14 RDBC trials concluded HC superior to placebo in venous disease with mild and infrequent side effects*

*Pittler MH, Ernst E. Arch Dermatol. 1998;134(11):1356-1360

Blumenthal, M, Goldberg A, Brinckman J. 2000. Herbal Medicine— Expanded Commission E Monographs. Boston, MA: Integrative Medicine Communications

Anti-oxidants


Oxidant by-products of normal metabolism result in extensive damage to DNA, proteins and lipids, leading to aging and degenerative diseases including cancer, cardiovascular disease, immunoincompetence, brain dysfunction and cataracts.* Low intakes of fruits and vegetables double the risk of many types of cancer versus high intakes.



*Proc NY. Acad Sci. 1993; 90: 7915-7922

Vitamins C and E


Pretreatment with vitamin C and E prevented a fall in vasodilation which occurred after a high fat meal. No such fall was noted after a low fat meal.*

*Plotnick GD, Corretti MC. et al. Effect of Antioxidant Vitamins on the Transient Impairment of Endothelium-Dependent Brachial Artery VasoActivity Following a Single High-Fat Meal. JAMA.1997;278(20):1682-1686.

Vitamin E


 

High risk CV pts. had “no apparent effect” from Vit E (NEJM, 2000;342:154-60). No significant adverse events Preventive effect suggested in Stampfer, Rimm studies (NEJM, 1993; 328) Intermittent claudication Vit E found useful (Goodwin, Ann Int Med, Nov 1997)

Italian Multicenter Study on the Safety and Efficacy of Coenzyme Q10 as Adjunctive Therapy in Heart Failure*
 

50-150 mg/d orally (avg 100 mg/d) 2664 patients observed over 3 months in open, noncomparative study (preliminary study)

  

>70% improvement in cyanosis, edema, rales, palpitations, vertigo >40% improvement in dyspnea, arrhythmia, insomnia, nocturia Low incidence of side effects 1.5% Treats mitochondrial “fatigue”, energy depletion

*Baggio E, Gandini R. et al. Molec Aspects Med. 1994.15 Suppl:s287-94

Coenzyme Q10


CHF - Stroke index at rest and work improved significantly (p< .05), the pulmonary artery pressure at rest (p< .05) and work decreased and the pulmonary capillary wedge pressure at rest and work decreased (p< .05) with CoQ10 100mg bid*

*Munkholm H, Hansen HH. Coenzyme Q10 treatment in serious heart failure. Biofactors. 1999;9(2-4):285-9

Vitamin B6


27/28 patients diagnosed with idiopathic CTS improved substantially on B6, 100 mg/day vs placebo. ¼ of patients were noted to be pyridoxine-depleted based on serum studies.*

*Carpal Tunnel Nutr Rep Int.1986 34(6):1031-40

Osteoarthritis--glucosamine sulfate, chondroitin sulfate


Drovanti A, Bignamini AA, Rovati AL. Therapeutic activity of oral glucosamine sulfate in osteoarthritis: a placebo-controlled double-blind investigation. Clin Ther 1980;3(4):260-72 Morreale P, et al. Comparison of the antiinflammatory efficacy of chondroitin sulfate and diclofenac sodium in patients with knee osteoarthritis. J Rheumatol 1996; 23: 1385-91.



Recent studies on Glucosamine


McAlindon, TE, et al. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 283(11): 1483-84. Feb 2000
RPC study showed reduction in cartilage loss and symptoms of OA over a 3 yr period in 106 pts (Reginster, Jan 2000 Lancet)



General Guidelines for Advising Patients Who Seek Alternative Medical Therapies

Ask, don’t tell  Be willing to learn  Communicate, Collaborate  Diagnose  Explain and Explore options/preferences


Ask the Unasked Questions
   

“What, if any, alternative therapies have you tried for this problem?” “Considered?” “Have questions about?” “Besides these prescriptions, are you taking any over the counter products, supplements, or herbs?”

Recommendations
 




Maintain open communication with your patients An open mind doesn’t mean you always say “yes”...but don’t always say “no” Short learning curve (30 hours of reading) to become familiar with alternative therapy Check our website for resources

Therefore….


Learn enough to be able to converse and consult with patients regarding
  

beneficial vs. harmful therapies interactions with conventional therapy appropriate referral when conventional therapy is not working

 

Consider this area as a practice builder, source of referrals, new patients Offers options when conventional therapies have been exhausted

UTMB’s Alternative and Integrative Health Care Program Website
http://atc.utmb.edu/altmed

Evidence Based Curriculum in Alternative Therapies
   

UTMB received a 5 year grant for $1.5 million to develop a core curriculum in AT Will include focus on evidence, communication, life-long learning skills Target audiences: medical, nursing, allied health students, house staff Faculty and community preceptors/CME

Integrative Healthcare: Complementary and Alternative Therapies for the Whole Person

By: Victor S. Sierpina, MD FA Davis Philadelphia, 2001 www.B&N.com www.amazon.com

Other Useful References


Novey DW. 2000. Clinician’s Complete Reference to Complementary/Alternative Medicine. St. Louis: Mosby
Dossey, L. 1999. Reinventing Medicine—Beyond Mind-Body to a New Era of Healing. San Francisco:Harper Collins



References
 


Murray M, Pizzorno J. 1998. Encyclopedia of Natural Medicine. Rocklin, CA: Prima. PDR for Herbal Medicines. 2000. Montvale, NJ: Medical Economics Co.
Jonas WB, Levin JS (eds). 1999. Essentials of Complementary and Alternative Medicine. Philadelphia: Lippincott, Williams & Williams

References






Rosenfeld I. 1996. Dr. Rosenfeld’s Guide to Alternative Medicine—What Works, What Doesn’t—And What’s Right For You. New York: Random House. Pressman AH, Buff S. 1999. The Complete Idiot’s Guide to Alternative Medicine. New York: Alpha Books. Dillard J, Ziporyn T. 1998. Alternative Medicine for Dummies. Foster City, CA: IDG Books Worldwide, Inc.

References


 

Wirth S (ed) 1999. Integrative Medicine—A Balanced Account of the Data. Ukiah, CA: Boitumelo Publishing Inc. Kemper KJ. 1996.The Holistic Pediatrician. New York: Harper Collins Alternative Therapies in Health and Medicine. Published by the Innovision Communications, 101 Aliso Viejo, CA 92656 800-899-1712; bimonthly peer reviewed journal.

UTMB’s Alternative and Integrative Health Care Program Website
http://atc.utmb.edu/altmed


				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:18
posted:9/30/2008
language:English
pages:67