alternative medicine and the elderly common herbal therapies matthew faiman, md, mba

Alternative Medicine and the ElderlyCommon Herbal Therapies

Matthew Faiman, MD, MBA

• Introduction• Why Patients use Alternative Medicine• Specific Therapies

• St.John’s Wort • Echinacea • Garlic • Ginger • Anti-oxidants • Ginkgo Biloba

Why Patient’s Use Alternative Medicine

Definition(1): • do not conform to standards of mainstream community• receive little attention in medical schools• not commonly reimbursed by health insurance plans

(1) Ness et al. Alternative Medicine: What the data say about common medical therapies. Geriatrics;1999; 54(10) 33-43.


• Who uses alternative medicine?• Eisenberg et al(1). Two surveys 1990 & 1997 • embraced by all segments of the population • 1990 est. 60 million persons used at least 1 of 16 alternative therapies • 1997 f/u increased to 83 million adults • largest increase in use of herbal medicine, massage, megavitamins, self-help groups,

folk remedies and homeopathy(1) Eisenberg et al. Trends in Alt. Medicine in the US 1990- 1997. JAMA 1998;280: 1569-2575


• 1990- 22 million saw an alternative medicine practitioner vs. 1997- 39 million. Equals 628 million visits compared to 385 million to PCP• out of pocket costs est. $34 billion• particular increase seen in use of St. John’s Wort and Ginkgo Biloba• age > 65 not well investigated but

epidemiology reviewed and there is support in both males and females


• Astin investigated possible predictors of alternative health care (1) • tested 3 hypotheses: alternatives were sought out because: 1) dissatisfaction with conventional treatment 2) alternatives provide more personal

autonomy and control 3) alternatives more compatible with patient’s

values or beliefs regarding the nature of health and illness

(1) Astin. JAMA 1998;279 (19) 1548-1553.


Results: Predictors included: • being more educated (OR 1.2) • classified in subculture “cultural creatives” (1.95) • having a transformational experience (1.76) • poorer overall health (1.32) • believing in importance of body, mind, and spirit in treating health problems (1.42) • health problems: anxiety (3.13), back problems(2.3), chronic pain(1.98), or UTI (2.16)


Comments: • negative attitudes toward conventional

medicine was not a predictor • Age or Income not a predictor • Future studies to delineate those who use

alternative medicine in conjunction with conventional medicine vs. those using alt. medicine exclusively

St. John’s Wort• hypericum perforatum- herb• approved in Germany and is best selling anti- depressant• hypericin is the most active ingredient• mechanism- inhibition of uptake of, serotonin, NE and dopamine• Seven trials reviewed in meta-analysis: • heterogeneous populations, diff. Degree of

depression, 4-8 week therapy (short duration), dosage differences

• comparative trials used TCA (in lower than usual dose)

St. John’s Wort

• no specific studies in the elderly-- small subsets with limited analysis• Recommendation: Hypericin vs. SSRI• Dosage: 300 mg (LI160 extract used in Germ)but not available in US• Side Effects: dry mouth, dizziness, fatigue, constipation, and nausea

• contraindicated with SSRI- risk of serotonergic syndrome

Echinacea• echinacea- members of the daisy family (9 species)• Rx derived from 3 species E.angustifolia, E. pallida and E. purpurea.• believed to act as a non-specific stimulant of the immune system and aid in wound healing• most commonly used for URI, colds/influenza• also approved for UTIs in Germany• Study: 3-arm, RDB, PCT n= 302 for 12 mos.• Main outcome: time until first URTI• Results: no significant difference in time to first

URI though participants believed they

Echinacea

derived more benefit than placebo • Grimm and Muller N =108, patients received 4ml E. purpurea with 8 weeks f/u----> no sig. Difference• Side Effects: generally well-tolerated, possibility of anaphylaxis. Contraindicated in autoimmune disorders--- AIDS and TBDosage: in US, 8-9 ml of juice in hydroalcoholic preparation• there are no studies in the elderly available

Garlic

• Allium sativum (allicin) has been used for thousands of years• Popular attention on its lipid lowering effect.•1994 British study meta-analysis pooled results of 16 trials.• Results: decrease in TC- 12%. Decrease in TG but only by dried garlic powder with standardized allicin content• no effect on HDL or LDL• no study on mortality or cardiovascular morbidity

Garlic

other uses: hypertension- limited evidence- possible decreased risk of gastric CADose:600-900 mg/d garlic powder approx. one medium sized clove of fresh garlic• no studies in geriatric population• benign side effects -------> hallitosis

Ginger• Zingiber officinale believed to be effective against nausea, vomiting, motion sickness and vertigo but limited evidence• 2 randomized PCT ineffective in post-op nausea and vomiting in patients undergoing laparoscopic gyne procedures• Tested also in sea-sickness in RCT 80 naval officers• decreased vomiting and sweating better than placebo

Ginger

• clearly not geriatric population studied and extrapolation would be premature.• Dose: motion sickness 500 mg capsule. 2 caps prior to departure than 1 PO q4h prn• Side effects: may alter bleeding time.

Antioxidants • Vitamin E and Selegiline• studies involving AD reveal multifactorial and much interest in reactive oxygen species, free radicals specifically re: lipid peroxidation causing neuronal degeneration• delicate balance between free radical conversion and elimination• other hypotheses: catabolism of dopamine----> free radicals• glutamate and amyloid B protein accumulation• Antioxidants include Vit. E,C,A, selegiline, Coenzyme Q and superoxide dismutase

Antioxidants• Alzheimer’s Disease Cooperative Study eval. High dose Vit E (1000 IU bid) and Selegiline 5 mg bid in slowing progression of AD• primary endpt.: death, institutionalization, loss of 2/3 basic ADL or progression to severe dementiaResults: no significant difference from placebo.Other endpoints: Vit E increased time to nursing home placement.Drawbacks: randomization imbalance, baseline MMSE differed• Dosage: Safe drug. Dosage higher than 300 IU

AntioxidantsIU/d associated with H/A, weakness, bleeding and increased cholesterolOther Issues:

• optimal dose/duration of Vit E in AD• combination with other antioxidants Vit A/C, coenzyme Q unknown• HOPE trial 400 IU/d N=9541 for 4.5 years found no difference re: cardiac outcomes

Ginkgo Biloba• living fossil tree around for approx. 200 million years• cultivated for its nut and its leaves• Ginkgo (Chinese for Yin-Kuo “ silver apricots”) Biloba (referring to its two-lobed fan shaped leaves)• preparations used for medicinal purposes contain 24% gingko-flavone glycosides and 6% terpenoids. The terpenoids include bilobalide and gigkolides a,b,c,m,and j.• gingkolides are antagonists of platelet-activating factor

Ginkgo• PAF’s biologic effects include platelet aggregation and smooth muscle contraction.• Flavonoids thought to contribute to antioxidant and free radical scavenger effects• Extract of GB referred to as EGB761• approved in Germany for treatment of dementia• dozens of articles from French and German lit.• Faults: majority contained the diagnosis: “cerebral insufficiency”- broad category including depressed mood, fatigue, lack of motivation, dizziness and tinnitus

Ginkgo• Le Bars et al (1): study GB in dementia• 52 week, DB, PCT, multicentre study involving 202 mild-moderate dementia. Mean age = 69.• EGB761 120 mg/d divided tid.• objective measures: ADAS-Cog

- Alzheimer’s Disease-Assesment Scale- Cognitive subscale

Results: improved ADAS-Cog by 1.4 points (p<.01) compared with 2.5 points seen with Aricept dose 5 mg(1) Le Bars et al. A Placebo-Controlled, Double Blind, Randomized Trial of an Extract of GB for Dementia JAMA; 1997;278(16): 1327-1332

Ginkgo• Issues: high dropout rate at 52 weeks (50%), better educated• Oken et al.: Meta-analysis of all articles, 4 summarized• Modest effect but statistically significant (p< .001)• Side Effects: nonspecific GI complaints

• 3 reports: 2 subdural hematomas and 1 Intracebebral Hemorrhage

Oken et al. Efficacy of GB on Cognitive Function in AD Arch Neurology. 1998;55; 1409-1415.

Ginkgo

Contraindications: antiplatelet and anticoagulants.• Other uses: 2 well conceived trials studied Intermittent Claudication. Findings: decrease pain and increase distance of walking.

Dosage: unknown. Standardized preparation (Quintera brand) now available in the US.

Conclusions• Alternative medicine use is increasing over time.• Physicians need to be aware of patient’s use mof OTC meds in history taking, esp. anti-platelet and anticoagulants.• drug-drug interactions• much research still needs to be done in this field especially in the elderly.• It is in its infancy

alternative medicine and the elderly common herbal therapies matthew faiman, md, mba

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