Chief’s ConferenceChief’s Conference

Herbal Supplements: Herbal Supplements: A to ZA to Z

Katina Robertson, MDKatina Robertson, MD

Emory University Family Medicine ProgramEmory University Family Medicine Program

Thursday, January 7, 2010Thursday, January 7, 2010

AAloe Veraloe VeraAloe vera, Aloe barbadensisAloe vera, Aloe barbadensis

► Common Names Common Names —aloe vera, burn plant, lily —aloe vera, burn plant, lily of the desert, elephant's gallof the desert, elephant's gall

►HistoryHistory: used in Ancient Egypt– “plant of : used in Ancient Egypt– “plant of immortality”. Presented as burial gifts to immortality”. Presented as burial gifts to deceased pharaohsdeceased pharaohs

► Leaves contain clear gel often used Leaves contain clear gel often used topicallytopically►Oral preparation Oral preparation (juice or dried substance (juice or dried substance

“latex”) from inner lining of green leaves“latex”) from inner lining of green leaves

AAloe Veraloe VeraUsesUses► Constipation– strong Constipation– strong

laxative properties: laxative properties: aloin, aloe-emodin and aloin, aloe-emodin and barbaloinbarbaloin

► Genital Herpes– Genital Herpes– hydrophyllic cream hydrophyllic cream prepprep

► Psoriasis VulgarisPsoriasis Vulgaris► Seborrheic DermatitisSeborrheic Dermatitis► Aphthous stomatitis Aphthous stomatitis

“canker sores”“canker sores”► DM type IIDM type II

► Lichen PlanusLichen Planus► Skin burnsSkin burns► Wound healingWound healing► Ulcerative Colitis– Ulcerative Colitis– 2004 2004

randomized, placebo controlled randomized, placebo controlled trial. 44 patients, 100mL BID x trial. 44 patients, 100mL BID x 4wks. 30% vs 7% had clinical 4wks. 30% vs 7% had clinical remission and 37% vs 7% had remission and 37% vs 7% had clinical improvement.clinical improvement.

AAloe Veraloe Vera

Adverse EventsAdverse Events► Diarrhea, GI upsetDiarrhea, GI upset► HypoglycemiaHypoglycemia in combination with oral in combination with oral

diabetes medsdiabetes meds► case report of aloe vera induced case report of aloe vera induced hepatitishepatitis in in

Des Moines, Iowa VAMC Des Moines, Iowa VAMC (Annals of Pharm, 2007)(Annals of Pharm, 2007)

► In 2002, FDA required that all OTC aloe laxative products In 2002, FDA required that all OTC aloe laxative products be removed from the U.S. market or reformulated because be removed from the U.S. market or reformulated because the companies that manufactured them did not provide the companies that manufactured them did not provide the necessary safety datathe necessary safety data

BBlack Cohoshlack Cohoshactaea racemosa or Cimifuga racemosaactaea racemosa or Cimifuga racemosa

► Common NamesCommon Names: black snakeroot, bugbane, bugwort, : black snakeroot, bugbane, bugwort, rattleroot, rattletop, rattleweed, and macrotys-- Insects rattleroot, rattletop, rattleweed, and macrotys-- Insects avoid itavoid it

► HistoryHistory: Native American medicine – malaise, Gyn d/o, : Native American medicine – malaise, Gyn d/o, kidney d/o, malaria, rheumatism and sore throat. 19kidney d/o, malaria, rheumatism and sore throat. 19thth century home remedy, diuretic, and to cause century home remedy, diuretic, and to cause menstruationmenstruation

► Member of Member of buttercupbuttercup family, perennial plant in N. family, perennial plant in N. AmericaAmerica

► Oral preparation are from the Oral preparation are from the rootsroots and and rhizomesrhizomes (underground stem)– (underground stem)– RemifeminRemifemin most well studied prep most well studied prep

BBlack Cohoshlack Cohosh► Use: primarily hot flashes, post-menopausal sxsUse: primarily hot flashes, post-menopausal sxs► ? Estrogenic properties? Estrogenic properties► Evidence: None consistentEvidence: None consistent

o Kupperman Index-Kupperman Index-- measures of hot flashes, depression and - measures of hot flashes, depression and insomnia (not vaginal dryness)insomnia (not vaginal dryness)

o German study: 60 women s/p hysterectomy. Compare 8 mg/d of a German study: 60 women s/p hysterectomy. Compare 8 mg/d of a black cohosh extract version of Remifemin with three estrogen black cohosh extract version of Remifemin with three estrogen regimens: regimens: estriol (1 mg/day), (1 mg/day), conjugated estrogens (1.25 mg/day), (1.25 mg/day), and estrogen-and estrogen-progestin (2 mg (2 mg estradiol / 1 mg / 1 mg norethisterone acetate) for 6mo. In all groups modified Kupperman ) for 6mo. In all groups modified Kupperman index was significantly lower at 4, 8, 12, and 24 wks post Tx. Black index was significantly lower at 4, 8, 12, and 24 wks post Tx. Black cohosh decreased symptoms similarly to the other treatments.cohosh decreased symptoms similarly to the other treatments.

o NCCAM NCCAM (Natl Center on Complimentary and Alternative Medicine)–(Natl Center on Complimentary and Alternative Medicine)–currently currently funding 12-month, RPCT on whether black cohosh is effective in funding 12-month, RPCT on whether black cohosh is effective in reducing the frequency /intensity of menopausal sxs , improve QOLreducing the frequency /intensity of menopausal sxs , improve QOL

BBlack Cohoshlack Cohosh► Not regulated by FDA, compositions vary greatlyNot regulated by FDA, compositions vary greatly► Common Common adverse effectsadverse effects: headaches, gastric complaints, : headaches, gastric complaints,

heaviness in legs, weight gainheaviness in legs, weight gain► Case reports of acute hepatitis (one requiring liver transplant Case reports of acute hepatitis (one requiring liver transplant

3 wks after starting the herb)3 wks after starting the herb)► U.S. Pharmacopeia (the standards-setting organization for U.S. Pharmacopeia (the standards-setting organization for

foods and drugs) advises black cohosh products be labeled foods and drugs) advises black cohosh products be labeled with : "with : "Discontinue use and consult a healthcare practitioner if Discontinue use and consult a healthcare practitioner if you have a liver disorder or develop symptoms of liver you have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundicetrouble, such as abdominal pain, dark urine, or jaundice" "

► Relative contraindication if liver dz, breast cancer, pregnantRelative contraindication if liver dz, breast cancer, pregnant► No published studies beyond 6 mos of useNo published studies beyond 6 mos of use

o If estrogenic-- long term effects on uterine tissue and CV risk?If estrogenic-- long term effects on uterine tissue and CV risk?

CCarnitinearnitine► Generic term for compounds that Generic term for compounds that

include include L-carnitineL-carnitine, , acetyl-L-acetyl-L-carnitinecarnitine, and , and propionyl-L-carnitinepropionyl-L-carnitine

► Found in most cells in body… Found in most cells in body… ► Main Role: transport long-chain Main Role: transport long-chain

FAs into mitochondria for FAs into mitochondria for oxidization.oxidization.

► Concentrated in Concentrated in skeletalskeletal and and cardiaccardiac musclemuscle that utilize FAs for that utilize FAs for energyenergy

► Healthy children and adults DO Healthy children and adults DO NOT need to consume carnitine NOT need to consume carnitine from food/ supplements, as the from food/ supplements, as the liverliver and and kidneyskidneys produce produce sufficient amounts from the AAs sufficient amounts from the AAs lysinelysine and and methioninemethionine to meet to meet daily needsdaily needs

► Animal products like meat, fish, Animal products like meat, fish, poultry, and milk are the best poultry, and milk are the best sources. sources.

► Adult diet– 60-180mg/dAdult diet– 60-180mg/d

Food Milligrams (mg)

Beef steak, cooked, 4 ounces

56-162

Ground beef, cooked, 4 ounces

87-99

Milk, whole, 1 cup 8

Codfish, cooked, 4 ounces 4-7

Chicken breast, cooked, 4 ounces

3-5

Ice cream, ½ cup 3

Cheese, cheddar, 2 ounces 2

Whole-wheat bread, 2 slices 0.2

Asparagus, cooked, ½ cup 0.1

Kidneys efficiently conserve carnitine, so even carnitine-poor diets have little impact on the body's total carnitine content

CarnitineCarnitine► FDA approved to treat carnitine deficiencies onlyFDA approved to treat carnitine deficiencies only

Primary-- genetic d/o manifests w/ cardiomyopathy, Skeletal muscle weakness, Primary-- genetic d/o manifests w/ cardiomyopathy, Skeletal muscle weakness, hypoglycemiahypoglycemia

Secondary– renal dz or drugs (chemotx, antiseizure, pivampicillin) that reduce Secondary– renal dz or drugs (chemotx, antiseizure, pivampicillin) that reduce absorption/increase excretionabsorption/increase excretion

► Other UsesOther Uses Athletic performanceAthletic performance– no evidence it improves exercise/physical performance– no evidence it improves exercise/physical performance AgingAging– decline in mitochondrial function thought to contribute to aging, – decline in mitochondrial function thought to contribute to aging,

carnitine decreases with age. Meta-analysis of PCT- DB suggests acetyl-L-carnitine decreases with age. Meta-analysis of PCT- DB suggests acetyl-L-carnitine may reduce deterioration in older adults with mild cognitive carnitine may reduce deterioration in older adults with mild cognitive impairment from Alzheimer's disease . Subjects took 1.5-3.0 grams/day of impairment from Alzheimer's disease . Subjects took 1.5-3.0 grams/day of acetyl-L-carnitine for 3-12 months.acetyl-L-carnitine for 3-12 months.

CV D and PVDCV D and PVD DM type II-DM type II-- recent analysis of two multicenter clinical trials of subjects with - recent analysis of two multicenter clinical trials of subjects with

either type 1 or type 2 diabetes found Tx with acetyl-L-carnitine (3 g/day either type 1 or type 2 diabetes found Tx with acetyl-L-carnitine (3 g/day orally) for one year provided significant relief of nerve pain and improved orally) for one year provided significant relief of nerve pain and improved vibration perception in those with diabetic neuropathy. The treatment was vibration perception in those with diabetic neuropathy. The treatment was most effective in subjects with type 2 diabetes of short duration. most effective in subjects with type 2 diabetes of short duration. Diabetes Diabetes Care 2005;28:96-101Care 2005;28:96-101

Male infertilityMale infertility ESRD and HD patients ESRD and HD patients (studies small, not PCT or blinded)(studies small, not PCT or blinded)

CCarnitinearnitine► At doses of 3g/day or more… adverse eventsAt doses of 3g/day or more… adverse events Nausea/vomitingNausea/vomiting Abdominal crampsAbdominal cramps DiarrheaDiarrhea ““fishy” body odorfishy” body odor Muscle weakness in uremic ptsMuscle weakness in uremic pts ? Lower seizure threshold? Lower seizure threshold

DDandelionandelionTaraxacum officinaleTaraxacum officinale

► Common NamesCommon Names— dandelion, lion's tooth, — dandelion, lion's tooth, blowballblowball

► Dandelion greens are great source of Vitamin ADandelion greens are great source of Vitamin A► HistoricallyHistorically– used in Native American and – used in Native American and

traditional Arabic medicine to treat liver, spleen, traditional Arabic medicine to treat liver, spleen, kidney diseasekidney disease

► Leaves are dried to make Leaves are dried to make teasteas, , capsulecapsule, , extractsextracts► Today, used as Today, used as diureticdiuretic and for and for minor digestive minor digestive

problemsproblems► No evidence No evidence for use to treat any conditionfor use to treat any condition► Side Effects: generally safe, rare reports of GI Side Effects: generally safe, rare reports of GI

upset, diarrheaupset, diarrhea

EEchinaceachinacea Echinacea purpurea, Echinacea angustifolia Echinacea purpurea, Echinacea angustifolia

► Common NamesCommon Names— echinacea, purple coneflower, — echinacea, purple coneflower, coneflower, American coneflowerconeflower, American coneflower

► Believed to stimulate the Believed to stimulate the immune systemimmune system► Traditionally used to treat/prevent Traditionally used to treat/prevent URIURI or viral or viral

syndromessyndromes. Less commonly for . Less commonly for boils/acneboils/acne► Plant and roots are dried to make teas, squeezed Plant and roots are dried to make teas, squeezed

juice, extracts or preps for topical usejuice, extracts or preps for topical use► No evidence No evidence for use to treat any conditionfor use to treat any condition► Side Effects: if taken orally– Side Effects: if taken orally– allergic rxns allergic rxns (rash, (rash,

anaphylaxis), anaphylaxis), asthmaasthma flare. Worse in those with flare. Worse in those with atopy and allergies to daisy family (ragweed, atopy and allergies to daisy family (ragweed, chrysanthemums, marigolds, etc)chrysanthemums, marigolds, etc)

FFlaxseed/laxseed/FFlaxseed Oillaxseed OilLinum usitatissimumLinum usitatissimum

► Common NamesCommon Names— flaxseed, linseed— flaxseed, linseed► UsesUses: :

Flaxseed itself contains Flaxseed itself contains lignanslignans ( (phytoestrogensphytoestrogens, or plant , or plant estrogens): laxative, hot flashes, breast painestrogens): laxative, hot flashes, breast pain

Flaxseed oil preparations lack lignans- arthritisFlaxseed oil preparations lack lignans- arthritis Both-- hyperlipidemia, cancer prevention.Both-- hyperlipidemia, cancer prevention.

► Contains soluble Contains soluble fiberfiber► Whole or crushed flaxseed can be mixed with H2O or Whole or crushed flaxseed can be mixed with H2O or

juice. Also in powder and capsule form.juice. Also in powder and capsule form.► Some studies suggest: alpha-linolenic acid (found in Some studies suggest: alpha-linolenic acid (found in

both) may benefit people w/ CAD. No consistent data.both) may benefit people w/ CAD. No consistent data.► Rare side effects: b/c fiber source, take w/ water to Rare side effects: b/c fiber source, take w/ water to

prevent constipation or intestinal blockageprevent constipation or intestinal blockage

GGinkgoinkgoGinkgo bilobaGinkgo biloba

► Common NamesCommon Names— — ginkgo, ginkgo, Ginkgo bilobaGinkgo biloba, fossil tree, maidenhair , fossil tree, maidenhair tree, Japanese silver apricot, baiguo, bai guo ye, kew tree, yinhsingtree, Japanese silver apricot, baiguo, bai guo ye, kew tree, yinhsing

► ginkgo tree- one of oldest types of trees in the worldginkgo tree- one of oldest types of trees in the world► Ginkgo seeds- used in traditional Chinese medicine for Ginkgo seeds- used in traditional Chinese medicine for

thousands of years. Cooked seeds occasionally eaten.thousands of years. Cooked seeds occasionally eaten.► Leaf extracts Leaf extracts tablets/capsules, teas, skin products tablets/capsules, teas, skin products► UsesUses: :

Traditionally- asthma, bronchitis, fatigue, tinnitusTraditionally- asthma, bronchitis, fatigue, tinnitus Today-Today- improve memory (Alzheimer’s, dementia), intermittent improve memory (Alzheimer’s, dementia), intermittent

claudication, sexual dyfunction, multiple sclerosis, tinnitusclaudication, sexual dyfunction, multiple sclerosis, tinnitus

GGinkgoinkgoGinkgo bilobaGinkgo biloba

► EvidenceEvidence Ginkgo biloba for Prevention of Dementia Ginkgo biloba for Prevention of Dementia studystudy (JAMA 2008) (JAMA 2008)

► RPCT-DBRPCT-DB5 academic ctrs betw 2000-2008, 3,069 elderly pts age ≥ 75 with 5 academic ctrs betw 2000-2008, 3,069 elderly pts age ≥ 75 with normal cognition or mild cognitive impairment (MCI)normal cognition or mild cognitive impairment (MCI)

► placebo vs 120mg G biloba extract BIDplacebo vs 120mg G biloba extract BID► Q6 month eval x median 6.1 yrs . Primary outcomeQ6 month eval x median 6.1 yrs . Primary outcome incident dementia or AD incident dementia or AD► Ineffective in slowing cognitive decline.Ineffective in slowing cognitive decline. 246 (placebo) vs 277 (receiving 246 (placebo) vs 277 (receiving G G

biloba)biloba)

Ginkgo for Memory Enhancement- Ginkgo for Memory Enhancement- Six-week RPCT- DB. 203 pts Six-week RPCT- DB. 203 pts age ≥ 60 without cognitive impairment. Results- No improvement age ≥ 60 without cognitive impairment. Results- No improvement in performance on standard neuropsych tests of learning, in performance on standard neuropsych tests of learning, memory, attention, concentration, naming or verbal fluency (JAMA memory, attention, concentration, naming or verbal fluency (JAMA 2002)2002)

NCCAM future studies- asthma, MS, intermittent claudication, NCCAM future studies- asthma, MS, intermittent claudication, cognitive decline, sexual dysfunction 2/2 antidepressants, and cognitive decline, sexual dysfunction 2/2 antidepressants, and insulin resistanceinsulin resistance

IS IT OK TO TAKEIS IT OK TO TAKE… … CAN’T HURT CAN’T HURT …. …. CAN ITCAN IT??

GGinkgoinkgoGinkgo bilobaGinkgo biloba

► Side EffectsSide Effects Headache, nausea, GI upset, diarrhea, dizziness, Headache, nausea, GI upset, diarrhea, dizziness,

allergic reactionsallergic reactions some data suggest some data suggest increase bleeding risk. Use increase bleeding risk. Use

caution in people on anticoagulant drugs, w/ caution in people on anticoagulant drugs, w/ bleeding d/o, or who have scheduled surgical or bleeding d/o, or who have scheduled surgical or dental proceduresdental procedures

Uncooked ginkgo seeds contain a chemical Uncooked ginkgo seeds contain a chemical known as known as ginkgotoxinginkgotoxin, which can cause , which can cause seizures. Consuming large quantities of seeds seizures. Consuming large quantities of seeds over time can cause over time can cause DEATHDEATH!! !!

Ginkgo leaf and ginkgo leaf extracts appear to Ginkgo leaf and ginkgo leaf extracts appear to contain little ginkgotoxincontain little ginkgotoxin

HHorse Chestnutorse Chestnut Aesculus hippocastanum Aesculus hippocastanum

► Common NamesCommon Names— horse chestnut, buckeye, Spanish chestnut— horse chestnut, buckeye, Spanish chestnut► native to Balkan Peninsula, but grows throughout N. native to Balkan Peninsula, but grows throughout N.

HemisphereHemisphere► Used for centuries for many diseases, NOW used to treat Used for centuries for many diseases, NOW used to treat

chronic chronic venous insufficiency venous insufficiency and and hemorrhoidshemorrhoids► seed extract seed extract standardized to contain standardized to contain 16 to 20 % aescin 16 to 20 % aescin

(escin), (escin), the active ingredient, is the most commonly used the active ingredient, is the most commonly used form. Also topical forms.form. Also topical forms.

► Small studies have found extract comparable to using Small studies have found extract comparable to using compression stockings for venous insufficiencycompression stockings for venous insufficiency

► RisksRisks Homemade preparations of horse chestnut should NOT be used. Homemade preparations of horse chestnut should NOT be used.

Raw horse chestnut seeds, leaves, bark, and flowers contain Raw horse chestnut seeds, leaves, bark, and flowers contain esculinesculin, which is , which is poisonouspoisonous

When properly processed, extract contains little or no esculin. Can When properly processed, extract contains little or no esculin. Can cause cause itching, nausea, GI upsetitching, nausea, GI upset

KKavaava Piper methysticum Piper methysticum

► Common NamesCommon Names— — kava, kava kava, awa, kava pepperkava, kava kava, awa, kava pepper► Native to islands of the S. Pacific --member of pepper Native to islands of the S. Pacific --member of pepper

family family ► Used as ceremonial beverage in S. Pacific for centuries. Used as ceremonial beverage in S. Pacific for centuries. ► In past for fatigue, asthma, UTI, topical anesthetic. In past for fatigue, asthma, UTI, topical anesthetic.

NOW used to treat chronic NOW used to treat chronic anxiety, insomnia, anxiety, insomnia, and and menopausal sxs.menopausal sxs.

► root and rhizome (underground stem) -used to prepare root and rhizome (underground stem) -used to prepare beverages, extracts, capsules, tablets, and topical beverages, extracts, capsules, tablets, and topical solutionssolutions

► Little evidence that it is efficacious in any diseases: ?Little evidence that it is efficacious in any diseases: ?anxiety Tx anxiety Tx

AND…AND…

KKavaava Piper methysticum Piper methysticum

► Risks >> BenefitsRisks >> Benefits Kava has been reported to cause Kava has been reported to cause liver damageliver damage, including , including

hepatitis and liver failurehepatitis and liver failure

associated with several cases of associated with several cases of dystoniadystonia (abnormal muscle (abnormal muscle spasm)spasm)

interact with several drugs, including anti-Parkinson's medsinteract with several drugs, including anti-Parkinson's meds

Long-term and/or heavy use of kava may result in Long-term and/or heavy use of kava may result in scaly, scaly, yellowed skinyellowed skin

Avoid driving/operating heavy machinery – can cause Avoid driving/operating heavy machinery – can cause drowsinessdrowsiness

LLicorice Rooticorice Root Glycyrrhiza glabra, Glycyrrhiza uralensis Glycyrrhiza glabra, Glycyrrhiza uralensis

► Common NamesCommon Names— — licorice root, licorice, liquorice, sweet licorice root, licorice, liquorice, sweet root, gan zao (Chinese licorice)root, gan zao (Chinese licorice)

► Grown mostly in Greece, Turkey, and Asia. Long h/o use in Grown mostly in Greece, Turkey, and Asia. Long h/o use in both Eastern and Western Medicine– both Eastern and Western Medicine– stomach ulcers, stomach ulcers, bronchitis, sore throat, viral infxns – including Hep Cbronchitis, sore throat, viral infxns – including Hep C

► contains a compound called glycyrrhizin (or glycyrrhizic contains a compound called glycyrrhizin (or glycyrrhizic acid)acid)

► Peeled licorice root - available in dried and powdered forms. Peeled licorice root - available in dried and powdered forms. Also root in capsule, tablet and liquid extracts formAlso root in capsule, tablet and liquid extracts form

► Licorice can be found with glycyrrhizin removedLicorice can be found with glycyrrhizin removed called called DGLDGL ("deglycyrrhizinated licorice“)- thought to have fewer ("deglycyrrhizinated licorice“)- thought to have fewer side effectsside effects

► Some evidence glycyrrhizin may reduce complications from Some evidence glycyrrhizin may reduce complications from hepatitis Chepatitis C

BUT…BUT…

LLicorice Rooticorice Root Glycyrrhiza glabra, Glycyrrhiza uralensis Glycyrrhiza glabra, Glycyrrhiza uralensis

► RisksRisks:: In large amountsIn large amounts licorice containing glycyrrhizin can licorice containing glycyrrhizin can

cause cause HTNHTN, , salt and water retentionsalt and water retention, and , and hypokalemiahypokalemia

safety of using licorice as a supplement for more than 4 - 6 safety of using licorice as a supplement for more than 4 - 6 weeks has not been thoroughly studiedweeks has not been thoroughly studied

Taking licorice together with diuretics or other meds that Taking licorice together with diuretics or other meds that reduce potassium levels can cause reduce potassium levels can cause severe hypokalemiasevere hypokalemia

May interact with May interact with corticosteroidscorticosteroids

May increase risk of May increase risk of preterm laborpreterm labor

MMilk Thistleilk Thistle Silybum marianum Silybum marianum

► Common NamesCommon Names— milk thistle, Mary thistle, holy thistle, — milk thistle, Mary thistle, holy thistle, silymarinsilymarin

► Native to Mediterranean- used for thousands of yrs to treat Native to Mediterranean- used for thousands of yrs to treat many ailments, especially liver problemsmany ailments, especially liver problems

► Believed to have protective effects on liver & to improve liver Believed to have protective effects on liver & to improve liver fx, NOW used to treat fx, NOW used to treat liver cirrhosis, chronic hepatitis, GB dzliver cirrhosis, chronic hepatitis, GB dz

► Other claims: lower Other claims: lower cholesterol, insulin resistance in pts with cholesterol, insulin resistance in pts with DM II w/ cirrhosis, cancer cell growth (breast, cervix, prostate)DM II w/ cirrhosis, cancer cell growth (breast, cervix, prostate)

► Biological active part– Biological active part– silmarinsilmarin from seeds to make from seeds to make capsules, extracts, strong tea infusionscapsules, extracts, strong tea infusions

► Currently mixed data on effect on liver fx. Curent phase II trial Currently mixed data on effect on liver fx. Curent phase II trial by NCCAM and NIDDK on use for chronic Hep C and NASH by NCCAM and NIDDK on use for chronic Hep C and NASH (fatty liver)(fatty liver)

► Side Effects–Side Effects– few… laxative effect, GI upset, bloating. Allergic few… laxative effect, GI upset, bloating. Allergic Rxns to those allergic to daisy family (ragweed, Rxns to those allergic to daisy family (ragweed, chrysanthemum, marigold)chrysanthemum, marigold)

NNonioni Morinda citrifolia Morinda citrifolia

► Common NamesCommon Names— noni, morinda, Indian mulberry, hog apple, — noni, morinda, Indian mulberry, hog apple, canary woodcanary wood

► evergreen shrub native to tropics of Pacific Ocean, from SE Asia evergreen shrub native to tropics of Pacific Ocean, from SE Asia to Australia, especially in Polynesia.to Australia, especially in Polynesia.

► Traditional use- polynesian dye, topical prep for joint & skin Traditional use- polynesian dye, topical prep for joint & skin conditionsconditions

► Today, people drink noni fruit juice as Today, people drink noni fruit juice as general health tonic general health tonic and and for for chronic dz chronic dz (cancer, CVD, DM)(cancer, CVD, DM)

► Lab research suggestLab research suggest has has antioxidantantioxidant, , immune-stimulatingimmune-stimulating propertiesproperties

► NCCAM and NCI -- ? efficacy in breast cancer prevention and TxNCCAM and NCI -- ? efficacy in breast cancer prevention and Tx► Side Effects: Side Effects:

High in K+, High in K+, avoid if on K+ rich diet or CRDavoid if on K+ rich diet or CRD Reports of Reports of liverliver damage damage Makers of noni juice “warned” by FDA about making Makers of noni juice “warned” by FDA about making

unsubstantiated health claimsunsubstantiated health claims

EveningEvening P Primrose Oilrimrose Oil Oenothera biennis Oenothera biennis

► Common NamesCommon Names— primrose oil, EPO— primrose oil, EPO

► native to N. America and contains native to N. America and contains gamma-linolenic acid gamma-linolenic acid ((GLAGLA), ), an essential fatty acidan essential fatty acid

► Traditional use- eczema in 1930sTraditional use- eczema in 1930s

► Today, Today, mastalgia, RA, PMS, menopausal sxs, DM and cancermastalgia, RA, PMS, menopausal sxs, DM and cancer

► Extracted from seeds-- usually put into capsules for use. Extracted from seeds-- usually put into capsules for use.

► No effect on menopausal or PMS sxsNo effect on menopausal or PMS sxs. Mixed data on RA, . Mixed data on RA, mastalgia (small studies, ?able study design)mastalgia (small studies, ?able study design)

► Side Effects: mild -- GI upset, HASide Effects: mild -- GI upset, HA

RRed Yeast Riceed Yeast Rice Monascus purpureus Monascus purpureus

► Common NamesCommon Names— Angkak, Beni-koji, Hong Qu, — Angkak, Beni-koji, Hong Qu, Red Koji, Red Red Koji, Red Leaven, Red Rice, Leaven, Red Rice, Red yeast, Zhitai, Zue Zhi KangRed yeast, Zhitai, Zue Zhi Kang

► Brand NameBrand Name– Cholestin3– Cholestin3

► fermented product of the yeast species found on ricefermented product of the yeast species found on rice

► medicinal and non-medicinal purposes in China since 900 A.Dmedicinal and non-medicinal purposes in China since 900 A.D

► contains several compounds collectively known as contains several compounds collectively known as monacolins- monacolin K= powerful HMG-CoA reductase monacolins- monacolin K= powerful HMG-CoA reductase inhiabitor and is the same chemical as lovastatin inhiabitor and is the same chemical as lovastatin

RRed Yeast Riceed Yeast Rice Monascus purpureus Monascus purpureus

► EvidenceEvidence:: Recent studies- eval as alternative to statin for intolerant

pts► Small RPCT- 62 pts in community cards practice (Annals 06/09)► ½ placebo & ½ RYR 1800mg BID x 24wk► All patients were concomitantly enrolled in a 12-week therapeutic All patients were concomitantly enrolled in a 12-week therapeutic

lifestyle change programlifestyle change program► Primary outcome: LDL► RYR --LDL RYR --LDL 4343 mg/dL @wk 12 & mg/dL @wk 12 & 3535 mg/dL@ wk 24 (P 0.001) mg/dL@ wk 24 (P 0.001)► Plac-- LDL Plac-- LDL 1111 mg/dL @wk 12 & mg/dL @wk 12 & 1515 mg/dL@ wk 24 (P 0.011) mg/dL@ wk 24 (P 0.011)► No difference in CPK, pain severity of liver enzNo difference in CPK, pain severity of liver enz

► Risks: same as those for statins incl myopathy, Risks: same as those for statins incl myopathy, rhabdomyolysis, hepatotoxicityrhabdomyolysis, hepatotoxicity

► Monitoring organizations - large variation in the active Monitoring organizations - large variation in the active compounds in RYR supplements- some supplements compounds in RYR supplements- some supplements contaminated with citrinin, a nephrotoxic mycotoxincontaminated with citrinin, a nephrotoxic mycotoxin

SSaw Palmettoaw Palmetto Serenoa repens, Sabal serrulata Serenoa repens, Sabal serrulata

► Common NamesCommon Names— saw palmetto, American dwarf palm — saw palmetto, American dwarf palm tree, cabbage palmtree, cabbage palm

► Palm tree native to SE U.S. First use by Seminole Tribe in Palm tree native to SE U.S. First use by Seminole Tribe in FloridaFlorida

► Today, Today, urinary symptoms urinary symptoms assoc w/ assoc w/ BPHBPH. Also . Also chronic chronic pelvic pain, bladder d/o, decreased libido, and hair losspelvic pain, bladder d/o, decreased libido, and hair loss

► Fruit is ground, dried, or whole and prepped in form of Fruit is ground, dried, or whole and prepped in form of liquid extract, tablet/capsule, tea infusionliquid extract, tablet/capsule, tea infusion

► Mixed data-- 2006 DB, RPCT study of 225 men w/ mod-Mixed data-- 2006 DB, RPCT study of 225 men w/ mod-sev BPH showed no improvement w/ 320mg SP daily vs sev BPH showed no improvement w/ 320mg SP daily vs placebo. Primary outcome- max urinary flow rate and placebo. Primary outcome- max urinary flow rate and score on Amer Uro Assn Sx Index (AUASI) score on Amer Uro Assn Sx Index (AUASI) (NEJM 2006)(NEJM 2006)

► Side EffectsSide Effects: mild- GI upset, ? decreased libido and : mild- GI upset, ? decreased libido and breast tenderness in menbreast tenderness in men

TTurmericurmericCurcuma longaCurcuma longa

► Common NamesCommon Names— turmeric, turmeric root, Indian saffron— turmeric, turmeric root, Indian saffron► Shrub related to ginger, grown in Asia and AfricaShrub related to ginger, grown in Asia and Africa► Known for warm, bitter taste and golden color-- commonly Known for warm, bitter taste and golden color-- commonly

used in fabric dyes & foods (curry, mustards, & cheeses)used in fabric dyes & foods (curry, mustards, & cheeses)► TodayToday, heart burn, stomach ulcers, and gallstones, anti-, heart burn, stomach ulcers, and gallstones, anti-

inflammatory effects, cancer Txinflammatory effects, cancer Tx► finger-like underground stems (rhizomes) - dried and oral finger-like underground stems (rhizomes) - dried and oral

prep as powder,capsules, teas, or liquid extracts. Also prep as powder,capsules, teas, or liquid extracts. Also topical pastetopical paste

► Prelim Prelim animal data animal data suggests anti-inflammatory and anti-suggests anti-inflammatory and anti-cancer propertiescancer properties

► Side EffectsSide Effects: mild- high doses indigestion. May worsen : mild- high doses indigestion. May worsen gallbladder dzgallbladder dz

VValerianalerianValeriana officinalisValeriana officinalis

► Common NamesCommon Names— — setwall, Baldrianwurzel, and phusetwall, Baldrianwurzel, and phu► perennial plant native to Europe and Asia, perennial plant native to Europe and Asia,

distinctive odor that many find unpleasantdistinctive odor that many find unpleasant► Preps made from roots, rhizomes into teas, tinctures, Preps made from roots, rhizomes into teas, tinctures,

extracts for capsules, tabletsextracts for capsules, tablets► 22ndnd century uses- insomnia. 16 century uses- insomnia. 16thth century- anxiety, HA, century- anxiety, HA,

palpitations, tremor. WWII- relieve stress from air raidspalpitations, tremor. WWII- relieve stress from air raids► TodayToday, treatment of , treatment of insomniainsomnia disorders disorders► Systematic review of several trials-- inconclusive data on Systematic review of several trials-- inconclusive data on

efficacy for insomnia. Limitations- sample size/power, efficacy for insomnia. Limitations- sample size/power, differing dosing amounts and sources of valeriandiffering dosing amounts and sources of valerian

► Side EffectsSide Effects: HA, dizziness, pruritis, GI upset: HA, dizziness, pruritis, GI upset

YYohimbeohimbePausinystalia yohimbePausinystalia yohimbe

► Common NamesCommon Names— yohimbe, yohimbe bark— yohimbe, yohimbe bark► Yohimbe tree -- tall evergreen native to W. AfricaYohimbe tree -- tall evergreen native to W. Africa► Bark traditionally used as an aphrodisiacBark traditionally used as an aphrodisiac► Today, yohimbe bark as a dietary supplement-- in many Today, yohimbe bark as a dietary supplement-- in many

forms, not regulated. forms, not regulated. ► dried bark – used as tea or bark extract put into dried bark – used as tea or bark extract put into

capsules/tablets and is a dietary supplement (not FDA capsules/tablets and is a dietary supplement (not FDA regulated)regulated)

► a regulated Rx form-- a regulated Rx form-- yohimbine HClyohimbine HCl indic for indic for Erectile dysfx Erectile dysfx Tx Tx but cannot use this as evidence that the dietary but cannot use this as evidence that the dietary supplement is efficacious.supplement is efficacious.

► No clinical trials conducted thus far on dietary supp versionNo clinical trials conducted thus far on dietary supp version► Side EffectsSide Effects: assoc with HTN, tachycardia, HA, anxiety, : assoc with HTN, tachycardia, HA, anxiety,

dizziness, sleeplessness. dizziness, sleeplessness. Caution if MAOI, BP meds, TCAs, Caution if MAOI, BP meds, TCAs, phenothiazines, renal diseasephenothiazines, renal disease

ReferencesReferences1.1. Becker DJ, Godon RY, Halbert SC, French B, Morris PB, Rader DJ. Red yeast rice Becker DJ, Godon RY, Halbert SC, French B, Morris PB, Rader DJ. Red yeast rice

for dyslipidemia in statin-intolerant patients: a randomized trial. for dyslipidemia in statin-intolerant patients: a randomized trial. Ann Intern Ann Intern MedMed. 2009;150:830-839, W147-149.. 2009;150:830-839, W147-149.

2.2. Tisha R. Joy and Robert A. Hegele. Narrative Review: Statin-Related Tisha R. Joy and Robert A. Hegele. Narrative Review: Statin-Related Myopathy. Myopathy. Ann Intern Med. Ann Intern Med. June 16, 2009 150:858-868June 16, 2009 150:858-868..

3. http://dietary-supplements.info.nih.gov/Health_Information/Information_About_Individual_Dietary_Supplements.aspx

4.4. Langmead L, Feakins RM, Goldthorpe S, Holt H, Tsironi E, De Silva A, Jewell Langmead L, Feakins RM, Goldthorpe S, Holt H, Tsironi E, De Silva A, Jewell DP, Rampton DS. Randomized, double-blind, placebo-controlled trial of oral DP, Rampton DS. Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis. aloe vera gel for active ulcerative colitis. Aliment Pharmacol TherAliment Pharmacol Ther. 2004 Apr . 2004 Apr 1;19(7):739-47.1;19(7):739-47.

5.5. Solomon PR, Adams F, Silver A, et al. Ginkgo for memory enhancement: a Solomon PR, Adams F, Silver A, et al. Ginkgo for memory enhancement: a randomized controlled trial. randomized controlled trial. Journal of the American Medical AssociationJournal of the American Medical Association. . 2002;288(7):835–840.2002;288(7):835–840.

6.6. DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. of dementia: a randomized controlled trial. Journal of the American Medical Journal of the American Medical AssociationAssociation. 2008;300(19):2253–2262.. 2008;300(19):2253–2262.

7.7. Bent S, Kane C, Shinohara K, et al. Saw palmetto for benign prostatic Bent S, Kane C, Shinohara K, et al. Saw palmetto for benign prostatic hypertrophy. hypertrophy. New England Journal of MedicineNew England Journal of Medicine. 2006;354(6):557–566.. 2006;354(6):557–566.

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