herbs & supplements
DESCRIPTION
Herbs & Supplements. Did you remember to take your Gingko today ? Robert Baldor, MD Professor Family Medicine & Community Health. Why patients use CAM. 38% of US/$34 billion out-of-pocket in 2007 Arthritis/Back/Neck/Joint pain Anxiety Cholesterol management URIs Headache/Migraine - PowerPoint PPT PresentationTRANSCRIPT
1
Herbs & Supplements
Did you remember to takeyour Gingko today ?
Robert Baldor, MDProfessor
Family Medicine & Community Health
2
Why patients use CAM
• 38% of US/$34 billion out-of-pocket in 2007• Arthritis/Back/Neck/Joint pain• Anxiety• Cholesterol management• URIs• Headache/Migraine• Insomnia
3
A Clinician’s Perspective
• What’s available• Efficacy • Safety
4
Herbal Therapies (Top Dozen)
• Gingko biloba• St John’s Wort• Ginseng• Garlic• Echinacea• Saw Palmetto
• Kava Kava• Valerian• Soy • Evening Primrose• Grape seed• Milk Thistle
5
Gingko Extracts
• Ancient Chinese herbal treatment• Maidenhair tree leaves • Effects from flavonoids - antioxidant• Reduces capillary fragility, vasodilator
6
Ginkgo Considerations
• Recommended to stabilize cognition in Alzheimer's or multi-infarct dementia; improves walking with claudication
• 120-240 mg BID, TID• Appears safe• Avoid with anticoagulants
7
((2002 Cochrane)2002 Cochrane)
Marketed For ...
• Memory enhancement • Improved concentration
• No evidence for improved memory/concentration in normal, healthy individuals (NEJM 2002)
8
St. John’s Wort
• Flowering plant (H. perforatum)• Hypericin, a naphthodianthrone is the main
active ingredient• Inhibits neurotransmitter uptake of serotonin,
norepinephrine, & dopamine• Binds to GABA receptors
9
St. John’s Wort
• Outsells Prozac in Germany 7:1• Meta-analysis - appears effective as low
doses of standard antidepressants • Phototoxicity
10
Depression
11
Depression
Consumers Report 2004
Ginseng
• From genus panax (panacea!)• An adoptogen - no studies compared to
stimulants such as caffeine• Considered safe• Siberian Ginseng
– An abundant Russian herb thought to have the same properties as Ginseng
– No published studies
12
The wonder herb . . .
• Ginseng is expensive - study of 54 products - 85% contained little or no ginseng, but ….
varying amounts of caffeine!• Glacial Tropical Citrus Vitamin Water
21 mg of caffeine – Coke has 24 mg!
13
Red Bull…
• Taurine (essential amino acid) 1000mg• Glucuronolactone (conjugates with toxic
metabolites for excretion) 600 mg• B complex vitamins• Caffeine 80 mg (24 gms in Coke)• Sugar 27 grams (39 gms in Coke)
14
• B Vitamins– Niacin: 30 milligrams, or 150% of the RDV– Vitamin B6: 40 milligrams, or 2,000% of RDV– Vitamin B12: 0.5 milligrams , or 8,000% of RDVand……– As much caffeine as a cup of premium coffee
• A cup (8oz) of Starbucks has 180mg of caffeine
Garlic (allium sativum)
• Organosulfer compounds • May block carcinogens in food• Garlic extract - decreases cholesterol 7%• Available in ‘odor free’ capsules
• Active agent (allium) is odoriferous
16
Long regarded to deter vampires• Norwegian experiment with leeches (lack of vampires)• Garlic-smeared hand preferred in 66% of time• Leeches attached in 14.9 secs vs 44.9 secs when going
to the non-garlic hand (p < 0.05)• The traditional belief that garlic can deter vampires is
probably wrong• The reverse may in fact be true
17Tidsskr Nor Laegeforen. 1994 Dec 10;114(30):3583-6.
Echinacea
• For Rx of colds ($100 million in sales)• Appears to alleviate some cold symptoms -
no evidence for cure • 1998 randomized trial showed no ability to
prevent colds (JFP 1999)
18
Zinc & Colds• Inhibits rhinovirus in tissue culture• Meta-analysis showed no conclusive evidence for
reducing colds (Arch IM 1997)
• Controlled trial of lozengers - ineffective & side effects - taste, N&V (JAMA 1998)
• Randomized blinded trial of nasal gel – decreased length of cold by 2 days (ENT J 2000)
• Improved Rx vs. antibiotics ?
19
Saw Palmetto• Appears safe and effective for BPH,
comparable to finasteride (Proscar)• Inhibits the 5a reductase conversion of
testosterone to dihydrotestosterone (a prostate growth stimulator)
• 160 mg bid or 320 mg qdJAMA1998; AFP2003
20
Anxiolytics GABA Binding Activity
• Valerian (insomnia) • Kava kava (anxiety)• Chamomile (insomnia)
21
Valerian
• Some efficacy for insomnia• Unclear evidence for anxiety • Appears safe, maybe helpful to wean from
benzodiazepines dependence• 300 - 600 mg before bedtime or as tea (2-3 gm
of dried root)
22
AFP 2003AFP 2003
KAVA & Hepatotoxicity
• 70 reports of kava induced liver failure, with 4 deaths and 7 liver transplants
• FDA 2002 advisory – avoid kava if having or at risk for liver disease
• Last year UK banned Kava sales
23
Phytoestrogens for Menopause
• Plant compounds resembling estradiol• Isoflavones most potent• Supplements of unclear benefits v. foods -
Soy, Tofu, Black Cohosh• Consider for mild menopausal Sx• Reports of Black Cohosh induced hepatitis
24
Relief of Hot Flashes
25
WHAT RELIEVED HOT FLASHES?
Consumers Report 2004
Milk Thistle
• Flavonoid complex called silymarin • Used for improving liver function in hepatitis,
cirrhosis• Meta- analysis – appears safe but no clear
benefit….
26
Am J Med 2002
27
“Not much - just flushing out my arteries.”
The NewYorker
What about Red Wine?• ‘The French paradox’ – low incidence of CVD – but a
relatively high fat diet. • Grapes contain flavonoids (resveratol), potent
antioxidants - ? account for positive effects• Red wine has 160ug/oz; peanuts 70 ug/oz• Grape juice is not fermented –negligible amounts• No enough evidence to conclude that red wine is
more effective than other alcoholic bevearges in lowering CVD risk
28
29
“It’s a B-complex. Didn’t they used to put chocolate on the pillow?”
Chocolate (flavonoids)• 1 oz has as much flavonoids as 6 apples, 5
cups of tea or 2 glasses of red wine• Flavonoids reduce platelet aggregation• Decreased platelet activation 6 hours after
eating chocolate– Didn’t measure glucose or lipid levels (MARS funded)
• Recent meta-analysis dark cocoa products reduce BP 5/2 mmHg (AJH, 2010)
30
Ginger (zigiber officinale)
• Used for centuries to treat nausea• Post-op nausea, motion & sea sickness• Chemotherapy results disappointing• Commonly used but not recommended for
pregnancy (bleeding, miscarriage)
31
32
“Michael has had an interesting side-effect from taking St. John’s Wort”
FDA Approval
• Drugs must be safe and effective • Average $230 million & 12 years • No patent to recoup costs for herbs
33
Dietary Supplement Act Of 1994
• Applies to ‘dietary supplements’– vitamins, minerals, herbs, natural substances
• Health claims not specified on label • FDA must prove unsafe before removing
34
Health Foods?….L-Trypthophan
• An amino acid - assumed safe• Used for insomnia• Eosinophilia myalgia syndrome developed
– 38 deaths!!• Banned by FDA in 1990
35
FDA Concerns ….• Over 2000 reports of adverse effects in 2009• No manufacturing oversight:
– 1/3rd of supplements <50% of stated ingredients(Ginseng products only contain caffeine)
– Niacin product contained 10x safe level( GI distress, hepatic damage, MI)
• Proposed rule to prevent the sale of supplements that are sub- or super- potent, that contain drugs, or contaminants (i.e. bacteria, pesticides, glass, lead)
36
37
“Something from the supplement cart?”
The NewYorker
Common Supplements
• Glucosamine/ chondroitin• CoQ-10• Melatonin• Amino Acids
• Fish Oils/omega FA• DHEA• Acidophilus• Chromium• Sports enhancement
38
Glucosamine & Chondroitin• Glucosamine (crab shell chitin)• Chondritin (cow cartilage)• The ‘raw materials for new cartilage’• Evidence for pain & disability relief in
osteoarthritis, comparable to ibuprofen & acetaminophen
• Safe – few side effects
39
Cochrane Review 2005
40
Consumers Report 2004
Coenzyme Q10• Fat soluble vitamin• Involved in mitochondrial oxidation producing ATP• Some anti-oxidant properties• In CHF, cardiac tissues under ↑’d oxidative stress
w/decreased tissue levels of Q10• Approved in Japan since 1974 to treat CHF• Some evidence for benefit in Parkinson’s &
mitochondrial diseases• 200mg qday lower BP 16/10 mmHG• Safe but expensive (50-1200 mg/day)
41
AFP 2005
Melatonin
• Modified amino acid (tryptophan)• Released from pineal gland by diminishing
light levels• Role in humans not fully elucidated• Small, conflicting sleep studies
42
Melatonin for Sleep• Induces sleep if plasma levels are low• Shift workers• Jet Lag• 0.1 – 10 mg qhs
43
Insomnia
44
Insomnia
Consumers Report 2004
Fish Oils & Omega 3 fatty acids
• Fish oil supplements supported by RCTs– Lower triglycerides– Reduce CAD and stroke risk with known CVD disease – Lowers BP slightly (10/4 mmHg)
• No evidence for primary prevention
45
DHEA (Dihydroepiandrosterone)
• Produced by adrenals, unclear role outside of Rx for adrenal insufficiency
• Converted to estrogens and testosterone• Plasma levels decline with age• Schedule II - an anabolic steroid• DHEA supplements are Yam extracts, not
converted to DHEA
46
Marketed as...• Anti-aging• Hirsutism & deeping voice seen• Concern for prostate or breast cancer• Series of studies 1995 - 1998 in J. Clin
Endocrinology - some perceived sense of well being, but no obvious benefits
47
Acidophilus - a probiotic (organism used medically)
• Lactobacillus acidophilus - bacteria that live in the intestine and vagina
• Good evidence to support L. acidophilus vaginal suppositories to Rx bacterial vaginosis
• Some studies suggest eating yogurt enriched with L. acidophilus may be similarly beneficial
• Benefit in colic treatment ?• Marketed to improve digestion, no clear evidence of
benefit
48
Chromium for weight loss ??
• Essential trace mineral - Insulin cofactor• China & Israeli studies for DM treatment• Diabetics not chromium deficient• Mixed results from a variety of studies• Safe up to 1000mcg/day
49
The Medical Letter 2006
Marketed To....
• Loose fat • Boost energy
• ... no published support for such effects
50
Weight loss ….Health Foods??
• Metabolife contains Ma Hung • Bitter orange extract contains synephrine• Chomper is a natural laxative, contains
digitalis - induces arrhythmias • Tryptophan & phenylalanine - amino acids ?
efficacy
51
Health Foods?….
• Associated Press 5/22/00 …Herbalife Founder Mark Hughes dies at the age of 44 of ...
.. NaturalNatural causes!
52
Ma-Huang or Ephedra
• MetaboLife, Herbal Ecstasy• Contains Ephedrine• Linked to 155 deaths & strokes• Banned by NFL, NCAA after heat stroke
deaths while using the supplement• FDA Ban in 2004• Ban overturned, FDA overstepped authority
53
54
“I’m taking you off wine, women and song
and putting you on broccoli”
A Clinician’s Perspective ..... varying approaches
• Acceptance Acceptance - ask about & tolerate use of herbal products by patients
• EndorsementEndorsement - accept patient use of natural products as initial therapy, monitor for effects
• Integration Integration - prescribe herbs with advice on use, dosing, etc.
55
56
Resources• www.NaturalStandard.com• NIH CAM Center (nccam.nih.gov)• NIH Office of Dietary Supplements
(odp.od.nih.gov/ods/)• Food & Drug Administration (fda.gov)• www.consumerlab.com• Medical Letter• Published studies
57
Current Consensus …the best nutritional strategy for promoting
optimal health & reducing the risk of chronic disease is to choose wisely from a wide variety of foods, with emphasis on anti-oxidant rich fruits, vegetables & whole grains .
AHA 2002 ADA 2002AHA 2002 ADA 2002
58
Best Advice . . .
• Buy from well-known national companies• Label includes:
– Herbs common & scientific name– Manufacture’s name & address– Dosing guidelines– Potential side effects– Batch & Lot number and expiration date
• US Pharmacopoeia verification seal
59
60
A Final Thought…..
• The Japanese eat very little fat and suffer fewer heart attacks than the British or Americans
• However, the French eat a lot of fat and also suffer fewer heart attacks than the British or Americans
• The Germans drink very little red wine and suffer fewer heart attacks than the British or Americans
• While the Italians drink excessive amounts of red wine & suffer fewer heart attacks than British or Americans
• Conclusion: Eat and drink what you like. Speaking English is apparently what kills you!
61
62