mcphs natural products information services

Herbs and Dietary Supplements: What Every Healthcare Practitioner Should Know

Lana Dvorkin Camiel, PharmDMassachusetts College of Pharmacy and Health Sciences

MCPHS - Natural Products Information Services

❖ CDINP - NP division - established in January, 1999

❖ Questions on herbs and dietary supplements (HDS)

❖ Primarily from pharmacists, physicians, nurses, patients

❖ 617 732-2759

Categories of Drug Information Questions

❖ General information

❖ Dosage

❖ Interactions

❖ Highest percentage

❖ Most cases reported in the literature - SJW, Ginkgo

❖ Adverse effects

❖ Pregnancy & lactation

❖ Cost

❖ Therapeutic use

❖ Pharmacology

❖ Compatibility

❖ Other

“For 2/3 of the people on earth Traditional Medicine is herbal

medicine.”

Amanda McQuade Crawford

Herbal Medicine Trends in USA

❖ 1990-1997 surveys - use increased from 3 to 12% - Eisenberg, et. al.

❖ 1997 telephone survey - 17% used herbs that year - Landmark Report on Public Perception of Alt Medicine

❖ 2001 survey - 2/3 of those under 33 used some type of CAM; herbal supplements - second most popular therapy - Kessler, Annals of Int Med

❖ Michigan survey - 21% used herbs - Rafferty, et. al.

❖ Minnesota & Mississippi - 61-71% - MMWR Morbidity Mortality Report & Harnack, et. al.

HDS Users❖ 20% of 2982 NC adults, 5% gave to children

❖ Wheaton Ann Epidemio. 2005 Oct:15(9)678-685

❖ 45% of pediatric patients presenting to ED

❖ Lanski SI, et. al. Pediatrics 2003 May; 111(5 Pt 1):981

❖ 62% of pregnant women

❖ Maats FH Aust NZ J Obstet Gynaecol 2002 Nov; 42(5):494

❖ Patients with chronic conditions

❖ Astin J JAMA 1998 May 20; 279(19):1548

Birth of an Industry - Research Explosion

0

2500

5000

7500

10000

1980-1990 1990-1995 1995-2000 2000-2010

DS studies on Medline

Objectives❖ Describe major HDS

quality assurance issues

❖ Discuss precautions, interactions and toxicity related to HDS

❖ Discuss commonly used HDS

❖ Describe reliable HDS information resources

Quality Control and Cautions

Product Issues❖ Plant Species and Parts

❖ Common Product Formulations

❖ Method of Preparation

❖ Dosage Forms

❖ Standardization

❖ Packaging

Product Issues - Quality Control

❖ Adulteration

❖ Contamination

❖ Potency

❖ Freshness and quality of ingredients

Product Issues - Quality Assurance Programs

❖ United States Pharmacopeia DS Verification Program

❖ ConsumerLab.com

❖ National Sanitation Foundation International

❖ Natural Products Association

Communication Issues❖ HDS Counseling

❖ Considerations for Special Groups

❖ Older Adults

❖ Children

❖ Pregnant/Lactating Patients

❖ Renal Disease

❖ Surgery

❖ Oncology

Avoid in Pregnancy❖ Emmenogogues

❖ Abortifacient

❖ Uterine stimulants/ Oxytocics

❖ Uterine relaxants (at the end of pregnancy)

❖ Plants with hormonal activity

❖ Teratogens/ Mutagens/ Genotoxins/ Fetotoxins

Avoid While Breast Feeding❖ Laxatives

❖ Stimulants

❖ Irritants

❖ Hepatotoxic pyrrholizidine alkaloids

❖ Genotoxins

❖ Compounds toxic to small children

❖ Antigalactogogues

Avoid Before Surgery

❖ Garlic

❖ Ginger

❖ Ginseng

❖ Saw Palmetto

❖ Fish Oil

❖ Chondroitin

Hazards from HDS

❖ False Advertising/Quackery

❖ Hazards Introduced by the Consumer

❖ Product Hazards: Adverse Effects and Drug Interactions

Interactions❖ Pharmacodynamic

❖ Synergism

❖ Antagonism

❖ Pharmacokinetic

❖ Absorption

❖ Distribution/Displacement

❖ Metabolism

❖ Excretion

Pharmacodynamic(Synergy/Antagonism)

❖ Similarity in:

❖ Physiological effects

❖ Pharmacological effects

❖ Adverse effects

Pharmacokinetic (Absorption)

❖ Changes in:

❖ Motility

❖ Gastrointestinal pH

❖ Absorption and chelation

❖ Malabsorption

Pharmacokinetic (Distribution/Displacement)

❖ Free drug - main issue

❖ Important factors:

❖ Rate of elimination

❖ Extent of distribution

❖ Extent of protein binding

❖ Therapeutic index

Pharmacokinetic (Metabolism)

❖ Enzyme induction

❖ Enzyme inhibition

❖ Hepatic disorders

Pharmacokinetic (Excretion)

❖ Elimination and reabsorption - primarily affected by change in urinary pH

Toxicities❖ Hepatotoxicity

❖ Unsaturated Pyrrolizidine Alkaloids (UPA’s)

❖ Comfrey, Coltsfoot, Senecio, Sassafrass

❖ Echinacea - Saturated Pyrrholizidine Alkaloids - NOT hepatotoxic

❖ Germander, Greater Celandine, Kava, Black cohosh, Chaparral, Ephedra

❖ Nephrotoxicity

❖ Aristolochic Acid Nephrotoxicity (AAN)

❖ Oxalates

❖ Cardiotoxicity

❖ Digitalis, Aconite

Reporting Toxicities and Interactions

❖ FDA’s MedWatch Program

❖ 800-FDA-1088

❖ http://www.fda.gov/medwatch

❖ Center for Food Safety and Applied Nutrition

❖ InteractionReport.org

❖ http://www.interactionreport.org

❖ The European Scientific Cooperative on Phytotherapy (former Phytonet)

❖ http://www.escop.com

Most Commonly Used HDS

“Plants live in harmony with nature. One might even say that plants are nature. Out of this union comes their incredible generosity to us and to all their fellow beings.”

Elliot Cowan

Diet vs. Supplements❖ Traditionally herbs and spices -

an important part of diet

❖ Highest benefit - from getting large number of species of plants in your meals

❖ Most epidemiologic research is done on plants consumed as/with food

❖ Supplements - way to add to the diet, if deficient

Echinacea - E. angustifolia, E. pa!ida, E. purpurea❖ 3 different species used

❖ Non-specific immunomodulation - URI prevention, common cold, vaginal candidiasis

❖ Polysaccharides, alkylamides

❖ Tongue tingling

❖ Autoimmune disease according to some resources

❖ Acute vs. chronic use

❖ Allergic reaction in susceptible individuals - Aster family

Which of the following statement is TRUE?

1. Echinacea is known to produce a non-specific immunomodulation

2. According to research E. angustifolia, E. purpurea and E. pallida are comparable in their efficacy

3. Echinacea needs to be given for at least 8 weeks to have any benefits

4. Recommending Echinacea to be given to a patient on a chronic basis is a wise approach to cold/respiratory illness prevention

Garlic - A!ium sativum❖ Cardiovascular disease - HTN,

hyperlipidemia, cancers, fungal/bacterial infections

❖ Bulb - sulfur compounds - many are unstable - alliin, allicin, ajoene

❖ Mild BP & lipid lowering

❖ HMGcoA reductase inhibitor, 14-alpha demethylase inhibitor - cholesterol, stimulation of nitric oxide & endothelium derived relaxation factor

❖ ADR’s - odor, mild GI, flora changes, asthma/topical dermatitis, platelet inhibition

Which of the following statement is FALSE?

1. Medicinal effects are attributed to many sulfur compounds

2. Garlic decreases LDL cholesterol by 9-12% and systolic blood pressure by 5-7%

3. Odor is one of the main adverse effects that prohibits many patients from consuming larger amounts of this plant

4. Garlic is known to interact with many CNS medications

Ginger - Zingiber officinale❖ Rich traditional use

❖ Morning sickness, postoperative nausea and vomiting, vertigo

❖ Applicable parts - rhizome and root - fresh vs. dry

❖ Variety of effects - analgesic, antitussive, anti-inflammatory, antibiotic, other

❖ Well tolerated - in large doses (above 5 gm) - abdominal discomfort, diarrhea, pepper-like irritant (mouth/throat), dermatitis in sensitive individuals


1. Ginger has the strongest evidence in morning sickness and postoperative nausea and vomiting

2. There are preliminary findings or insufficient evidence for efficacy of ginger in chemotherapy-induced nausea and vomiting and rheumatoid

3. Ginger is widely recognized for its skin cooling and protectant effects

4. Ginger is generally well tolerated - some GI effects are possible

Ginseng - Panax ginseng, Panax quinquefolius❖ Korean, American, Siberian, Indian

❖ Red, White

❖ Cognitive function, diabetes, erectile dysfunction

❖ Adaptogen - effects on HPA axis

❖ Use in young vs. older patients

❖ Well tolerated - significant use, especially in Asia

❖ ADR’s - insomnia, mastalgia, vaginal bleeding, amenorrhea, palpitations, HTN


1. Ginseng is considered to be an adaptogen and indicated to attenuate fatigue during time of stress

2. Ginsenosides exert their adaptogenic properties via the hypothalmic-pituitary-adrenal axis

3. Although oral Ginseng supplementation is usually well tolerated, some ADR’s include insomnia, HTN, nervousness, tachycardia, palpitations and vaginal bleeding

4. Ginseng is the best and appropriate recommendation to enhance athletic performance in health young adults based on research available

Ginkgo - Ginkgo biloba❖ Microvasculature - Alzheimer’s

dementia, tinnitus, SSRI related libido loss, diabetic neuropathy, other

❖ Concentrated extract (leaf) - 50:1; standardized to flavonoids and terpenoids

❖ Increases cholinergic transmission, improving symptoms of Alzheimer’s; free radicals scavenging

❖ Mild GI ADR’s

❖ Bleeding, seizures - severe toxicities; caution with anticoagulants/antiplatelet agents (theoretical interactions)


1. There appears to be a significant improvement in cognitive and social functioning in patients with progressive degenerative demential taking Ginkgo

2. Ginkgo appears to increase cholinergic transmission and is similar to some prescription medications prescribed to patients with Alzheimer’s disease

3. Ginkgo is a strong antioxidant that scavenges free radicals, inhibits lipid membrane peroxidation, and prevents progression of tissue degeneration

4. Ginkgo does not have any theoretical or documented interactions with other herbs or drugs

St. John’s Wort - Hypericum perforatum

❖ Mild to moderate depression, somatization disorder; rich historical use

❖ SSRI, MAOI

❖ Standardization to hypericin, hyperforin, many other compounds

❖ Enzyme inducer (CYP3A4, CYP2D6), inducer of intestinal P-glycoprotein/multi-drug resistance 1 (MDR-1) drug transporter

❖ Cyclosporin, oral contraceptives, indinavir, other

❖ Photosensitivity, skin rashes, GI effects


1. SJW is an effective plant in treating severe forms of depression

2. Hypericin is considered to act by inhibiting monoamino oxidase, while hyperforin inhibits selective serotonin reuptake receptors

3. SJW is generally well tolerated; patients working outside should include this plant into their daily routine to prevent sun rashes and similar effects

4. SJW is known as an enzyme inhibitor and often increases concentration of drugs taking concomitantly with it

Fish Oil❖ CV effects/CNS effects/

Arthritis - different doses

❖ Eicosapentanoic acid (EPA), docosahexaenoic acid (DHA)

❖ Use in pregnancy

❖ Well tolerated - fishy aftertaste, halitosis, heartburn, dyspepsia, nausea, loose stools, rash

❖ Increased risk of bleeding


1. EPA and DHA are omega-3 fatty acids that enhance production of anti-inflammatory mediators in the body

2. Patients with hypertriglyceremia should avoid fats, including fish oil, at all cost

3. Fish oil is absolutely contraindicated in anyone taking antihypertensive and anticoagulant agents

4. Anti-inflammatory and neuroprotective doses are generally close to 1 gm/day

Probiotics❖ Diarrhea, atopic dermatitis, atopic

disease, respiratory infections (esp. in children), bacterial vaginosis, irritable bowel syndrome

❖ Lactobacillus, Bifidobacteria, Saccharomyces boulardi

❖ Prebiotics, Storage issues

❖ Usually well tolerated - flatulence - common, subsides with use

❖ Avoid in severely ill and immunocompromised patients


1. Probiotics include a number of species of Lactobacillus, Bifidobacteria and Saccharomyces boulardii

2. To increase effectiveness of probiotics patients should consume prebiotics and fiber

3. Probiotics generally have a very long life and last for a few years out of refrigerator

4. Patients traveling to exotic destinations should take probiotics before and after their travels

Information Resources

Good Herbal Web Resources - Starting Point (Free)

❖ American Botanical Council - news, resources, trends

❖ http://www.herbalgram.org

❖ American Herbalists Guild - education

❖ http://www.americanherbalist.com

❖ American Herbal Products Association - manufacturing concerns

❖ http://www.ahpa.org

Good Herbal Web Resources - Starting Point (Free)

❖ National Center for Complementary and Alternative Medicine (NCCAM) - education, research - herbs and CAM

❖ http://www.nccam.nih.gov

❖ MCPHS Natural Products News

❖ http://www.facebook.com/MCPHSNaturalProducts

❖ CDINP Medication Health News

❖ http://www.facebook.com/MedicationHealthNews

Natural Medicines Comprehensive Database

❖ Referenced, Peer Reviewed Continuously Updated❖ Search brand names❖ http://www.naturaldatabase.com❖ Medline Plus - free patient’s monographs

Natural Standard

❖ Extensive, well researched monographs❖ Graphic representation of strength of evidence❖ http://www.naturalstandard.com

Consumer Labs

❖ Information on Quality❖ Inexpensive; From Natural Pharmacist❖ http://www.consumerlab.com

AltMedex

❖ Part of Micromedex - in 1.0, will be eventually in 2.0❖ Well referenced, lengthy “evaluations”❖ Includes Commission E monographs & Herbal

Medicines: a guide for healthcare professionals❖ For toxicities and ID’s also consider Poisondex

HerbMed/HerbMed Pro

❖ Now part of American Botanical Council❖ Linked by categories; linked to PubMed❖ Unique information - patents, maps, images❖ http://www.herbalgram.org

IBIDS - From NIH (Free)

Mobile Resources❖ Extensive, well researched

monographs❖ ePocrates Pro❖ 5-Minute Consult❖ Mobile Micromedex❖ Natural Medicines

Comprehensive Database❖ Natural Standard❖ Office of Dietary

Supplements mobile app❖ Number of other providers

Summary❖ Understand regulatory issues related to herbs and dietary

supplements

❖ Familiarize yourself with most prominent information resources - books, databases, web sites

❖ Learn 20-25 most commonly used supplements

❖ Learn several toxic plant commonly found on the market and understand the reasons to avoid them

❖ Know local resources for additional information, referral and purchasing

References❖ Mills, S., Bone, K. The Essential Guide to Herbal Safety. Churchill

Livingstone. 2004

❖ Brinker F, Stodart N. Herb Contraindications and Drug Interactions. Eclectic Medical Pubns. 3rd edition. 2001

❖ Braun L, Cohen M. Herbs & Natural Supplements: An Evidence-Based Guide. 2010

❖ Berardi R, et. al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. APhA Publications. 16th edition. 2009

❖ Jellin J, ed. Natural Medicines Comprehensive Database. Accessed March 2013

❖ Ulbricht, C and Basch, E., eds. Natural Standard. Accessed March 2013

“A thing is right, if it tends to preserve the integrity, stability, and beauty of the biotic whole.”

Aldo Leopold

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