Transcript Complementary Therapies

Complementary and Alternative Medicine
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Complementary and Alternative therapies tend to
focus on the whole person, taking into
consideration an individual’s physical, emotional,
mental and spiritual health
– http://www.mayoclinic.org/healthy-lifestyle/
consumer-health/in-depth/alternativemedicine/art-20045267
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Terminology r/t Complementary and
Alternative Medicine (CAM)
• Complementary and alternative medicine (CAM) is the popular term for health
and wellness therapies that have traditionally not been part of conventional
Western medicine.
• “Complementary” refers to using a non-mainstream approach together with
conventional medicine (eg using acupuncture to help with side effects of
cancer treatment
• “Alternative” refers to using a non-mainstream approach in place of
conventional medicine (eg using certain diets to cure cancer instead of
surgery, chemo, radiation, or biological modifiers)
• “Traditional” generally refers to knowledge, skills, and practices based on the
theories, beliefs, and experiences indigenous to different cultures used for
health (WHO).
• “Integrative care” results when health care providers and facilities offer both
types of care.
• “Natural” treatments are not necessarily natural… and they’re not necessarily
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safe!
What is considered an “alternative” therapy?
– Types of therapies that are broadly identified as
“alternative” change over time
– See the National Center for Complementary and
Alternative Medicine (NCCAM)
– http://www.mayoclinic.org/healthy-lifestyle/consumer-health/indepth/alternative-medicine/art-20045267
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Examples of alternative therapies -per NCCAM
• Whole medical systems- philosophy-based practices, such as:
ancient healing systems (eg ayurveda from India, or traditional Chinese
medicine); homeopathy (minute doses of a substance that cause
symptoms to stimulate the body's self-healing response); naturopathy
(focuses on noninvasive treatments to promote innate healing,
incorporates variety of practices, eg massage, acupuncture, herbal
remedies, exercise and lifestyle counseling)
• Mind-body medicine- meditation, prayer, relaxation, yoga, art therapies
• Biologically based practices - treatments use ingredients found in
nature, eg herbs (ginseng, ginkgo, echinacea, etc.); dietary supplements
(selenium, glucosamine sulfate, etc)
• Manipulation and body-based practices- chiropractic or osteopathic
manipulation, massage
• Energy medicine- work with a person’s chi, prana or life force. Energy
therapies include qi gong, therapeutic touch, reiki and magnet therapy.
• Distinctions between therapies aren't always clear-cut. Some systems
use techniques from more than one category. http://www.mayoclinic.org/healthy-lifestyle/consumer5
health/in-depth/alternative-medicine/art-20045267?pg=2
Also see National Center for Complementary and Alternative Medicine (NCCAM)
CAM Use
• Most CAM studies in the U.S. show that few people forego
conventional medicine.
• However, the percentage of the US population that reports
using some form of CAM is:
– approximately 38 percent of adults (about 4 in 10)
– approximately 12 percent of children (about 1 in 9)
• Usually used for symptoms, not cure
• Nonvitamin/ nonmineral natural products and deepbreathing exercises are the most common forms of CAM
used
• Use has increased for several therapies, including deep
breathing exercises, meditation, massage therapy, and
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yoga.
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https://nccih.nih.gov/sites/nccam.nih.gov/files/news/camstats/2007/72_dpi_CHARTS/chart5.htm
Top 10 Selling Herbal Supplements in 2010
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Cranberry
Saw Palmetto
Soy
Garlic
Ginkgo
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Echinacea
Milk Thistle
Black Cohosh
St. John’s Wort
Ginseng
http://ahpa.org/Portals/0/pdfs/2011%20AHPA%20Annual%20Report_FINAL.pdf
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https://nccih.nih.gov/sites/nccam.nih.gov/files/news/camstats/2007/72_dpi_CHARTS/chart6.htm
What health conditions are people
using herbs or supplements to treat?
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Female hormonal imbalance/menopause – soy, black cohosh
Urinary problems - cranberry, saw palmetto
CV risk/cholesterol – garlic, milk thistle
Arthritis – omega 3, glucosamine, chondroitin, co-enzyme Q-10
Overall wellness & vitality – combination herbs, omega-3, co-E
Q10, ginseng
• Colds/immune support - echinacea
• Cognitive problems – ginkgo
• Depression – St, John’s Wort
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Dietary supplements…
• … are defined by FDA as “vitamins, minerals, herbs or other botanicals,
amino acids, and substances such as enzymes, organ tissues,
glandulars, and metabolites” intended to supplement the diet and to
promote health and relieve symptoms of disease.
• … are regulated under:
1) Dietary Supplement & Health Education Act of 1994 (DSHEA)
2) Dietary Supplement and Nonprescription Drug Consumer
Protection Act (2006)
3) Current Good Manufacturing Practices of 2007 (CGMPs)
• Nonetheless, as of 2016, these products can STILL be marketed
WITHOUT ANY PROOF OF SAFETY OR EFFICACY
• Label: must identify product as a dietary supplement
 must state: This product is not intended to diagnose, treat, cure or
prevent any disease.
 may insinuate specific benefits to body structure or function but
may not overtly claim
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Dietary supplements, cont’d
• Current Good Manufacturing Practices of 2007 (CGMPs) is a set of
standards issued by the FDA in response to serious concerns listed
below. These practices were designed to ensure that:
 Dietary supplements be devoid of impurities, adulterants (such as
heavy metals, toxins, pharmaceuticals)
 Labels accurately reflect the identity, purity, quality or strength of
what’s inside
 Label lists active and inactive ingredients
• Dietary Supplement and Nonprescription Drug Consumer Protection
Act (2006)
 Mandates reporting of serious adverse events for nonprescription
drugs and dietary supplements such as deaths; hospitalizations;
life-threatening experiences; persistent or significant disabilities;
or birth defects.
 Manufacturers and distributors must report these to the FDA
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within 15 days.
Concerns about CAM Therapies
• People typically don’t tell their providers about CAM
– Health professionals need to non-judgmentally address CAM in
the medication history. Concern for medication interactions,
disease intx or organ effects
– ?pro-active education?
• Safety
– Adverse effects of the herb/supplement
– Drug-herb Interactions – direct or indirect effects
– Contaminants – toxins or pharmaceuticals
• Efficacy
– Will it treat the problem?
– Is the patient foregoing potentially effective treatment?
– Placebo effect can be strong!
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Drug-Herb Interactions
 Principal concerns are for
1. increased toxicity
2. decreased therapeutic effects
 Major Types of interactions:
• Pharmacokinetic or pharmacodynamic mechanisms
 Induction of Cytochrome P450 enzymes
 St. John’s Wort
 Inhibition of Cytochrome P450 enzymes
 Resulting in:
 Additive, Synergistic, or Potentiating effects- Increasing/
magnifying the same effects
 Inhibition, Antagonism- Exerting opposite effects
 Or something entirely new and different
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Most Common Drug-Herb Interactions
• “The popularity of herbal medicinal products (HMPs)
makes it important to understand potential interactions
between herbs and prescribed drugs. The likelihood of
herb-drug interactions could be higher than drug-drug
interactions, if only because drugs usually contain single
chemical entities, while almost all HMPs (even single-herb
products) contain mixtures of pharmacologically active
constituents.” Fugh-Berman, A., and Ernst, E., (2001)
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Most Common Drug-Herb Interactions
• St John’s Wort – of herbs, most intx
• Warfarin- of drugs, most intx;
– 8 of the 10 most widely used supplements have the potential to interact with
the blood-thinning medication warfarin – mayoclinic,org
• “Patients taking drugs with a narrow therapeutic index
(cyclosporine, digoxin, hypoglycemic agents, lithium, phenytoin,
procainamide, theophylline, tricyclic antidepressants, and warfarin)
should be discouraged from using herbal products. All drugs with a
narrow therapeutic index may either have increased adverse effects
or be less effective when used in conjunction with herbal products.“
• Crit Care Nurse. 2002 Apr;22(2):22-8, 30, 32; quiz 34-5. Herbal
remedies: drug-herb interactions. Kuhn MA1.
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Clinical herbal interactions with conventional drugs:
from molecules to maladies.
Curr Med Chem. 2011;18(31):4836-50.
• Limited clinical studies and case reports have identified a
number of herb-drug interactions potentiated by the
concurrent use of herbal medicines with prescription drug.
• Drugs that have a high potential to interact with herbal
medicines usually have a narrow therapeutic index,
including warfarin, digoxin, cyclosporine, tacrolimus,
amitriptyline, midazolam, indinavir, and irinotecan.
• Many of them are substrates of cytochrome P450s (CYPs)
and/or P-glycoprotein (P-gp).
• Herbal medicines that are reported to interact with drugs
include garlic (Allium sativum), ginger (Zingiber officinale),
ginkgo (Ginkgo biloba), ginseng (Panax ginseng), and St.
John's wort (Hypericum perforatum).
• Well-designed studies are warranted to address the
mechanisms and clinical significance of important herb-drug17
interactions.
The clinical consequence of herb-drug interactions
varies from being well-tolerated to moderate or serious
and even life-threatening events.
• garlic has been shown to increase the clotting time and international
normalized ratio (INR) of warfarin, cause hypoglycaemia when taken
with chlorpropamide, and reduce the area under the plasma
concentration-time curve (AUC) and maximum concentration of
saquinavir in humans
• ginkgo may potentiate bleeding when combined with warfarin or
aspirin, increases blood pressure when combined with thiazide
diuretics, and has even led to a coma when combined with trazodone,
a serotonin antagonist and reuptake inhibitor used to treat depression
• ginseng reduced the blood levels of warfarin and alcohol as well as
induced mania if taken concomitantly with phenelzine, a non-selective
and irreversible monoamine oxidase inhibitor used as an
antidepressant and anxiolytic agent.
• Multiple herb-drug interactions have been identified with St. John's
wort that involve significantly reduced AUC and blood concentrations
of warfarin, digoxin, indinavir, theophylline, cyclosporine, tacrolimus,
amitriptyline, midazolam, and phenprocoumon.
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• Curr Med Chem. 2011;18(31):4836-50.
Resources for learning more about CAM and herbs
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Resources for learning more about CAM and herbs
http://hsl.uw.edu/toolkits/nurse
https://naturalmedicines-therapeuticresearch-com.offcampus.lib.washington.edu/
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Resources for learning more about CAM and herbs
 You can’t know everything, so know your resources
 http:hsl.uw.edu and its vetted, reviewed resources, such as …
 https://naturalmedicines-therapeuticresearch-com.
Where to get info on CAM:
 NIH: The “National Center for Complementary and Integrative Health” and the
“National Center for Complementary and Alternative Medicine (NCCAM) may be the
same resource (?)
 https://nccih.nih.gov/
 https://www.nlm.nih.gov/medlineplus/complementaryandintegrativemedicine.html
Where to get info on herbs:
 National Institutes of Health- many webpages
 Food and Drug Administration has many downloadable monographs on herbal
medicines, herbal supplements, CAM, etc
 https://nccih.nih.gov/health/herbsataglance.htm
 http://nccam.nih.gov/health/herbsataglance.htm
 https://www.nlm.nih.gov/medlineplus/druginformation.html
 Longwood Herbal Task Force – has clinician education sheets and patient education
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handouts
http://www.longwoodherbal.org/
Make time to relax!
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