Transcript Complementary Therapies IJ 06092016x

Suggestions for next time
• Macuvision
• Discuss specific indications instead of genaralities eg curcumin for arthritis
(cf: anti-inflammatory)
• Problems With St John's Wort: Another important message in the
guideline is regarding the potential problems with the popular herbal
therapy St John's wort, sold over the counter at drug stores and in health
food stores. http://annals.org/article.aspx?articleid=2490527
Complementary Therapies
Ingrid Johnston
Consultant Pharmacist
Define the following
• Complementary therapy
• Alternative therapy
• Where do you find evidence for benefit or harm?
Overview
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Benefits and risks of complementary therapies
Cranberry
Calcium and vitamin D
Fish/Krill oil
Glucosamine
Curcumin
Probiotics
CoQ10
Case study
What are potential problems with
complementary therapies?
1. Adverse effects
2. Drug interactions
3. Cost
4. Delay of more effective therapy
5. False hope/disappointment
CRANBERRY
Cranberry
Main actions
– Interferes with attachment of bacteria to urinary tract
– Overall human studies suggest it does not acidify the urine
Evidence
– No evidence for treating UTIs
– Conflicting evidence but may have some benefits for UTI
prevention
Cranberry
Practice points
– Juice may contain high sugar content
– GI upset (3L or greater!)
Interactions
– Warfarin: possible so INR should be monitored
– Large amounts of juice can promote
formation of oxalate kidney stones
VITAMIN D & CALCIUM
Vitamin D
Main actions
– Essential for Ca and phosphate homeostasis
– Important for optimal bone and muscle function
– Diverse roles throughout the body
Evidence
– reduce fracture risk in older people (when combined with
adequate calcium)
– Deficiency is an independent predictor of falls
– Conflicting/unsubstantiated for many other
conditions
Which came first – deficiency or disease?
Vitamin D deficiency
Restricted/inadequate sun exposure
Medications
– Corticosteroids
– Anticonvulsants (phenytoin, valproate, carbamazepine)
Malabsorptive diseases
– Coeliac
– Crohns
– Cystic fibrosis
Other diseases
– Pancreatic insufficiency
– Chronic hepatitis
Vitamin D
Practice points
– Check levels at the end of winter or beginning of spring in
those at high risk
– Ensure appropriate levels of supplementation
Interactions
– May interfere with action of calcium channel
blockers
Vitamin D
Note:
Large annual doses of vitamin D are
not recommended either to treat vitamin D
deficiency or to prevent fractures.
Calcium
Main actions
Essential mineral for many body processes
Evidence
Prevention and treatment of deficiency for BMD and
overall health and wellbeing
Calcium deficiency
Low Vitamin D levels
Low amounts of acid in the GUT
– Calcium carbonate needs an acidic environment
– Calcium citrate does not need an acidic environment
Increasing Age
– By 65 years of age absorption is 50% of adolescent levels
Low oestrogen levels
High fibre diet
Corticosteroids
Calcium and cardiovascular risk
“Calcium intake and the risk of heart attack and stroke is the
subject of ongoing research.
Because adverse events have not been a major focus of
osteoporosis prevention trials, it is important that adverse
outcomes are verified in the available studies. When externally
verified cardiovascular disease event rates (such as heart attacks)
in women, as opposed to self-reported but non-verified events
and events occurring in men are considered, no adverse effect of
calcium supplementation and vitamin D supplementation on
heart attacks or cardiovascular events have been identified.”
- Osteoporosis Australia Statement on Calcium and
Vitamin D supplements Reviewed June 2015
Calcium – practice points
Practice points
– aim to reach total calcium dose of 1000–1300 mg/day
– when dietary intake of calcium is not sufficient,
supplements may be required at a daily dose of around
500-600 mg per day
Interactions
– Possible with many medications
FISH OIL
Fish Oil
Background
– Most studied components are omega-3 polyunsaturated
essential fatty acids
– eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA)
– most concentrated dietary source of both EPA and DHA is
deepsea oily fish
Fish vs fish oil supplements?
EPA/DHA content and ratio?
Fish Oil - evidence
Cardiovascular disease
– Fish and fish oil supplements reduce the risk of both
primary and secondary cardiovascular disease
– Decrease death from coronary heart disease
– Hypertension
– Hypertriglyceridaemia
Osteoarthritis
Rheumatoid arthritis
Fish Oil – Practice Points
Dose and duration of treatment varies
Adverse effects
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GI upset
Fishy taste/burps
Fishy odour of skin and urine
Raised LDL
Interactions
- Possible with high doses and
antiplatelets or anticoagulants
Oils ain’t oils?
Krill oil
– Lower EPA:DHA content
– Increased bioavailability
Algal oil
– Predominantly DHA
Calamari oil?
Salmon oil?
GLUCOSAMINE
Glucosamine
Main actions
– Essential for the synthesis of many body tissues including
cartilage, ligaments, tendons and synovial fluid
– Osteoarthritis
Evidence
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Conflicting for pain relief and structure-modification
Sulfate vs hydrochloride?
With chondroitin?
With methylsulfonylmethane (MSM)?
Glucosamine
Practice points
– No apparent adverse effects
– 2 to 3 month trial
– 3+ years to slow joint degeneration
Interactions
– None documented
CURCUMIN
Curcumin
Main actions
– Major constituent of turmeric
– Anti-inflammatory
– Anti-oxidant
Evidence
– Currently insufficient evidence to support use for any
health condition
Curcumin
Practice points
– Take with food to increase absorption
– May cause GI upset and bleeding
– Avoid in PU disease and GORD
Interactions
– ?antiplatelets and anticoagulants
– ?cyclophosphamide – reduced effect
Curcumin
Curcuma longa, Curcuma domestica
100-300mg standardized extract (95% curcumin) daily
Do not confuse with Javanese turmeric (Curcuma
xanthorrhiza) or Zedoary (Curcuma zedoaria)
PROBIOTICS
Probiotics
Background
– Diverse range of live micro-organisms that confer benefit
on the host
– Often from cultured milk products
– Lactobacillus, Bifidobacterium, Enterococcus,
Streptococcus, Bacillus, E.coli, Saccharomyces yeasts
Proposed actions
– Inhibit pathogens in the gut
– Enhance gut mucosal function
– Modulate host immune responses
Probiotics – evidence
Complicated by wide variety of different strains
Possible indications
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Acute infectious diarrhoea
Prevention of antibiotic associated diarrhoea
Travellers diarrhoea
Inflammatory bowel disease
Genitourinary infections
Infant colic and reflux
Probiotics
Practice points
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Take with food
Some need refrigeration
Flatulence and diarrhoea common
May need to take long term for maximum benefits
Interactions
– Antibiotics – separate dose by 2 hours
COENZYMEQ10
CoQ10
Background
– Ubiquinone, ubiquinol, ubidecarenone
– Occurs naturally in most cells
– Contained in meats and seafood
Main actions
– Antioxidant
– Membrane stabiliser
– Enzyme co-factor
CoQ10
Evidence
– ?Heart failure
– ?Hypertension
– ?Statin induced myopathy
Practice Points
– May take 10 – 12 weeks to improve heart conditions
– Food increases absorption
– May cause GI upset and skin rash
CoQ10
Interactions
– Antihypertensive – effect may be potentiated
– Cancer chemotherapy/radiotherapy – antioxidant
properties may protect tumor cells and decrease effect
– ?warfarin
– Theophylline - may delay theophylline clearance
CASE STUDY
88 year old man in residential care
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Osteoarthritis
Falls/risk of falls
Asthma
Hypertension
Ankle oedema
Vascular dementia
– Severe
• Cramps
• Parkinson's Disease
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Dyspepsia
Cataracts
Degenerative disc disease
Hearing problems
Peptic ulcer disease
Sciatica
COPD
Non-english speaking
Case Study
Prescribed medication
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Sinemet 100 mg/25 mg
Tramadol 100 mg SR
Tramadol 50 mg
Coloxyl with Senna
Lactulose
Temaze 10 mg
1 tds
1 bd
1 midday
2n
20 mL bd prn
1 n prn
Parkinson's disease
Moderate analgesia
Moderate analgesia
Constipation
Constipation
Insomnia
Ming Gold
3 at 8am & 3 at 12.30pm
Increase stamina and
performance
Orbitol Plus
2 bd
Antioxidant
Prostality
1 bd
Prostate
Orachel Tablets
1 bd
Protect against heart disease
Cascading Revenol
1n
Antioxidants
Chelamin
1 tds
Mineral supplement
Feroxin
10 mL m
Iron supplement
Carnasine Booster Patch
Apply to sternum
Tues, Thurs & Sat
To increase lifespan
Glutathione Booster Patch
Apply M, W F
(Apply 4 fingers widths below
umbilicus)
Anti-ageing
Energy enhancer patch
Apply M, W, F. On 0700 off
1900
Tan patch left side White
patch R side
Increases energy
Lactoflora Double Sachet
2m
Probiotic
Ming Dynasty VMM
3 tds .
Supports immune response
I lost count at 83 different ingredients
Issues
• Family provide the nutraceuticals as they have a business
supplying these products.
• Pharmacy packs into Websters
• Doctor orders these products on the medication chart.
• At times family do not supply stock in time so father goes
without
– This makes facility non-compliant with accreditation
standards
• Resident sometimes vomits after having these products
administered.
– Swallowing difficulties.
Traditional Chinese Medicine (TCM)
Traditional Chinese Medicine (TCM)
Evidence and where to find it
• National Institutes of Health Natural Centre for
Complementary & Alternative Medicine (NCCAM)
• MedlinePlus : Drugs, Supplements & Herbal
information
• IM Gateway – Integrative medicine
• Australian Pharmaceutical Formulary
• Braun and Cohen “Herbs and natural supplements”
• Cochrane
• Victorian Therapeutics Advisory Group
Role of the health professional
• Appreciate consumers cultural and social beliefs
– Non-judgemental
• Recognise and report adverse reactions and
interactions
• Influence on pathology results
• Provide same level of evidence based advice as with
all medicines
• Remain up to date
• Be aware of evidence on safety and efficacy
Quality Use of Medicine
• Provide latest evidence on CAMs
• Discuss use of CAMs at MAC meetings
– Draft Policy and Procedure
– Complementary Therapy Care Plan
– Sample letter to residents regarding CAMs
Summary
“There is no alternative medicine. There
is only medicine that works and
medicine that doesn’t work.”
- Richard Dawkins
Professor of the Public Understanding of Science
Oxford
What quality improvement activities are you likely to implement
following this session in regards to your own work?
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