Transcript CAM - Northeast Regional Epilepsy Group

What do we know about
alternative treatments of
epilepsy"
Enrique Feoli MD
North East Regional Epilepsy
2014
Alternative Treatments
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Complementary and Alternative medicines
(CAM)
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Non conventional therapies
Herbs and Epilepsy
CAM
Complimentary and Alternative
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CAM
On the rise
 42% US
 65% Germany
 20% UK
 1/6 people taking Rx also take Herbal
 > 50 y.o.: 2.66 herbals and 2.26 Rx
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CAM
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< 40% share their use with Drs.
Legislation requiring regulation/licensing of
Herbs in Germany, France, Sweden, Australia.
In US the Dietary Supplement Health and
Education Act of 1994 removed these products
from FDA jurisdiction
Herbs for Epilepsy
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Valerian root
Skullcap
European Mistletoe
Marijuana
Black cohosh
Lobelia
Kava
Hyssop
Blue vervain
Yarrow
Geranium
Kelp
Bupleurum
Passion flower
Carline thistle
Elderberry
Mugwort
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Lady’s slipper
Aloe
Betony
European Peony
Ginseng
Flax seed oil
Ginger
Linden
Chrysanthemum
Forskolin
Behen
Burning bush
Calotropis
Gotu Kola
Groundsel
Lily of the Valley
Tree of Heaven
Yew
How often do people take herbs?
Overall use of complementary and alternative
medicines (CAM) in U.S. 1990-1997.
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Herbal product use increased 4x
In 1997, adults - 33 million office visits regarding herbal
products & high-dose vitamins; spent ~$8 billion
In 1997, ~15 million adults took prescription medications
with herbs and/or high-dose vitamins
Eisenberg et al. JAMA 1998;280:1569-75.
How often do people take
herbs?
Herb
Top 10 selling
herbs and
dietary
supplements:
2002
U.S. sales
($ millions)
Gingko biloba
150
Echinacea
70
Garlic
50
Ginseng
40
Soy
35
Saw palmetto
30
St. John’s wort
30
Valerian
16
How often do persons with epilepsy
take herbs?
U.S. and England studies:
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Up to 1 in 3 persons with epilepsy use CAM
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Most do not discuss their CAM use with doctors
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Herbs taken include ginseng, St. John’s wort, melatonin, gingko
biloba, garlic and black cohosh
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Treat seizures (<10%), other symptoms (20%), and general health
(>70%)
Peebles et al. Epilepsy Behav 2000;1:74-7
Easterford et al. Epilepsy Behav 2005;6:59-62
Federal regulation of herbs
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Herbal products are classified by the
government as dietary supplements.
Dietary supplements are regulated by the 1994
Dietary Supplement and Health Education
Act (DSHEA); prescription drugs - much
more rigorous requirements of the Federal
Food, Drug, and Cosmetic Act.
Federal standards by DSHEA
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Claim -- an effect on bodily structure or
function, not against a specific disease.
Label must include a disclaimer that FDA
has not evaluated the product
Federal regulation of herbs
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Not required to be produced under Good
Manufacturing Process standards, like drugs
No government agency (eg, FDA) independently
verifies the quality/production
Could be contaminated with microbes, pesticides,
toxic metals, or adulterated (eg, herbs or drugs)
Potency and amount per pill/capsule may vary
significantly within the same bottle or from batch to
batch, or from one branded product to another
Federal regulation of herbs
Standards set forth by the DSHEA:
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Manufacturers are responsible for the truthfulness of
labeling claims
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No government agency independently reviews and
verifies the claims and supporting evidence
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Only manufacturers control product quality and
verify safety
Standardization
How much of the active ingredient?
For example, bottle says “carbamazepine 200 mg”
This is a major problem for herbal products because
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the active ingredient (s) are usually not known
the amount of the assumed active ingredient may vary from pill to pill
and product to product
it is usually not possible to measure levels in the blood to guide dosage
? The active ingredient
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St. John's wort standardized by its content of hypericin
(typically to 0.3% hypericin)
Hypericin not confirmed as the active ingredient
Case
40 y/o woman with epilepsy well controlled on CBZ
Was feeling depressed and began to take St John’s wort.
She had multiple recurrent seizures and came to the office for a follow up.
She did disclose that she began a over he counter tx.
Problem; St john’s W, decreases the effectiveness of CBZ
You wonder whether St. John’s wort could affect your carbamazepine or birth control
pill, and whether it is safe and actually helps depression
Herbal Anticonvulsants:
Mechanisms
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Sedative effect/improved sleep: Valerian, Kava,
Lobelia, passion flower.
Increase in brain GABA/GABA receptors
(Valerian, Kava)
Agonist of benzodiazepine receptors (Passion
flower).
Antioxidants (TJ-960)
Herb/AED Interactions
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Don’t use Valerian or Kava with alcohol,
barbiturates, benzos- sedation/coma.
Hemorrhagic complications with Gingko and St.
John’s wort.
St. John’s wort can lower carbamazepine levels.
Shankapulshpi (Ayurvedic formula) decreases 1/2
life of phenytoin and decreases its efficacy.
Tell your physician about herb use; anticipate
potential for interactions.
Herbs and Seizure Medications
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Increase Side effects
Valerian Root
 Kava Kava
 Passion Flower
 Chamomile
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Herbs that cause Seizures
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Kava Kava: GTC from toxicity and withdrawal.
Marijuana: intoxication or withdrawal.
Skullcap: confusion and convulsions with high doses.
Ma Huang: has ephedrine, pseudoephedrine, lowers
threshold.
Gamolenic acid lowers seizure threshold: evening primrose
oil, borage (starflower).
Goldenseal: hydrastine lowers threshold.
Ginseng: lowers threshold.
Ginkgo biloba: GTCs reported. Neurotoxin 4’-omethylpyridoxine.
Thujone-containing herbs: wormwood, sage; lower
threshold.
Herbs and seizures
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Worsen seizures
Ephedra
 Ma Huang
 Mate
 Guarana
 Borage oil
 ? Ginkgo
 ? Ginseng
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Bad
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Effects on Serum Concentration of AED’s (HerbDrug interactions) P450 enzymes:
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St. John’s wort
Garlic
Echinacea
Pine bark extract
Pygenol
Milk thistle
American hellebore
Gingko
Mugwort
Pipissewa
Side-Effects of Herbs
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Natural doesn’t equal safe!
Herbs and herbal preparations contain many
compounds.
Black cohosh, Valerian, green tea have
tannins - can affect absorption of Ca, Cu, Fe,
Mg.
Black cohosh can cause miscarriage via
uterine stimulation.
Lobelia - respiratory paralysis and death.
Samuels et al, 2008
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What are the Ingredients?
Epi-Still is a 100% herbal formula and contains
the following ingredients in therapeutic dosage:
Passion flower, Skullcap, Cicuta virosa (30C),
and Cuprum metallicum (30C).
Hello. I was just wondering if anyone has heard of the herbal medication for seizures called Epistill? I
Synergy 02
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More than 70 minerals
More than 18 amino acids
Plant source silica
Active ingredient?
 Is it just water and minerals?
 No trails/tests indicating that
is useful
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Take Home
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In any given person herbs may be helpful, but in most
they likely are not
In any given person herbs may worsen epilepsy
Herbs definitely can effect AED levels
No good studies
Communication between doctors and patients is crucial
Perspective
Part II
 Non
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Conventional Therapies
Yoga
Biofeedback
Aromatherapy
Acupuncture
Non Conventional Therapies
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Yoga
Biofeedback
Aromatherapy
Acupuncture
How effective are alternative or
complementary approaches to epilepsy?
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No scientific research in epilepsy and there is
very little evidence of their effectiveness
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Some people who have tried complementary
treatments have felt that these have helped their
epilepsy and improved their quality of life.
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Certainly, reducing stress can reduce seizures in
some people, and or improve quality of life.
Can relaxation, yoga control
epilepsy?
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Some people have found that yoga or meditation
helps them prevent stress-induced seizures and
improves their quality of life
Can epilepsy be controlled by
acupuncture?
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the goal is to bring the person's health into a
better mental, physical and emotional balance.
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Acupuncture has been used in patients with
epilepsy with mixed results.
Can epilepsy be controlled using
aromatherapy?
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Aromatherapy uses pure aromatic oils from
plants for stimulation and relaxation and to aid
the healing process. Dr. Tim Betts, a British
researcher, has had some success using oils on
patients with epilepsy who can predict an
imminent seizure.
Can epilepsy be controlled through
biofeedback?
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Biofeedback for epilepsy uses EEG machines to
help people identify and alter their own seizurerelated brain activity. The person with epilepsy is
trained over time to use relaxation or other
biofeedback techniques to generate a more
normalized brain wave pattern, which may in
turn reduce their seizures.
Take Home
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There are no scientific studies that support the
use of non conventional therapies to control
seizures.
Some has shown to improve quality of life
(yoga)
Discuss with your doctor before starting any
non conventional therapies
Thank you for coming!
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