Transcript www.med.umich.edu

Herbs and Health:
Real World Basics
Sara L. Warber, MD
Co-Director, UM Integrative Medicine
Assist Prof, Dept of Family Medicine
Context
Historical Context
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Physical evidence dates
back 60,000 years
All cultures have traditions
of herb use for healing
2000 BC - First known
materia medica in Sumeria
1st Century AD - Chinese
Materia Medica
Cultural Context
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In China, 40-50% of meds used are
traditional herbs
In Africa, 80% of population uses herbal
medicine for primary care
In Germany, 90% of adults use herbs in
lifetime
Ethnic populations in US very likely to be
using herbs
25% of prescription drugs from plants
Pediatric Herbal Remedies
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Aloe vera
43%
Chamomile tea 29%
Echinacea
28%
Garlic
11%
Ginger
11%
Tea tree oil
8%
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Ottolini MC. Ambulatory Peds Mar-Apr 2001
Goldenseal
Ginseng
Ginkgo biloba
St John’s wort
Feverfew
7%
5%
4%
4%
4%
Asking about herbs
Do we really need to ask?
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458 VA patients (Pittsburgh, LA)
43% taking herbs/supplements plus
medications
2% at risk for serious adverse event
42-48% at risk for minor adverse events
59-88% never asked by physicians about
use
Glassman P. quoted in Family Practice News. June 15, 2000.
Regulations
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Federal Trade Commission (FTC)
Food & Drug Administration (FDA)
Role of FTC
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FTC governs the advertising and
promotion of herbs and dietary
supplements. It can:
– Outlaw unfair or deceptive practices
– Stop unsubstantiated advertising
– Investigate complaints and seek civil
penalties for violations of trade
regulations
Role of FDA
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Stop the marketing of toxic or unsanitary
products
Stop the marketing of products with false or
unsubstantiated claims
Take action against a product which poses “ a
significant unreasonable risk of illness or
injury”
Prohibit claims that a product cures or treats
a disease
Stop the marketing of a new (post 1994)
dietary ingredient if safety data is lacking
Case study: Ephedra
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Ephedra HWLDS - 0.95 kg lost/mo
Ephedrine alone - 0.5 kg lost/mo
Ephedrine/caffeine combo - 1.0 kg
lost/mo
Ephedrine/caffeine modest dose
response effect over multiple trials
Rand Meta-analysis
Ephedra/Ephedrine Safety
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RCTs - no serious adverse effects
Sentinel events: MI, CVA, seizures, &
psychiatric cases.
Adverse events reports
– Ephedra - 21 sentinel serious adverse
events (including 2 deaths)
– Ephedrine - 11 sentinel events (including
3 deaths)
Rand Meta-analysis
Expertise – Who has it?
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Consumer/patient
Clerk in store
Herbalist – what tradition? How certified?
Chiropractor (DC)
Nutritionist (RD)
Pharmacist (PharmD, PhD)
Naturopathic Doctor (ND)
Board Certified Holistic Physician (MD, DO)
Fellowship-trained Integrative Physician
Evidence
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Traditional use
Basic science
Clinical science
Traditional use
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Often based on
hundreds to thousands
of years of observation
60-70% of traditionally
used herbs are
pharmacologically
active
German Commission E
Traditional
preparations
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Infusion - flowers and leaves steeped
in hot water, ie, teas
Decoction - bark, roots or seeds boiled
in water
Tincture – extraction with alcohol or
vinegar or glycerin and water
More preparations
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Capsules
– dried and ground herbs in a gelatin or
vegetable capsule
– dried extract of plant part
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Salve - an oil and beeswax/lanolin
mixture used topically
Basic Science
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Mechanism of action
Pharmacokinetics, etc
Toxicity
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Often done AFTER clinical studies
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Clinical Science
Federally funded studies
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Echinacea
Ginseng
Gingko biloba
Garlic
SJW
Peppermint
Ginger
Soy
Chamomile
Kava kava
19
22
8
48
28
0
9
>200
1
6
Problems
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Toxicity
Interactions
Adverse reactions
Toxicity
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Renal toxicity
– Stephania
(Fang ji)
– Aristolochia
(Fang chi)
Lobelia
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Yohimbe
Liver toxicity
– Chaparral
– Comfrey
– Germander
– Jin Bu Huan
Physician Actions
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Avoid products with multiple herbs
Consider following LFT’s, BUN, Cr
Consider herbs in differential
Obtain samples when problems
suspected
Report to MedWatch 1-800-332-1088
Interactions
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St John’s wort
– Studies - digoxin,
protease inhibitors,
TCAs
– Case reports cyclosporine, warfarin,
oral contraceptives,
theophylline, SSRIs
– Theoretical - iron
Adverse Reactions
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52 y.o. male for R knee replacement
Surgery went well, some oozing of
blood
Continued bleeding post operatively
Smart medical student saves the day
– Ginkgo biloba, garlic, green tea
Product Quality
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Genetics, growing conditions,
harvest time, product preparation
Misidentification, contamination,
adulteration
Quality Solutions
Standardization
 Independent testing
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– www.consumerlab.com
– www.nsf.org
Searching for answers:
real world work
Health Professional’s Actions
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Honor your patients reasons for usage
Encourage open communication
Read about herbal remedies
Be honest about what you learn
Avoid criticism
List herbal remedies in the patient
chart
Weigand JM et al, FP Recertification, 22(9):45-62