Transcript Complimentary & Alternative Medical Therapies

TREATMENT INTERACTIONS &
TODAY’S MYELOMA PATIENT
Timothy Tyler, Pharm.D., FCSHP
Director of Pharmacy Services
Comprehensive Cancer Center
Desert Regional Medical Center
Objectives
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Understand at a basic level, the complexity of
current treatments for Multiple Myeloma
Review major interactions and cautions with
standard and complementary treatments
Review specific oral supplements of concern
Focus on appropriate sources of information
Have Fun (that’s okay – really!)
Comprehensive Cancer Center
Desert Regional Medical Center
Comprehensive Cancer Center
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Established in 1990 – 21st year of operation
Part of 5 cancer center chain (CA / FL / NY / NJ)
DRMC-CCC began a CAM team in 1999
Presented 6 month study at ISOPP VII (Prague)
CAM team established weekly meetings 2000
Team is composed of a Physician, Physiologist,
Pharmacist, Dietician, Social Worker
Patient satisfaction survey results demonstrate
ongoing satisfaction with service
CAM = Complementary & Alternative Medicine
The Desert Experience
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108 cancer patients from a single physician
surveyed from 1/99 through 6/99
Brief patient interview with a questionnaire
Overall 85% prevalence rate in CAM usage
About 50% of which was multivitamins or
multivitamin w/ mineral supplement
Information not volunteered prior to survey
CAM = Complementary & Alternative Medicine
The Desert Experience
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85% used at least one form of CAM (includes
multivitamin, +/- mineral combination)
52% of those using CAM take only a multivitamin, +/- mineral combination
29% used herbal preparations
13% used food derivatives/supplements
9% used (other) complementary therapies
CAM = Complementary & Alternative Medicine
Possibly Unrealistic Goals …
According to the late Varro Tyler, Ph.D., Sc.D. and
professor emeritus of pharmacognosy at the School of
Pharmacy at Purdue University, people do set somewhat
unrealistic treatment goals. If people do set unrealistic
goals for themselves as it pertains to herbal products, many
time they verge on “paraherbalisim – the belief in the
superiority of anything natural and organic”. The most
dangerous misconception that this concept brings is that
natural substances cannot cause harm. Tyler warns that
“some highly toxic substances are derived from plants.”
Foreman J. The Boston Globe 3/17/97
Traditional Oriental Medicine (TOM)
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“Traditional” medical in such places such as:
China, Japan, Cambodia, Korea, and Vietnam
Basic principles:
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Five elements of wood, fire, earth, metal, and water.
Tao = “the way”, significance of change & process
Yin & Yang = 2 opposing forces that drive change
Ch’i = invisible universal energy force that is believed to flow
through all living organisms.
Acupuncture = opens the meridians and/or directing the flow of
ch’i to promote health
Combines diet, acupuncture, meditation, physical
exercise, healing exercise, herbal medicine, and massage
to promote health.
Acupuncture
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NIH supports efficacy in the control of:
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Chemotherapy-related nausea & vomiting
Palliation of chronic pain
Studies suggest that it is reasonable to
accept the use of acupuncture in
conjunction with a standard antiemetic to
control chemotherapy-related nausea and
cancer-related pain.
NIH = National Institute of Health
Acupuncture
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Caution should be exercised in patients with:
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A compromised immune system
Affected limb of someone who has a lymph node
dissection (impaired lymphatic drainage)
Avoid insertion of needles in patients who are:
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Thrombocytopenic (low platelet counts)
Using anticoagulant therapy (warfarin, aspirin, etc)
Manual Healing Methods
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Touch and manipulation, used for hundreds of
years in the medical profession
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Three types:
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Hippocrates discussed the benefits of therapeutic
touch with students
Massage
Bodywork
Chiropractic
Use with extreme caution with bone pain and
bone disease – particularly with Multiple Myeloma
Massage
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Involves manipulation of soft tissues
Benefits may include:
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 stress aches & pain
Improved circulation
Lymph movement & motility
Enhanced digestion & intestinal function
General relaxation 
Massage Studies Results …
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Inconclusive for relief from cancer-related pain
Evidence does not indicate promotion of tumor
metastasis at this time
1 trial showed that massage reduced nausea in
patients undergoing autologous (self) BMT
2 trials found manual lymph drainage to be
effective with compression bandaging or sleeves
in patients with arm lymphedema after surgery
for breast cancer
BMT = Bone Marrow Transplant
Massage
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Studies have shown that massage can be helpful
in treating pain, anxiety, depression, and lethargy
Concerns:
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Patients who are prone to bleed, thrombocytopenic or
receiving anticoagulation therapy
Deep abdominal massage has been associated with
internal bleeding
Avoid over stents or other prosthetic devices
Multiple Myeloma patients have greater fracture risk
Agents Used in Multiple Myeloma
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IV CHEMOTHERAPY
Bortezomib (Velcade)
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Carmustine (BCNU)
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Cyclophosphamide (Cytoxan)
Doxorubicin, Lipo. (Doxil) 
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Melphalan (Alkeran)
Vincristine (Oncovin)
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ORAL CHEMOTHERAPY
Dexamethasone (Decadron)
Lenadiomide (Revlamid)
Melphalan (Alkeran)
Prednisone (Deltasone)
Thalidomide (Thalamid)
SUPPORTIVE CARE
Pamidronate (Aredia)
Zolendronic Acid (Zometa)
NOTE = Agents Listed are FDA-Approved (excluding compendia) for the treatment of Multiple Myeloma
Antioxidants vs. Chemotherapy
To date, no definitive studies in humans have
demonstrated long term effects of combining oral
antioxidants and chemotherapy. There is sufficient
cause for concern regarding potential interactions and it
should be possible to predict obvious interactions and
suggest where caution should be exercised. Improving
short-term tolerance should not come at the expense of
decreased effectiveness.
Oncology – July 1999
Bortezomib + Green Tea = Bust
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Green tea contains powerful polyphenols such as
epigallocatechin gallate (EGCG)
Preliminary research in vitro and in vivo shows green
tea polyphenols interact with Bortezomib (Velcade) and
other proteasome inhibitors.
The result is blocking the proteasome inhibitory effects
such that cell death is not induced in multiple myeloma
or glioblastoma cancer cell lines.
Patients taking boronic acid-based proteasome inhibitors
like Bortezomib (Velcade) should not take green tea.
Source = Natural Medicines Database
St. John’s Wort = No Way Jose
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St. John's Wort induces liver enzymes thus making it
problematic and somewhat patient variable
Drugs that might be affected include Chemotherapy
agents Etoposide, Paclitaxel, Vinblastine, Vincristine.
In addition, pain medications, steroids, antiemetics,
antidepressants, OTC acid blockers and numerous others
are impacted
Interaction Rating = Major (Do not take)
Severity = High
Occurrence = Probable
Level of Evidence = B
Source = Natural Medicines Database
Cyclophosphamide + Astragalus = ?
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Be cautious with taking Cyclophosphamide (Cytoxan) +
Astragalus in combination
Some evidence suggests astragalus might reduce
immunosuppression caused by Cyclophosphamide
Astragalus seems to stimulate immune function so theoretically,
taking Astragalus might decrease the effects of
immunosuppressive therapy such as steroids and chemotherapy
like Cyclophosphamide
The problem stems from when the treating clinician does not
know the patient is taking an immunomodulator
In addition to Astragalus, Alfalfa, Ashwagandha, Cat’s Claw,
Echinacea and about 38 other immunostimulants should be used
only after gaining approval from your doctor
Source = Natural Medicines Database
Chemotherapy + Alpha Lipoic Acid
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Theoretically, use of Alpha Lipoic Acid (ALA)
might decrease the effectiveness of chemotherapy.
Preliminary evidence from an unpublished study
suggests antioxidants may decrease the
effectiveness of chemotherapy
Natural Medicines Database listed this for
Bortezomib, Carmustine, Doxorubicin,
Cyclophosphamide, Melphalan, Vincristine
Source = Natural Medicines Database
Chemotherapy + Enzyme CoQ10
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Theoretically, taking Coenzyme Q-10 supplements
might prevent cardiotoxicity induced by Doxorubicin
& Cyclophosphamide
But there is also concern that coenzyme Q-10 might
lower effectiveness of doxorubicin by protecting
tumor cells from chemotherapeutic agents that work
by inducing oxidative stress
Similar concerns exists for the alkylating agents such
as Cyclophosphamide and radiation therapy
Source = Natural Medicines Database
Vitamin C and The Big ‘C’
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Dr. Linus Pauling
advocated in the 1970’s
3 trials to date using
10,000 mg daily
No difference in patient
survival has been seen
Therapy with mega doses
are not benign
Oncolink Website 3/17/2000
Vitamin C and The Big ‘C’
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The use of antioxidants like Vitamin C during chemotherapy
remains controversial
There's concern that antioxidants could reduce the activity of
chemotherapy drugs which generate free radicals
Mechanisms other than the antioxidant effects of vitamin C might
be involved. This might include prevention of the damaging to the
cell powerhouse (mitochondria) caused by many chemotherapy
drugs, which is involved in regulating cell death
In contrast, some researchers theorize that antioxidants might make
chemotherapy more effective by reducing oxidative stress that
could interfere with apoptosis (cell death) of cancer cells
More evidence is needed to determine what effects vitamin C has
on chemotherapy. Advise patients to consult their oncologist before
using vitamin C supplements, especially in high doses.
Source = Natural Medicines Database
Chemotherapy + Vitamin E
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The use of antioxidants like vitamin E during chemotherapy remains
controversial.
There's concern that antioxidants could reduce the activity of
chemotherapy drugs which generate free radicals, such as
Cyclophosphamide, Carmustine, and Doxorubicin
However, some researchers theorize that antioxidants might make
chemotherapy more effective by reducing oxidative stress that might
interfere with apoptosis (cell death) of cancer cells
More evidence is needed to determine what effect, if any,
antioxidants such as vitamin E have on chemotherapy
Natural Medicines Database advises patients to consult their
oncologist before using vitamin E supplements, particularly when
considering high doses especially with bleeding risks or surgery
Source = Natural Medicines Database
Acceptable CAM Treatments
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Nutrition – Fluid, Protein, Fat, MVI (RDA)
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Variety of fish (Omega 3 FA)
2-3 servings/day Soy in form of food
1-2 tablespoonfuls daily ground Flaxseed
Certain herbal products – consulted & supervised
Acupuncture for N/V and pain
Massage for anxiety and pain (Physician willing)
Moderate exercise (Physician willing)
Psychological and mind-body therapies
Source = Comprehensive Cancer Center CAM Team
Top 12 Notes on Medicinal Herbs
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Doctors should be asking you about your use of herbs/supplements
If they don't – volunteer the information especially when on treatment
Natural does not mean safe (strychnine is natural)
Lack of standardization: contents and efficacy may vary with brands
Lack of quality control/regulation: contamination
Do not use more than the recommended dose
Herbals generally should not be used for more than several weeks
Infants, children, and elderly should use with professional guidance
Medicinal herbs should not be taken during pregnancy and lactation
Avoid herbals that are known to have toxic/adverse side effects
Accurate diagnosis and discussion of proven treatments are essential
Stop all herbs at least 10 days prior to surgery
CAM or SHAM?
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Many have adopted a
“whatever works”
philosophy of medicine
There are products that
have documented aid
There are products with
documented harm
There are products we
don’t know much about
Web Surfing: Watch Four Red Flags
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One study suggests to avoid sites with one or more
of the following red flags:
1.
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Online purchase of described product is available.
Treatment description includes patient testimonials.
The treatment is described as a “cancer cure.”
The treatment is described as “having no side effects.”
The authors also point out that the absence of red
flags isn’t necessarily a guarantee of scientific
accuracy.
Created by congressional mandate in 1992 to “facilitate
the evaluation of alternative medical treatment
modalities”. Originally called the Office of Alternative
Medicine, it was renamed the National Center for
Complementary and Alternative Medicine in 1998. It is a
division of the National Institute of Health, which is
under the auspices of the Department of Health and
Human Services.
http://nccam.nih.gov
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Reasons People with Cancer Choose CAM
Making Choices
What is Complementary and Alternative Medicine
Types of Complementary and Alternative Medicine
Talk with Your Doctor Before You Use CAM
Natural Does Not Mean Safe!
Choose Practitioners with Care
Getting Information from Trusted Sources
Resources
Questions to ask about a Web site:
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Who runs and pays for the site?
Does it list any credentials?
Does it represent an organization that is well-known & respected?
What is the purpose of the site, and who is it for?
Is the site selling or promoting something?
Where does the information come from?
Is the information based on facts or only on someone's feelings / opinions?
How is the information chosen?
Is there a review board or is the content reviewed by experts?
How current is the information?
Does the site tell when it was last updated?
How does the site choose which other sites to link you to?
Elements of good information:
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Also Known As (AKA)
Scientific Names (geekius herbifora)
People Use This For (you’d be amazed)
Safety Profile (MANDATORY):
 Likely
Safe
 Likely Unsafe
 Definitely Unsafe
More good Elements:
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Effectiveness:
 Likely
Effective for…
 Likely Ineffective for…
 Unknown efficacy ?
Mechanism of Action
 Adverse Reactions
 Dosage and Administration
 References
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Nothing Exists in a Vacuum
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Interactions with Herbs & Supplements
Interactions with Drugs
Interactions with Foods
Interactions with Lab Tests
Interactions with Diseases or Conditions
Interactions with pocketbook!!!
Good CAM/Drug Information
Until there is a cure … There is the IMF