Transcript CAM Herbs - American Academy of Pediatrics

Herbs Every
Pediatrician Should
Know
Kathi J Kemper, MD, MPH
Director, Center for
Integrative Medicine
Professor of Pediatrics and
Public Health Sciences
Wake Forest University
Health Sciences
Disclaimer
• I have the following financial relationships with
the manufacturer(s) of any commercial
product(s) and/or provider of commercial
services discussed in this CME activity:
American Academy of Pediatrics, “Mental
Health, Naturally “ Author. Royalties
anticipated.
• The presentation will include no description of any
proprietary items for screening, diagnosis, or
treatments.
• I do not intend to discuss an unapproved or
investigative use of a commercial product in my
presentation.
Objectives
By the end of this presentation,
participants will be able to:
• Describe the role of herbal medicine
in the overall scheme of health care
• Identify at least one herbal product
they already use
• Confidently and effectively ask
patients about their use of herbal
products
• Use evidence-based resources to
advise patients about the safe and
effective use of herbal products and
report adverse events
Integrative Approach –
herbs’ role?
• Lifestyle – Environment,
Exercise/Sleep, Nutrition,
Mind-Body
• Supplements, including
herbs; vitamins, minerals,
amino acids, hormones,
medications
• Massage, PT, chiropractic,
osteopathic, surgical and
other biomechanical
approaches
• Biofield therapies
Role of herbs; ask all
• NOT a replacement for fundamentals
• May be a useful adjunct if used
wisely
• Patients may be using; ask!
• What is this patient ALREADY
taking???? Ephedra? Laxative herbs?
Diuretic herbs? Stimulant herbs?
Asking patients
• By show of hands, how many
people in this room use an
herbal product 4 + days
weekly to achieve a health
goal?
Common, unconscious
• When you ask, give examples!
• For example, coffee, tea,
commonly used products for
age/gender/condition
• For children - echinacea,
goldenseal, elderberry
• For men - saw palmetto
• For women - cranberry, vitex,
black cohosh
• For elderly - ginkgo
• Unique cultural/ethnic traditions garlic, chamomile
Be Safe!
1. Ask all patients and document the product,
ingredients and manufacturer in medical record
2. Herb-drug interactions can occur
3. ‘94 DSHEA means little consumer protection;
marked variability in purity and potency
4. Use caution during pregnancy, lactation and
infancy, and with other biochemical remedies
5. Opportunity costs - using herbs when another
approach would be more cost-effective and safer
M Cirigliano, JAMA, 1998;280:1565-6
Herbs and Medication differences
•
•
•
•
•
Processing
Purity
Potency
Politics/ regulation
PR – perceptions,
marketing
• Power of advertising;
impact on peer review
1994 DSHEA on food
supplements
1. Supplements can be marketed without testing
efficacy.
2. Safety need not be proved before marketing. Burden
is on FDA to prove product is unsafe. (Ephedra was
banned in 2004 after YEARS after reports of deaths)
3. Standards not required for manufacture.
4. Structure/function product claims allowed.
5. Label claims do not require extensive evidence.
6. FDA approval not needed for marketing claims.
More recent requirements for GMP
FTC has cracked down on marketing more in last 5
years.
Report adverse effects to FDA MedWatch
test.fda.gov/medwatch/
http://www.fda.gov/downloads/Saf
ety/MedWatch/HowToReport/Downl
oadForms/ucm082725.pdf
Toxicity
• Herbs themselves; direct (eg
allergies or rashes from
echinacea)
• Natural variability
• Wrong or diluted product
• Wrong dose (Excessive
ephedra)
• Manufactured NOT customary
(kava)
• Heavy metals (Ayurveda,
Mexican, Asian - melamine,
anyone?)
• Drugs; intentional “spiking”
Safety Summary
• Herbs are not
necessarily safe just
because they’re
natural
• Herbs work
biochemically
• FDA regulation
needed to assure
purity/potency
IF YOU BUY HERBS,
• Manufacturer has base in Germany,
France or Canada
• Label:
– Scientific (Latin species) name of
plant
– standardized extract
– expiration date, lot #
– source (leaves, root, flower, etc.)
• Local manufacturer whose plant you
have visited?
• CAN YOU RECOGNIZE IT?
Skin
• You have just spent a
little too much time in
the sun, getting your
vitamin D and
enjoying the pools
and beach
• Skin is red, not
blistered
• What herbal product
can you use to help
relieve the pain and
promote healing?
Aloe vera - History and
Common uses
• used by Egyptians
(Cleopatra’s beauty
secret?), Greeks,
Chinese, Ayurveda,
S. Africa, S.
America
• Used for:
– burns and skin
irritations
– ulcers, canker sores
– laxative
Aloe - active
ingredients
• glucomannan - emollient polysaccharide
• carboxypeptidase - bradykininase, reduces
pain
• magnesium lactate; zinc, calcium,
glucose, cholesterol, triglycerides
• salicylic acid and other anti-prostaglandin/
anti-thromboxane compounds
• acemannan - immune stimulator
• aloin or barbaloin- strong laxative; uterine
contractions?
Aloe - scientific evidence
of effectiveness
• minor burns and wound healing,
comparable to Silvadene; good
antibacterial properties
• acemannan stimulates killer T cells and
fights viral replication, including HIV;
increases WBC in HIV infected persons;
no studies on aloe affecting AIDS clinical
course
• preliminary studies suggest potential use
in duodenal ulcer, canker sores
• barbaloin, aloin are potent cathartics
Aloe - bottom line
• good for home treatment of minor
wounds including burns, scrapes,
etc.
• possibly useful for canker sores
• very safe for external use
Nervines
You have just had a rough day at the
office. You come home and try to
decide which herbal product might
help you relax. Assuming you aren’t
allergic to any, which of the following
“herbal remedies” is safest?
A. Beer
B. Whiskey
C. Chamomile/lemon balm tea
D. Kava kava
Chamomile
• Mild anti-inflammatory
• Mild sedative (stress,
insomnia)
• Mildly relaxes intestinal
spasms (colic)
• Yes, Peter Rabbit’s
mother was on to
something (1 Tablespoon
to be taken before
bedtime - rabbit dose)
Chamomile - Biochemistry/
Active Ingredients
•
•
•
•
chamazulene
alpha-bisapolol
apigenin
flavonoids and other
antioxidants
Chamomile - Scientific
Evidence
• apigenin binds GABA receptors - like
many sedatives
• RCT of essential oil fragrance in young
adults: signif. calming
• Case series:10/12 hospitalized patients
drinking c. tea slept
• Helps rats sleep
Shinomiya K. Biol Pharm Bull, 2005
• Good for stressed cows, too
Reis LS. J Vet Sci, 2006
Other herbal sedatives
• Valerian (sleep aid), hops, lemon
balm, passionflower (anxiety),
skullcap
• All recommended by German
commission E to treat restlessness
• Low risk
• Often found in combination
products
• NOT processed kava kava - potent
liver toxicity
Valerian - Smelly soporific
• Galen used to treat seizures
• 1700’s - sedative, anti-spasmodic
• WW1 - treat shell shocked soldiers;
anti-anxiety
• 120 chemical constituents; potency
varies by species and wanes over
time
• GABA receptors; positive effects in
mice and men
• Helpful for sleep, anxiety
Valerian - Scientific
Evidence: anxiety and
sleep
• RCT of 40 anxious adults; 100 mg TID X
21 d, signif improved sx compared with
placebo
• DB X-over study of 128 insomniac
adults, 400 mg qhs ->signif
improvement in sleep onset compared
with placebo
• Comparison study of 450 mg qhs:
shorter sleep onset and no hangover
• Young adults: 450 mgs qhs shorter sleep
onset and better quality of sleep than
placebo
Valerian - Toxicity/Side
Effects
• Very safe even in those who’ve taken
huge intentional ODs
• Mild side effects - headaches,
restlessness
• No apparent addictive or dependent
qualities; no interaction with EtOH
Stress, part 2
• You like caffeine, but
want to avoid the
jitteriness and
irritability. What else
might you drink?
• WHY?
Green tea
• Theanine (amino acid)
• Counteracts negative effects of
caffeine without making you
sleepy
Kimura K. Biol Psychiatry, 2007
Immune Function
• You are seeing a patient for a
health supervision visit (checkup). She is starting to develop
cold symptoms, and has taken
vitamin C and zinc lozenges,
and plans to make some
chicken soup.
• She washes her hands, sleeps
well and covers her cough.
• What herbal remedies does
evidence suggest MIGHT be
helpful (safe for most people)
to boost immune function?
Immune boosters?
• Echinacea - maybe (I do)
• Elderberry (brand tested
has been Sambucol) maybe (I do)
• Ginseng (brand tested has
been Cold-FX) - maybe (I
do)
• Astragalus - maybe (I
don’t)
Echinacea- Botany
• Activity varies by
species, part used,
harvest timing,
preparation, storage
• MANY different
constituents
Echinacea - Scientific
Evidence: Immune System
• Polysaccharides increase #
WBCs released from bone
marrow; activate
phagocytosis; enhance
production of TNF, interferon,
interleukeins 1 and 6
• Inulin stimulates alternative
complement pathway
Echinacea - Scientific
Evidence
• E. purpurea extracts taken daily in high doses
– reduce the number of cold and flu symptoms in
adults
– reduce the number of colds acquired by adults
• No benefits on cure kids; may help prevention
• Safety - some allergies (skin rashes)
Linde K. Cochrane Database Rev, 2006
Weber W. J Alt Comp Med, 2005
Taylor JA. JAMA, 2003
Elderberry
(Sambucol)
• used in folk medicine to treat
influenza, colds and sinusitis
• has antiviral activity against
influenza and herpes simplex
• RCT of adults with < 48 hours
influenza symptoms given 15 mL
QID, significantly reduced length of
symptoms
Zakay-Rones Z. J Int Med Res, 2004
Barak V. Isr Med Assoc J, 2002
Vlachojannis JE, Phytother Res. 2010
Ginseng
• 5 Canadian studies including > 700 adults
of Cold-FX, suggest it can help PREVENT
and reduce duration (by nearly 6 days) of
viral respiratory infections in adults
• 1 study shows it is feasible to give to
children
Seida JK. Evid Based Complement Alternat Med. 2009
Vohra S. Pediatrics, 2008
Case: Migraines
• 17 year old with recurrent migraines. She
keeps a headache diary, avoids triggers, gets
enough sleep; she has started B2
supplements, 5-HTP supplements, fish oil; is
thinking about massage and acupuncture. She
does not want to take drugs.
• Which herbal supplements might be helpful?
–
–
–
–
Ginger for nausea
Feverfew - for prevention
Butterbur (UPA-free)
All of the above
Ginger (Zingiber officinale)
• related to turmeric and cardamom
• contains: shogoal, gingerols
(sesquiterpenes), bisabolene,
zingiberene, zingiberol
• RCT: + effects on nausea and
vomiting with chemo, motion
sickness, pregnancy, post-op
• Safe- rare allergies, upset stomach
• Dose: 500 - 1000 mg/QID or tea ad
lib
White B. Am Family Phys, 2007
Feverfew: Tanacetum
parthenium
• Purity and potency vary
markedly between products;
British > American products in
general; higher with spring
harvest; look for at least 0.2%
parthenolide content
• 3+ RCT show 25-50 mg daily
help prevent migraines
• Safety: 10% mouth sores;
rebound if stopped
Tepper SJ. Curr Pain Headache Rep, 2008
Feverfew - Scientific
Evidence: Migraines
• Parthenolide reduces platelet activation
• P. prevents release of arachidonic acid and
serotonin, reducing prostaglandin-mediated
inflammation
• P. reduces damage to microvessel walls
• 3 RCT in humans show that 2-3 fresh leaves
(25-50 mgs BID of dried leaves) effectively
prevent migraine, and rebound HA when
leaves stopped
• NOT effective in treating HA acutely
Butterbur (Petadolex)
• 2 RCTs before 2006; 293 adults; 150
mg daily showed benefits, but not 100
mg daily
• 2008 German RCT in children showed
positive prophylactic effect (brand
used in most studies is Petadolex)
• Must be UPA-free!
Oelkers-Ax R, Eur J Pain,
Sadler, Pediatrics in Review,
Oelkers-Ax R. Eur J Pain,
Agosti R. Phytomedicine,
Pothman R. Headache,
2008
2007
2008
2006
2005
Depression case
•15 year old landscaper with recurrent
depression; gets plenty of exercise;
poor sleep; junk food junky, unwilling to
change; just broke up with girlfriend;
lost his job
•Is St. John’s wort a good idea?
(Note: if he asks you, he’s probably
already using it. Ask about which
brands he’s tried and what he’s already
read on the internet)
St Johns Wort
• Depression – possibly
effective 300 mg three
times daily
http://nccam.nih.gov/healt
h/stjohnswort/
• Sunburn
• Interferes with many other
medicines
• Which brands contain what
they say they do?
• http://www.consumerlab.c
om/results/sjw.asp
Resources
• Free
– NIH NCCAM
– *NIH MedLine Plus
– WFUBMC - BestHealth
• Subscription, but worth it
– Natural Medicines Comprehensive Database
– Natural Standard
– ConsumerLab.com
Suggested Practice
Changes
• Try drinking green tea to see how it affects you
• Try an aloe product on your next sunburn or canker
sore.
• Try using echinacea, ginseng, or elderberry for your
next cold
• Ask at least 50% of patients in the next week about
their use of herbs
• Advise your patients who use herbal products to avoid
herbal products from developing countries
• Ask your assistant to print out the FDA MedWatch form.
• Subscribe to an herbal information resource for 1 year
to see how useful it is in your practice.
• Join the AAP SOCIM ([email protected] or
www.aap.org/sections/chim/
Extra Info Slides
Product variability ginseng
• 25 commercial products
analyzed
• All products contained species
listed on label
• Ginsenoside concentrations
varied 15 and 36 fold in
capsules and liquids,
respectively
• Eleutheroside concentrations
varied 43- and 200- fold in
caps and liquids respectively
Harkey, et al. Am J Clin Nutr,
2001
Heavy metals in folk
remedies
• Lead (12 cases in US in 2002-2003
from Ayurvedic herbs from India)
• Mercury in TCM
• Arsenic and Mercury in Chinese herbal
balls
• AVOID HERBAL PRODUCTS FROM
DEVELOPING COUNTRIES
MMWR, 2004
Occup Environ Med, 1998
Also for Depression
• Saffron
• Studies from Iran suggest it
is as effective as
antidepressant medications
with fewer side effects
• Expensive to get the real
thing
• No insurance coverage
Curcumin (Turmeric)
• Anti-inflammatory (inhibits LOX and COX-2)
• Antioxidant; free radical scavenging
• 19 ongoing clinical trials for chemoprevention
of cancer; may reduce multi-drug resistance
and protect normal cells
• Increases antibacterial effects of commonly
used antibiotics
• Neuroprotective effects (Alzheimer’s
prevention?)
• Absorbed better with oil and black pepper
• Safety: causes biliary contractions (avoid if
stone history); inhibits platelet aggregation