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Herbs & Supplements

Herbs & Supplements. Did you remember to take your Gingko today ? Robert Baldor, MD Professor Family Medicine & Community Health. Why patients use CAM. 38% of US/$34 billion out-of-pocket in 2007 Arthritis/Back/Neck/Joint pain Anxiety Cholesterol management URIs Headache/Migraine

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Herbs & Supplements

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  1. Herbs & Supplements Did you remember to take your Gingko today ? Robert Baldor, MD Professor Family Medicine & Community Health

  2. Why patients use CAM • 38% of US/$34 billion out-of-pocket in 2007 • Arthritis/Back/Neck/Joint pain • Anxiety • Cholesterol management • URIs • Headache/Migraine • Insomnia

  3. A Clinician’s Perspective • What’s available • Efficacy • Safety

  4. Herbal Therapies (Top Dozen) • Gingko biloba • St John’s Wort • Ginseng • Garlic • Echinacea • Saw Palmetto • Kava Kava • Valerian • Soy • Evening Primrose • Grape seed • Milk Thistle

  5. Gingko Extracts • Ancient Chinese herbal treatment • Maidenhair tree leaves • Effects from flavonoids - antioxidant • Reduces capillary fragility, vasodilator

  6. Ginkgo Considerations • Recommended to stabilize cognition in Alzheimer's or multi-infarct dementia; improves walking with claudication • 120-240 mg BID, TID • Appears safe • Avoid with anticoagulants (2002 Cochrane)

  7. Marketed For ... • Memory enhancement • Improved concentration • No evidence for improved memory/concentration in normal, healthy individuals (NEJM 2002)

  8. St. John’s Wort • Flowering plant (H. perforatum) • Hypericin, a naphthodianthrone is the main active ingredient • Inhibits neurotransmitter uptake of serotonin, norepinephrine, & dopamine • Binds to GABA receptors

  9. St. John’s Wort • Outsells Prozac in Germany 7:1 • Meta-analysis - appears effective as low doses of standard antidepressants • Phototoxicity

  10. Depression Consumers Report 2004

  11. Ginseng • From genus panax(panacea!) • An adoptogen - no studies compared to stimulants such as caffeine • Considered safe • Siberian Ginseng • An abundant Russian herb thought to have the same properties as Ginseng • No published studies

  12. The wonder herb . . . • Ginseng is expensive - study of 54 products - 85% contained little or no ginseng, but …. varying amounts of caffeine! • Glacial Tropical Citrus Vitamin Water 21 mg of caffeine – Coke has 24 mg!

  13. Red Bull… • Taurine (essential amino acid) 1000mg • Glucuronolactone (conjugates with toxic metabolites for excretion) 600 mg • B complex vitamins • Caffeine 80 mg (24 gms in Coke) • Sugar 27 grams (39 gms in Coke)

  14. B Vitamins • Niacin: 30 milligrams, or 150% of the RDV • Vitamin B6: 40 milligrams, or 2,000% of RDV • Vitamin B12: 0.5 milligrams , or 8,000% of RDV and…… • As much caffeine as a cup of premium coffee • A cup (8oz) of Starbucks has 180mg of caffeine

  15. Garlic (allium sativum) • Organosulfer compounds • May block carcinogens in food • Garlic extract - decreases cholesterol 7% • Available in ‘odor free’ capsules • Active agent (allium) is odoriferous

  16. Long regarded to deter vampires • Norwegian experiment with leeches (lack of vampires) • Garlic-smeared hand preferred in 66% of time • Leeches attached in 14.9 secs vs 44.9 secs when going to the non-garlic hand (p < 0.05) • The traditional belief that garlic can deter vampires is probably wrong • The reverse may in fact be true Tidsskr Nor Laegeforen. 1994 Dec 10;114(30):3583-6.

  17. Echinacea • For Rx of colds ($100 million in sales) • Appears to alleviate some cold symptoms - no evidence for cure • 1998 randomized trial showed no ability to prevent colds (JFP 1999)

  18. Zinc & Colds • Inhibits rhinovirus in tissue culture • Meta-analysis showed no conclusive evidence for reducing colds (Arch IM 1997) • Controlled trial of lozengers - ineffective & side effects - taste, N&V (JAMA 1998) • Randomized blinded trial of nasal gel – decreased length of cold by 2 days (ENT J 2000) • Improved Rx vs. antibiotics ?

  19. Saw Palmetto • Appears safe and effective for BPH, comparable to finasteride (Proscar) • Inhibits the 5a reductase conversion of testosterone to dihydrotestosterone (a prostate growth stimulator) • 160 mg bid or 320 mg qdJAMA1998; AFP2003

  20. AnxiolyticsGABA Binding Activity • Valerian (insomnia) • Kava kava (anxiety) • Chamomile (insomnia)

  21. Valerian • Some efficacy for insomnia • Unclear evidence for anxiety • Appears safe, maybe helpful to wean from benzodiazepines dependence • 300 - 600 mg before bedtime or as tea (2-3 gm of dried root) AFP 2003

  22. KAVA & Hepatotoxicity • 70 reports of kava induced liver failure, with 4 deaths and 7 liver transplants • FDA 2002 advisory – avoid kava if having or at risk for liver disease • Last year UK banned Kava sales

  23. Phytoestrogens for Menopause • Plant compounds resembling estradiol • Isoflavones most potent • Supplements of unclear benefits v. foods - Soy, Tofu, Black Cohosh • Consider for mild menopausal Sx • Reports of Black Cohosh induced hepatitis

  24. Relief of Hot Flashes Consumers Report 2004

  25. Milk Thistle • Flavonoid complex called silymarin • Used for improving liver function in hepatitis, cirrhosis • Meta- analysis – appears safe but no clear benefit…. Am J Med 2002

  26. “Not much - just flushing out my arteries.” The NewYorker

  27. What about Red Wine? • ‘The French paradox’ – low incidence of CVD – but a relatively high fat diet. • Grapes contain flavonoids (resveratol), potent antioxidants - ? account for positive effects • Red wine has 160ug/oz; peanuts 70 ug/oz • Grape juice is not fermented –negligible amounts • No enough evidence to conclude that red wine is more effective than other alcoholic bevearges in lowering CVD risk

  28. “It’s a B-complex. Didn’t they used to put chocolate on the pillow?”

  29. Chocolate (flavonoids) • 1 oz has as much flavonoids as 6 apples, 5 cups of tea or 2 glasses of red wine • Flavonoids reduce platelet aggregation • Decreased platelet activation 6 hours after eating chocolate • Didn’t measure glucose or lipid levels (MARS funded) • Recent meta-analysis dark cocoa products reduce BP 5/2 mmHg (AJH, 2010)

  30. Ginger (zigiber officinale) • Used for centuries to treat nausea • Post-op nausea, motion & sea sickness • Chemotherapy results disappointing • Commonly used but not recommended for pregnancy (bleeding, miscarriage)

  31. “Michael has had an interesting side-effect from taking St. John’s Wort”

  32. FDA Approval • Drugs must be safe and effective • Average $230 million & 12 years • No patent to recoup costs for herbs

  33. Dietary Supplement Act Of 1994 • Applies to ‘dietary supplements’ • vitamins, minerals, herbs, natural substances • Health claims not specified on label • FDA must prove unsafe before removing

  34. Health Foods?….L-Trypthophan • An amino acid - assumed safe • Used for insomnia • Eosinophilia myalgia syndrome developed • 38 deaths!! • Banned by FDA in 1990

  35. FDA Concerns …. • Over 2000 reports of adverse effects in 2009 • No manufacturing oversight: • 1/3rd of supplements <50% of stated ingredients (Ginseng products only contain caffeine) • Niacin product contained 10x safe level ( GI distress, hepatic damage, MI) • Proposed rule to prevent the sale of supplements that are sub- or super- potent, that contain drugs, or contaminants (i.e. bacteria, pesticides, glass, lead)

  36. “Something from the supplement cart?” The NewYorker

  37. Common Supplements • Glucosamine/ chondroitin • CoQ-10 • Melatonin • Amino Acids • Fish Oils/omega FA • DHEA • Acidophilus • Chromium • Sports enhancement

  38. Glucosamine & Chondroitin • Glucosamine (crab shell chitin) • Chondritin (cow cartilage) • The ‘raw materials for new cartilage’ • Evidence for pain & disability relief in osteoarthritis, comparable to ibuprofen & acetaminophen • Safe – few side effects Cochrane Review 2005

  39. Consumers Report 2004

  40. Coenzyme Q10 • Fat soluble vitamin • Involved in mitochondrial oxidation producing ATP • Some anti-oxidant properties • In CHF, cardiac tissues under ↑’d oxidative stress w/decreased tissue levels of Q10 • Approved in Japan since 1974 to treat CHF • Some evidence for benefit in Parkinson’s & mitochondrial diseases • 200mg qday lower BP 16/10 mmHG • Safe but expensive (50-1200 mg/day) AFP 2005

  41. Melatonin • Modified amino acid (tryptophan) • Released from pineal gland by diminishing light levels • Role in humans not fully elucidated • Small, conflicting sleep studies

  42. Melatonin for Sleep • Induces sleep if plasma levels are low • Shift workers • Jet Lag • 0.1 – 10 mg qhs

  43. Insomnia Consumers Report 2004

  44. Fish Oils & Omega 3 fatty acids • Fish oil supplements supported by RCTs • Lower triglycerides • Reduce CAD and stroke risk with known CVD disease • Lowers BP slightly (10/4 mmHg) • No evidence for primary prevention

  45. DHEA (Dihydroepiandrosterone) • Produced by adrenals, unclear role outside of Rx for adrenal insufficiency • Converted to estrogens and testosterone • Plasma levels decline with age • Schedule II - an anabolic steroid • DHEA supplements are Yam extracts, not converted to DHEA

  46. Marketed as... • Anti-aging • Hirsutism & deeping voice seen • Concern for prostate or breast cancer • Series of studies 1995 - 1998 in J. Clin Endocrinology - some perceived sense of well being, but no obvious benefits

  47. Acidophilus - a probiotic(organism used medically) • Lactobacillus acidophilus - bacteria that live in the intestine and vagina • Good evidence to support L. acidophilus vaginal suppositories to Rx bacterial vaginosis • Some studies suggest eating yogurt enriched with L. acidophilus may be similarly beneficial • Benefit in colic treatment ? • Marketed to improve digestion, no clear evidence of benefit

  48. Chromium for weight loss ?? • Essential trace mineral - Insulin cofactor • China & Israeli studies for DM treatment • Diabetics not chromium deficient • Mixed results from a variety of studies • Safe up to 1000mcg/day The Medical Letter 2006

  49. Marketed To.... • Loose fat • Boost energy • ... no published support for such effects

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