Complementary and Alternative Medicine, Dietary Supplements, and Medications

1. Complementary and Alternative Medicine, Dietary Supplements, and Medications

2. CAM- Where is it? • A 14 yr old athlete with moderate, persistent asthma comes to clinic. He has an asthma action plan and has been adherent with his controller medication. Now he wants to try a breathing technique (Buteyko) so he can “get off” his meds. • A 3 yr old comes to the clinic for a well-child check-up. On exam you find a right otitis media. She is asymptomatic and you recommend watchful waiting. The parents would like to try a homeopathic remedy because they had heard that homeopathy worked better than placebo for children with an ear infection. Answer: Everywhere

3. CAM- every where you look

4. CAM in the News • Dying Woman Loses Marijuana Appeal March 14, 2007 • Evidence Mounts That Coping Skills Can Boost HIV Survival March 14, 2007 • Omega-3 in Fish Oils Might Ease Depression March 7, 2007 • Insomnia: Alternative Medicine Popular • 1.6 Million Adults Use Complementary Or Alternative Medicine For Insomnia September 2006

5. Ernst MJA 2006; 185 (11/12): 680-681

6. Complementary and Alternative Medicine (CAM) • Complementary and alternative medicine • A group of diverse medical and health care systems, practices, and products • Not considered part of conventional medicine • Some scientific evidence exists regarding CAM therapies • For most, questions of safety and efficacy persist • Complementary medicine is used together with conventional medicine. Alternative medicine is used in place of conventional medicine. http://nccam.nih.gov/health/whatiscam/

7. Integrative or Holistic Medicine • Integrative combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness. • “Healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.” http://nccam.nih.gov/health/whatiscam/ http://www.integrativemedicine.arizona.edu/about2.html

8. Major Classes of CAM Enhance the mind’s capacity to affect bodily function and symptoms • Chiropractice • Osteopathy • Massage Alternative medical systems Mind-body interventions Biologically -based therapies Manipulative & body-based methods Energy therapies • Homeopathic • Naturopathic • Traditional Chinese and Ayurvedic treatments • Dietary supp • Herbs • Foods • Vitamins • Natural • substances • Biofield therapy • Bioelectro- • magnetic • therapy http://nccam.nih.gov/

10. CAM Utilization Reasons for using CAM: • Consistentwith patient’s and families values: natural, and empowering • CAM providers are “patient-centered”, dedicated to promotinghealth. • Conventionaltherapies are perceived to be emotionally or spiritually without benefitConventional therapies are not effective or are associatedwith side effects. • CAM use is a circular: usage determines number of CAM practitioners

11. Effectiveness uncertain Acupuncture for asthma Acupuncture for hay fever Acupuncture for rheumatoid arthritis Chromium for diabetes Echinacea for common cold preventionor treatment Evening primrosefor eczema Effectiveness unlikely Acupuncture for body weight reduction Acupuncture for smoking cessation Flower remediesfor anxiety Homeopathy for anxiety Spinal manipulation for asthma Spinal manipulation for infantile colic CAM TreatmentsCommonly Thought Effective in Pediatrics

12. Conventional Medicine, Evidence? • Most conventional physicians believe in unconventional medicine because it is not scientific • What is evidence-based medicine? Treatment that will improve patient outcomes by well-designed, appropriately powered, randomized, controlled clinical trials. • There is not good evidence (Grade A) that many of the commonly used therapies in conventional medicine are effective (ex: heparin, aspirin, and warfarin). • The principal distinguishing characteristic of unconventional and conventional medicine therapies is the source of introduction. • Conventional therapies are introduced by mainstream Western physicians and scientists, whereas most unconventional modalities are introduced by "outsiders." • One of the reasons that most unconventional modalities are not evidence based is that the majority of them were introduced prior to the 20th Century

13. Whole Medical Systems Complete systems of theory and practice that evolved independently Traditional systems of medicine that are practiced by individual cultures throughout the world Includes traditional Chinese medicine, Ayurvedic medicine, homeopathy, naturopathy

14. Biologically Based Practices Includes: botanicals, animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, whole diets, and functional foods Dietary supplements are a subset of biologically based practices

15. Biologically Based - Supplements What is a supplement? Regulated by FDA http://www.fda.gov no requirements for FDA testing manufacturers responsible for ensuring product safety label requirements safety alerts: http://www.cfsan.fda.gov/~dms/ds-warn.html

16. Energy Medicine Veritable - energy that can be measured Includes sound, visible light, magnetism Putative – energy that has yet to be measured human beings are infused with a subtle form of energy Includes qi (ki in Japanese); doshas; prana, homeopathic resonance

17. Energy Medicine - Acupuncture Few complications Scientific evidence? post chemotherapy management of nausea pain relief NIH Consensus Statement (1997) http://consensus.nih.gov/1997/1997Acupuncture107html.htm

18. Manipulative and Body-Based Structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems Includes chiropractic manipulation, massage therapy, reflexology, rolfing, Alexander technique,Feldenkrais method

19. Mind-Body Medicine Interactions among the brain, mind, body, and behavior The ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health Includes relaxation, hypnosis, visual imagery, meditation, yoga, biofeedback, tai chi, group support, and spirituality

20. Other CAM Therapies Aromatherapy Colonic Irrigation Therapeutic Touch EDTA Chelation Cupping Primordial Sound Meditation

21. Evaluating Web Sites Accuracy Authority Bias Currency Coverage

22. Clinical Trials and CAM Why are there so few CAM clinical trials? Drug companies have to do studies to go on the market—supplement companies do not, so clinical trials sponsored by supplement companies are rare Alternative treatments are often customized for a specific person. Clinical trials try to prove something works for most people. Belief systems of some CAM practitioners do not agree with the idea of Western studies, so they do not participate CAM has only recently become “legit” in the scientific community

26. Dietary Supplements RUN THE WHOLE GAMUT!!! vitamins- C, E. minerals- Ca, Se amino acids-lysine fats- fish oil hormones- DHEA herbs- ginseng phytochemicals-garlic etc

27. FDA Regulations Protect Consumers • FDA regulates: Drugs are highly regulated by FDA • Vitamins & minerals regulated as foods • Supplements are considered safe until demonstrated to be hazardous by FDA • Herbals & botanicals totally unregulated

28. Who Benefits?Those at risk for developing nutritional deficiencies only! • People with vit, mineral deficiency • Vegans- vit D, B12 • Pregnant women- folate • Elderly persons- B12/folate • People at risk of osteoporosis- Ca, vit D • People at risk of losing blood- Fe • People on restricted diets- vit, minerals

29. Hormones • HGH • EPO • BHCG • Steroids

31. Human Growth Hormone • Normally secreted by the pituitary • Normal function of GH is growth and development of every body system, including bone and muscle • Can be stimulated by propanolol, vasopressin, clonidine, and levodopa • Synthetic growth hormone

32. Side Effects: • Acromegaly (may be irreversible) • Peripheral Neuropathy • Coronary Artery Disease • Cardiomyopathy • Diabetes, Hypothyroidism, arthritis • No available urine test available, but banned by NCAA and IOC

33. Erythropoietin • Hormone released by the kidneys in response to low Hct • Stimulates RBC production from bone marrow • Has recently been manufactured by recombinant DNA technique • Can increase Hct in renal patients by up to 35%, lasting up to 7 months • Used most by cyclists

34. Blood Doping • Induced Erythrocythemia: An increase in Hb following reinfusion of an athlete’s blood • Goal: to increase the oxygen-carrying capacity of Hb • Has been used as far back as 1947 • 1984: seven US Olympic cyclists guilty • Banned by IOC in 1985

35. Detection: • Blood doping and Erythropoietin: banned by IOC • No known urine test to detect • Testing: Measured Hct >50 • Measurement of serum Fe and Bilirubin to detect hemolysis after frozen PRBC transfusion

37. Anabolic Steroids • The ultimate ergogenic aid aka “Juice” • Creates the Superhuman Athlete • Testosterone derivatives (cholesterol) • Produced in the adrenal/ testes

38. Anabolic/Androgenic Steroids • Anabolism - Constructive • Catabolism - Destructive • Anabolic effects : inc. skeletal mm mass • anticatabolism • Androgenic effects: secondary sexual characteristics - pubic hair, genital size • No Pure Anabolic Steroids

39. Desired Effects: • Increase in strength • Increase in weight • Increase in aggressiveness • Increased capability of sustaining repetitive, high intensity workouts • Enhanced performance

41. Side Effects: • CV: MI - hypertension, inc. LDL, dec. HDL, cardiac hypertrophy, thrombosis • Endocrine: virilization, testis atrophy, azospermia, priapism, prostatic hypertrophy/ CA, gynecomastia, erectile dysfct, libido • Liver : peliosis hepatitis, hyperplasia, adenoma, no carcinoma, elevated LFTs • MS: epiphyseal closure, inc. bone density, dec. tendon strength

42. Side Effects (cont’d): • Skin: acne, hirsuitism, striae, androgenic alopecia, inc. sebaceous glands • Metabolic: hypernatremia, kalemia, phosphatemia, calcemia, “prediabetic” • Psychiatric : aggressiveness, extreme mood swings - depression/ mania, dependence, other drug use, “Reverse Anorexia” • Long Term - dec. life span

43. Specific Side Effects • Women (Virilzation): • Clitoril enlargement, Deepening of voice, Male pattern baldness, dec. breast size, libido • Children: • premature closure of growth plate in long bones & thus short stature

45. “Prohormones” • Androstenedione • DHEA • Androstenediol • Norandrostenedione • Norandrostendiol

46. Effects: • Benefits: Same as Testosterone • Increased energy • Enhanced recovery and growth from exercise • heightened sexual arousal and function • greater sense of well-being • Plasma levels of testosterone increased from 140% to 330% of normal levels after 50mg and 100mg doses • SE’s : Same as Testosterone • Banned by IOC, NCAA, NFL

47. Stimulants • Caffeine • Amphetamines • Cocaine • Ephedrine

48. Amphetamines • Have been used as far back as WWII when soldiers used them to delay fatigue • First study in 1959 showed significant improvement in performance • Available data suggest Amphetamines can improve performance in sports where speed, power and endurance are required

49. Side Effects: • Related to drugs’ effect on CNS: insomnia, instability, agitation and restlessness • Confusion, paranoia, hallucinations • Dyskinesias, especially in facial muscles • Cardiac complications: HTN, arrhythmias • GI disturbances • Severe rebound of fatigue and depression after discontinuance

50. Caffeine • A Methylxanthine: same class as theophylline and theobromine • Exerts its’ effects by: • Translocation of Calcium for more muscular availability • Increase in cAMP by inhibition of phosphodiesterase • Blockage of adenosine receptors, blocking the sedative properties of adenosine