Herbs and Supplements for GI Disorders

1. Herbs and Supplements for GI Disorders Kathi J. Kemper, MD Caryl J Guth Chair for Holistic and Integrative Medicine Professor, Pediatrics, Public Health Sciences, Family Medicine WFUSM Instructor, Harvard Medical School Author, The Holistic Pediatrician

3. Probiotic case You have just recommended probiotics for one of your patients, based on Dr. Pietzak’s lecture. The patient’s mother asks if there’s anything she can do to help the probiotics work better. Is there?

4. YES- Prebiotics Prebiotics are non-digestible food ingredients, such as non-digested short chain sugars and fiber that promote the growth of healthy bacteria in the intestines Examples: beta glucan, arabinoxylan, oligosaccharides (galacto- and fructo-oligosaccharides, FOS/GOS, inulin) Core symptoms are in 3 areas of hyperactivity, inattention, and impulsivity The most commonly-diagnosed behavioral disorder in children estimates of prevalence 3-11% However, prevalence may rise with the use of DSM-IV criteria, since it better characterizes the heterogeneity of ADHD in terms of its 3 subtypes: inattentive, hyperactive-impulsive, and combined. Wolraich study in school-children K-5 in Tennessee county: ADHD all types: 16.1% (6.8% if impairment considered) ADHD inattentive type 8.8% (3.2%) ADHD hyperactive/impulsive type 2.6% (.06%) ADHD combined 4.7% (2.9%) Increasing recognition of ADHD as a chronic condition persisting into adulthood and requiring long-term therapy on-going monitoring periodic assessment for consequences and complications Core symptoms are in 3 areas of hyperactivity, inattention, and impulsivity The most commonly-diagnosed behavioral disorder in children estimates of prevalence 3-11% However, prevalence may rise with the use of DSM-IV criteria, since it better characterizes the heterogeneity of ADHD in terms of its 3 subtypes: inattentive, hyperactive-impulsive, and combined. Wolraich study in school-children K-5 in Tennessee county: ADHD all types: 16.1% (6.8% if impairment considered) ADHD inattentive type 8.8% (3.2%) ADHD hyperactive/impulsive type 2.6% (.06%) ADHD combined 4.7% (2.9%) Increasing recognition of ADHD as a chronic condition persisting into adulthood and requiring long-term therapy on-going monitoring periodic assessment for consequences and complications

5. Prebiotics - Benefits Increased numbers of healthy bacteria (Lactobacillus, Bifidobacter) Increased short chain fatty acids such as butyrate, which suppresses growth of unhealthy gut bacteriaand provide energy to gut muscoal cells Increased absorption of calcium and magnesium Decreased gut inflammation Mixed results on glucose, cholesterol, triglycerides

6. Prebiotics: Sources, Side effects: Sources: breastmilk, barley, bran and whole grains, legumes, such as beans; vegetables such as leeks, onions, asparagus, greens such as chicory, spinach, burdock, fruits such as bananas, berries Doses: 1 – 2 grams daily (adults) Side effects: flatulence, diarrhea, allergies

7. Colic The mother of a newborn infant asks you about natural remedies for her baby’s colic. The baby is crying 4 hours a day. They’ve tried car rides, bouncy seats, etc. The grandmother has recommended Gripe Water, star anise, and fennel tea What are these things and are they safe?

8. Gripe Water Traditionally – dill extract ± bicarbonate (Woodard’s™), ± alcohol; Dill, fennel and caraway are spasmolytics Some include ginger, fennel (Baby’s Bliss™), chamomile, cinnamon and other herbs (Wellements™) Some contain homeopathic remedies and activated charcoal (eg. Colic Calm™) GRAS; allergies possible; small RCTs suggest benefits

9. Star Anise for Colic Illicium verum used in Caribbean and Latino populations and China Adulteration with Japanese star anise (Illicium anisatum) leads to malaise, jitteriness, hyperexcitability, nystagmus, vomiting, hypertonia, seizures Concerns about adulteration have led to product recalls in Spain, Japan, Scotland, China, Japan, Netherlands Avoid unless you’re sure of what you have!

10. Colic herbs in J Pediatrics 1993 publication of randomized, prospective, double-blind, placebo-controlled trial Product: Calme Bebi brand Extracts of fennel, German chamomile (Matricaria chamomilla), vervain (Verbena officinalis), licorice root Dose: up to 150 mL TID for 7 days Eliminated colic in 57% of infants compared with 26% in placebo (P<0.01) NO adverse effects noted

11. Nausea A teenager suffering from nausea associated with chemotherapy asks you if there are any natural remedies for nausea. She is tired of taking pills. She has already starting using SeaBands™. Can you advise her?

12. Ginger for Nausea Numerous RCTs suggest benefits of ginger in preventing and treating nausea

13. Ginger Dosing Capsules 500 mg – used in RCTs because easy to blind Dried/candied Tea 1 quart of water 1-2 inch slice of ginger root, cut up Boil; simmer 15 minutes; cool, sweeten; peppermint? Gingerale? Depends on brand. Most commercial brands have no ginger, just artificial flavoring

14. Irritable bowel syndrome (IBS) A 17 year old with a diagnosed by your partner as having irritable bowel syndrome says he read on the Internet that peppermint might help him. Should he eat more candy? What’s the evidence?

15. IBS - Peppermint Peppermint (Mentha piperita); primary ingredient, 29% - 48% menthol Uses: many digestive complaints, including colic, flatulence, diarrhea, dyspepsia, indigestion, nausea and vomiting Relaxes smooth muscle and slows GI transit Approved by German Commission E

16. Enteric coated peppermint oil Reduces spasms during upper GI, colonoscopy, barium enema Mixed, mostly positive results in adults and adolescents with IBS RCT in 110 adults with IBS, 79% had less pain with Colpermin versus 43% with placebo, P<0.05 (Liu, J Gastroenterol, 1997) RCT of 42 children with IBS, 75% improved with peppermint, P<0.05 (Kline J Pediatr, 2001)

17. Constipation The father of a 5 year old girl asks whether herbal laxatives he’s seen in the pharmacy, such as Senokot, are safe. Are they?

18. Fiber for constipation It depends (dried fruit anyone?) Fiber is safe if taken with sufficient water; no intestinal obstruction; no allergies Bran Psyllium (Plantago. ovata and P. psyllium) Flax seeds also contain lignans and omega three fatty acids Side effects: flatulence, abdominal pain, diarrhea, dyspepsia, nausea

19. Stimulant laxative herbs Cascara sagrada (Rhamni purshiana) and Senna (Senna folum); castor oil FDA approved for patients 2 years and older Use sparingly and briefly Chronic use can lead to dependence Side effects: cramping, diarrhea, severe diaper rash

20. Recurrent abdominal pain The mother of an 8 year old boy with benign chronic recurrent abdominal pain associated with the stress of starting a new school asks if there are natural remedies she can give him that might help. Are there?

21. Herbal remedies for stress-related abdominal pain Chamomile (Matricaria recutita) recommended by Peter Rabbit’s mother Contains flavonoids, anti-inflammatories, spasmolytic compounds Listed on formularies of 25+ countries Approved by German Commission E to treat abdominal spasms and inflammatory diseases of the GI tract May combine with fennel, peppermint, lemon balm Side effects: allergies

22. Lemon balm Iberogast™, German remedy containing 8 herbs: Iberis amara, Chelidonii, Cardui, Melissae folium, Carvi, Liquiritiae radix, Angelicae, Matricariae, Menthae piperitae Meta-analysis of studies in 595 adults shows positive effects on dyspepsia in adults (Melzer J, 2004)

23. Licorice: Glycyrrhiza glabra Contains: glycyrrhizin, glycyrrhizic acid, polyphenols, and polysaccharides TCM ulcer remedy; newer HepC? Inhibits 11 beta-hydroxysteroid dehydrogenase + other enzymes involved in the metabolism of corticosteroids. ? increased cortisol levels Anti-inflammatory and mineralocorticoid effects (BP, edema) NOT ANISE

24. Caveats with herbs Variable quality – think of produce Contaminants or wrong herbs included Heavy metals in some imports from developing countries with lower manufacturing standards Pharmaceuticals, e.g TCM Use identifiable products OR those from countries with higher standards, eg. Canada, Germany, Switzerland; check ConsumerLabs

25. Resources Compare brands http://www.consumerlabs.com NLM: http://www.nlm.nih.gov/medlineplus/druginfo/ Natural Medicines Comprehensive Database Natural Standard: http://www.naturalstandard.com/ NIH NCCAM http://nccam.nih.gov/ Contemporary Pediatrics NC NW AHEC on-line course on HDS https://northwestahec.wfubmc.edu/learn/herbs_ce/index.cfm

26. The History of Medicine 2000 BC: “Here, eat this root.” 1000 AD: “That root is heathen; say this prayer.” 1850 AD: “That prayer is superstition; drink this potion.” 1940 AD: “That potion is snake oil; swallow this pill.” 1985 AD: “That pill is ineffective; take this antibiotic.” 2000 AD: “That antibiotic is artificial; eat this root.”