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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

Herbs & Supplements

Did you remember to take

your Gingko today ?

Robert Baldor, MD

Professor

Family Medicine & Community Health

why patients use cam
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
a clinician s perspective
A Clinician’s Perspective
  • What’s available
  • Efficacy
  • Safety
herbal therapies top dozen
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
gingko extracts
Gingko Extracts
  • Ancient Chinese herbal treatment
  • Maidenhair tree leaves
  • Effects from flavonoids - antioxidant
  • Reduces capillary fragility, vasodilator
ginkgo considerations
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)

marketed for
Marketed For ...
  • Memory enhancement
  • Improved concentration
  • No evidence for improved memory/concentration in normal, healthy individuals (NEJM 2002)
st john s wort
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
st john s wort1
St. John’s Wort
  • Outsells Prozac in Germany 7:1
  • Meta-analysis - appears effective as low doses of standard antidepressants
  • Phototoxicity
depression
Depression

Consumers Report 2004

ginseng
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
the wonder herb
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!

red bull
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)
slide15

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
garlic allium sativum
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
long regarded to deter vampires
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.

echinacea
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)
zinc colds
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 ?
saw palmetto
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
anxiolytics gaba binding activity
AnxiolyticsGABA Binding Activity
  • Valerian (insomnia)
  • Kava kava (anxiety)
  • Chamomile (insomnia)
valerian
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

kava hepatotoxicity
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
phytoestrogens for menopause
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
relief of hot flashes
Relief of Hot Flashes

Consumers Report 2004

milk thistle
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

what about red wine
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
chocolate flavonoids
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)
ginger zigiber officinale
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)
fda approval
FDA Approval
  • Drugs must be safe and effective
  • Average $230 million & 12 years
  • No patent to recoup costs for herbs
dietary supplement act of 1994
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
health foods l trypthophan
Health Foods?….L-Trypthophan
  • An amino acid - assumed safe
  • Used for insomnia
  • Eosinophilia myalgia syndrome developed
    • 38 deaths!!
  • Banned by FDA in 1990
fda concerns
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)
common supplements
Common Supplements
  • Glucosamine/

chondroitin

  • CoQ-10
  • Melatonin
  • Amino Acids
  • Fish Oils/omega FA
  • DHEA
  • Acidophilus
  • Chromium
  • Sports enhancement
glucosamine chondroitin
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

coenzyme q10
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

melatonin
Melatonin
  • Modified amino acid (tryptophan)
  • Released from pineal gland by diminishing light levels
  • Role in humans not fully elucidated
  • Small, conflicting sleep studies
melatonin for sleep
Melatonin for Sleep
  • Induces sleep if plasma levels are low
  • Shift workers
  • Jet Lag
  • 0.1 – 10 mg qhs
insomnia
Insomnia

Consumers Report 2004

fish oils omega 3 fatty acids
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
dhea dihydroepiandrosterone
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
marketed as
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
acidophilus a probiotic organism used medically
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
chromium for weight loss
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

marketed to
Marketed To....
  • Loose fat
  • Boost energy
  • ... no published support for such effects
weight loss health foods
Weight loss ….Health Foods??
  • Metabolife contains Ma Hung
  • Bitter orange extract contains synephrine
  • Chomper is a natural laxative, contains digitalis - induces arrhythmias
  • Tryptophan & phenylalanine - amino acids ? efficacy
health foods
Health Foods?….
  • Associated Press5/22/00 …Herbalife Founder Mark Hughes dies at the age of 44 of ...

.. Naturalcauses!

ma huang or ephedra
Ma-Huang or Ephedra
  • MetaboLife, Herbal Ecstasy
  • Contains Ephedrine
  • Linked to 155 deaths & strokes
  • Banned by NFL, NCAA after heat stroke deaths while using the supplement
  • FDA Ban in 2004
  • Ban overturned, FDA overstepped authority
slide54

“I’m taking you off wine, women and song

and putting you on broccoli”

a clinician s perspective varying approaches
A Clinician’s Perspective ..... varying approaches
  • Acceptance - ask about & tolerate use of herbal products by patients
  • Endorsement - accept patient use of natural products as initial therapy, monitor for effects
  • Integration - prescribe herbs with advice on use, dosing, etc.
resources
Resources
  • www.NaturalStandard.com
  • NIH CAM Center (nccam.nih.gov)
  • NIH Office of Dietary Supplements (odp.od.nih.gov/ods/)
  • Food & Drug Administration (fda.gov)
  • www.consumerlab.com
  • Medical Letter
  • Published studies
current consensus
Current Consensus

…the best nutritional strategy for promoting optimal health & reducing the risk of chronic disease is to choose wisely from a wide variety of foods, with emphasis on anti-oxidant rich fruits, vegetables & whole grains .

AHA 2002 ADA 2002

best advice
Best Advice . . .
  • Buy from well-known national companies
  • Label includes:
    • Herbs common & scientific name
    • Manufacture’s name & address
    • Dosing guidelines
    • Potential side effects
    • Batch & Lot number and expiration date
  • US Pharmacopoeia verification seal
a final thought
A Final Thought…..
  • The Japanese eat very little fat and suffer fewer heart attacks than the British or Americans
  • However, the French eat a lot of fat and also suffer fewer heart attacks than the British or Americans
  • The Germans drink very little red wine and suffer fewer heart attacks than the British or Americans
  • While the Italians drink excessive amounts of red wine & suffer fewer heart attacks than British or Americans
  • Conclusion: Eat and drink what you like. Speaking English is apparently what kills you!
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