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Integrating Herbs with Conventional Medicine. Linda Diane Feldt RPP, NCTMB Holistic Health Practitioner and Herbalist. Objectives. Identify the difference between nourishing and medicinal herbs Identify how nourishing herbs are provided Identify how medicinal herbs are provided

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Integrating herbs with conventional medicine l.jpg

Integrating Herbs with Conventional Medicine

Linda Diane Feldt

RPP, NCTMB

Holistic Health Practitioner and Herbalist


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Objectives

  • Identify the difference between nourishing and medicinal herbs

  • Identify how nourishing herbs are provided

  • Identify how medicinal herbs are provided

  • Know reasons to use nourishing or medicinal herbs

  • Learn about 9 popular herbs

  • Learn some of the problems with herbal marketing and preparations

  • Time for questions and individual concerns


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Nourishing herbs

  • Nutrient rich

  • Bio-available

  • Generally considered safe, side effects uncommon

  • Dosage and strength less important

  • Tend to be local, whole, and common

  • Large amounts used, in contrast to medicinal plants

  • Includes tonics

  • Supportive to body systems

  • Long term use is usually beneficial


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Nourishing Herbs con’t.

  • Internal use

    • Infusions

      • Water based

      • Vinegar based

    • Whole plant

      • Cooked

      • Raw (salad)

  • External use

    • Compress

    • Poultice

    • Salve


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Medicinal Herbs

  • Dosage and strength important or critical

  • Tend to utilize more toxic parts of plant

  • Stimulate or sedate

  • More likely to have side effects

  • Are often plants that are less common, or rare

  • Long term use is generally discouraged

  • More extensive knowledge is needed to use safely and effectively


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Medicinal Herbs con’t.

  • Tinctures

    • Alcohol based

    • Glycerin

  • Extracts

  • Capsules


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Case Study: Prophylactic Use of Echinacea angustifolia and purpurea Tincture for Management of a Recurrent Staphylococcus Infection


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Case Study con’t.

  • 46 yo female CHF

  • Heart cath age 53, followed by staph infection

  • Broad spec. antibiotics no effect

  • Echinacea ang. 30-40 drops every 3 hours

  • Symptom improvement within 2 hours

  • Two days both, stopped Ech. Symptoms returned within 4 hours

  • Ech and Antibiotic together, no symptoms


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Case Study con’t.

  • MD stopped antibiotics, pt. stopped Ech. Symptoms returned

  • Ech. as before - symptoms gone

  • One day without Ech, some symptoms

  • Ech 10 drops day no symptoms

  • For next 7 years, until death, two skipped days symptoms return -proven at least five times


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Significant points

  • Echinacea fought an antibiotic resistant infection

  • Low dose (nourishing) as effective as high dose (stimulating)

  • Low dose safe to use long term

  • Long term use was necessary

  • Mechanism of action for effect of low dose unknown


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Popular Herbs


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Ginkgo biloba

St. John’s wort

Garlic

Echinacea

Goldenseal

Saw palmetto

Milk thistle

Black cohosh

Ginger

The Herbs


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Most ancient tree known

Uses: cerebral insufficiency, Alzheimer’s Ds, intermittent claudication, tinnitis

Powdered leaves

Tincture or infusion

Ginkgo biloba


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Ginkgo

  • Increases vascular flow

    • diabetic peripheral vascular disease

    • Raynauds syndrome

    • Other circulatory benefits fro varicose veins, hemorrhoids, eye disorders

  • Affinity for cerebral circulation

  • Inhibits platelet activity factor


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Ginkgo

  • Used to relieve tension, anxiety, elevate mood

  • Contains flavanoids, terpene lactones, ginkgolides A, B, and C, bilobalide, quercetin, and kaempferol.

  • ginkgolides control allergic inflammation, anaphylactic shock and asthma

  • antioxidant


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What to watch for

  • Can increase blood flow

  • Discontinue before surgery

  • Do not use with menstrual flooding

  • Do not use with other bleeding problems (ulcer, bruising, etc.)

  • Not suggested with blood thinners, aspirin, etc.


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52 week RCT, double blind, multi-center

Outcomes in 309 pts (ITT):

Pt cognition: tx no change, placebo worse (p=0.04)

Caregiver assess: tx slight improve, placebo worse (p=.004)

Dose: 120 mg/d of EGb 761

Safety: side effects equal

Problems: high dropout rate (50% tx, 62% placebo)

Gingko biloba & Dementia


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Ginkgo & Claudication

  • Meta-analysis of Egb 761

  • 5 placebo controlled trials

  • Moderate to large effect (0.75 Cohen’s d) on pain-free treadmill walking distance

Schneider B. Arzneimforsch 1992;42(4):428-436


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Ginkgo - Toxicology

  • Adverse events

    • GI complaints

    • bruising & spontaneous bleeding

  • Avoid if taking warfarin, heparin, or NSAIDs

  • Can increase insulin levels

  • May increase sedation with trazodone


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St. John’s Wort Hypericum Perforatum

Used as tincture, extract in pill form, topically as oil or salve

Popular as anti-depressant.

Also used for muscle aches, nerve pain, nerve regeneration, for herpes outbreaks, bruising


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St. John’s Wort

  • P450 Cytochrome system

  • Can interfere with effectiveness of other medications

  • Possible rash from exposure to sun (sheep and cows)

  • Use with other mood altering drugs of concern

  • Use by people with manic depressive and other psychological conditions of concern


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St. John’s Wort & Depression

  • Meta-analysis: 23 studies, 1757 pts

  • Mild-mod depression

    • Superior to placebo, rrr =2.67 (1.78-4.01)

    • As effective as TCA’s , rrr=1.10 (0.93-1.31)

    • Fewer side effects than TCA’s

    • Dose: 0.4-2.7 mg Hypericin (standardized extract)

  • Multi-center trial vs. SSRI’s at Duke

    Linde K, et al. BMJ 1996;313:253-8


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St. John’s Wort and Zoloft

  • Randomized controlled trial

  • St. John’s wort vs. Zoloft vs. placebo

  • effects

  • Side effects

    • Placebo < SJW < Zoloft (p= 0.000


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St. John’s Wort - Toxicology

  • Side effects

    • Theoretical risk - sunburn

  • Herb-drug interactions

    • Studies - digoxin, protease inhibitors, TCAs

    • Case reports - cyclosporine, warfarin, oral contraceptives, theophylline, SSRIs

    • Theoretical - iron

Facts & Comparisons Review of Natural Products, Dec 2000.


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Garlic (Allium sativum)

  • Uses

    • Lower cholesterol

    • anti-thrombotic

    • lower blood pressure

    • anti-microbial agent

    • Strengthen heart muscle

    • Reduce platelet clumping and clotting

    • Stabilize blood sugar levels


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Garlic

  • Some concern about use if bleeding is of concern

  • Odor

  • Large amounts can great gas

  • Potential decreased platelet aggregation


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Garlic

  • Contains alliin in intact garlic bulb

  • Alliin  allicin (crushed)

  • 600 – 900 mg of dried powder (1.3% allicin)


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Garlic - Evidence

  • German Commission E

    • elevated blood lipids

    • prevention of age-related vascular changes

  • 25 studies between 1979-1998 with 2,920 people

  • Mixed results highly dependent on type of garlic preparation


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Garlic - Evidence

  • 2 Meta-analyses

    • garlic lowered total cholesterol between 9-12%

  • Meta-analysis

    • Anti-hypertensive - 10% reduction

  • Double blind RCT - 152 subjects for 4 years

    • garlic reduced development of atherosclerosis


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Echinacea spp.

  • E. pallida purpurea angustifolia

  • Use: prevention and treatment of colds, flu

  • One of most popular herbs in US

  • German Commission E

    • supportive for colds, chronic URI, UTI

  • UK - GSL


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Echinacea

  • Stimulating dose not advised with autoimmune and some systemic diseases

  • Can interfere with immune suppression during chemotherapy treatment

  • Stimulating dose should be short term (3-4 days) only

  • No known side effects

  • Concern with steroid treatment - depends on use


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Echinacea - Human Evidence

  • 26 controlled trials (many open label)

  • 3 blinded RCT’s on URI

    • 1 showed dose dependent decrease in symptoms and duration of “flu”

    • 2 showed 13-20% relative risk reduction of acquiring URI

  • Dose: 30-60 gtts 1:5 (g/ml) tincture TID


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Echinacea Systematic Review

  • 16 randomized or quasi randomized trials

  • Echinacea preparation vs. no treatment or placebo

  • 8 trials on prevention, 8 trials on treatment

  • 3396 patients involved

  • Majority with positive results

  • Cannot say which preparation is best

Melchart, D. et al. Cochrane Database Syst Rev 2000;2.


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Goldenseal (Hydrastis canadensis)

  • Used in Native American medicine

  • Taken up by European immigrants

  • Deep forest dweller, endangered species

  • Part used is the root

  • Colds, flu, bacterial diarrhea, intestinal parasites, and ocular trachoma infections


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Goldenseal

  • Endangered herb

  • Internal use has antibiotic effect

    • concern for contributing to antibiotic resistant bacteria

  • Dose, duration, and strength important

    • Can be difficult to self-administer

  • Overused and misused by general public

    • Present in tooth paste, lip balm, herbal mixtures


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Goldenseal - Evidence

  • Antimicrobial activity vs. bacteria, viruses, fungi, protozoans, helminths, and chlamydia

  • Active components:

    • berberine (anticholinergic, antisecretory, and antimicrobial)

    • beta-hydrastine (astringent)

  • In rats, Goldenseal increases IgM antibodies


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Hexane extract of dried berries

Spasmolytic activity

Inhibition of androgen

Anti-inflammatory

Not an inhibitor of 5-reductase

Used for benign prostatic hypertrophy

Saw Palmetto (Serenoa repens)


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Saw Palmetto - Evidence

  • 18 RCT’s, 16/18 double-blinded

  • 2939 men, duration 4-48 weeks

  • Decreased nocturia, improved symptom scores vs. placebo

  • Improved symptom score, improved peak urine flow vs. finasteride

  • Dose: 400 mg dry extract BID

Wilt TJ, et al. JAMA 1998; 280:1604-1609.


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Saw Palmetto - Toxicology

  • Rats: 80x human dose for 6 months

    • No negative influences

  • Human trials, German Commission E

    • GI disturbances, headache

    • No significant adverse effects

  • Drug interactions

    • Theoretical - Estrogens, oral contraceptives, iron

    • German Commission E reports none


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Black Cohosh (Cimicifuga racemosa)

  • Fresh root tincture or dried root infusion

  • Remifemin, used in Germany since 1950’s

  • Used for hot flashes and night sweats

  • German Commission E:

    • Premenstrual discomfort

    • Dysmenorrhea

    • Menopausal neurovegetative symptoms


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Black Cohosh - Mode of action

  • Steroidal terpenes? isoflavones? others?

  • Methanol extracts bind estrogen receptors

  • Inhibits estrogen dependent breast tumor cell lines

  • Lowers LH in rats and women, no effect on FSHa

  • Stimulatory effect on endometriumb,c

  • Actein may be beneficial in hypercholesterolemia and peripheral arterial disease

a. Duker 1991; b. Stoll 1987; c. Warnecke 1985


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Black Cohosh - Clinical Trials

  • 5 RCTs in literature

  • Randomized, head to head trial

  • 60 pts, < 40 yr. old with hysterectomies

  • Estriol vs. conjugated estrogens vs. estrogen-gestegen sequential vs. black cohosh extract

  • Outcome: Kupperman’s Menopausal Index

  • Black cohosh equal to other treatments

Lehmann-Willenbrock, et al. Zentralblatt fur Gynakologie 1998;110:611-8

similar findings: Warnecke, 1985


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Black Cohosh Update

  • Recent RCT

    • 85 breast cancer survivors

    • 59 were on tamoxifen

    • 40 mg/d Remifemin vs. placebo x 2 months

    • No benefit for hot flashes

  • On-going trial at Columbia Univ

    • RCT, 1 year duration

    • hot flashes, endometrial thickness, bone metab, cognitive effects

Jacobson JS, et al. J. Clin. Oncol 2001;19:2739-45.


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Black Cohosh - Toxicology

  • Overdose: nausea, dizziness, nervous system disturbance

  • Mice -  spread of breast CA

  • Large doses may cause miscarriage. Contraindicated in pregnancy

  • Long term safety unknown


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Ginger Zingiber officinale

  • Used for nausea

  • Helpful for colds and flu

  • Warming herb

  • Many other folkloric uses


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Ginger for Nausea & Vomiting of Pregnancy

  • 2 trials show efficacy compared to placebo

  • excess Yang (excess Qi)

    • N not in AM, N worse p eating, N improves p vomiting

    • ginger is too “hot”, use peppermint

  • excess Yin (deficient Qi)

    • N in AM, N better p eating, N worse p vomiting

    • ginger will be helpful

Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196


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How to take ginger

  • Dose 3-9 grams fresh (or dried) peeled ginger root

  • Tea made from grated fresh root

  • Commercially available capsules

  • NOT ginger biscuits or ginger beer

Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196


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6-gingerol is mutagenic in vitro at high doses

Other compounds in ginger are anti-mutagenic

Widely used in Traditional Chinese Medicine

No contraindication in Pharmacopoeia of the People’s Republic of China (1995)

May increase miscarriage

Contraindicated in German Commission E

Ginger Root Safety?


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Protects liver

Promotes hepatic cell growth

Supports normal liver function

Antioxidant

Milk Thistle Silybum marianum


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Milk thistle

  • Hepatoprotective

    • antioxidant activity 1

    • toxin blockade at the membrane level 1

    • enhanced protein synthesis 1

    • antifibriotic activity 1

    • possible anti-inflammatory or immunomodulating effects 1

    • Stimulates action of nucleolar polymerase A causing in ribosomal protein synthesis, stimulating regenerative ability and formation of hepatocytes 2

      1 Milk Thistle: Effects on Liver Disease and Cirrhosis and Clinical Adverse Effects Summary, Evidence Report/Technology Assessment: Number 21 Sept. 2000. Agency for Healthcare Research and Quality, Rockville MD

      2 German commission E monographs


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Milk thistle

  • German Commission E Monographs report

    • No contraindications

    • No known side effects

    • No known interactions with other drugs


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Issues around herbal preparations

  • Preparations

    • Capsules and pills

    • Tinctures and extracts

    • Infusions

    • Teas

  • Effectiveness

  • Herbs in combinationformulas

  • Locally grown and wild crafting


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Slide credit # 14-48 based on material prepared with

Sara L. Warber, MD

Suzanne Zick, ND, MPH

Leslie Shimp, PharmD


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Contact Information

Linda Diane Feldt

P.O. Box 3218

Ann Arbor MI 48106-3218

734-662-4902

[email protected]

www.holisticwisdom.org

www.moonfieldpress.com

Free Herb Class 2nd Monday of each month, sponsored by the People’s Food Co-op,

at Crazy Wisdom Bookstore, Ann Arbor

Other classes and workshops listed on the web site.


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