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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


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


Consumers Report 2004


  • 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)

Herbs supplements

  • 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


    • 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.


  • 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)


  • 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) on the pillow?”

  • 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 on the pillow?”(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 St. John’s Wort”

  • 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 St. John’s Wort”

  • 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 St. John’s Wort”

  • An amino acid - assumed safe

  • Used for insomnia

  • Eosinophilia myalgia syndrome developed

    • 38 deaths!!

  • Banned by FDA in 1990

Fda concerns
FDA Concerns …. St. John’s Wort”

  • 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)

Herbs supplements

“Something from the supplement cart?” St. John’s Wort”

The NewYorker

Common supplements
Common Supplements St. John’s Wort”

  • Glucosamine/


  • CoQ-10

  • Melatonin

  • Amino Acids

  • Fish Oils/omega FA

  • DHEA

  • Acidophilus

  • Chromium

  • Sports enhancement

Glucosamine chondroitin
Glucosamine & Chondroitin St. John’s Wort”

  • 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

Herbs supplements

Consumers Report 2004 St. John’s Wort”

Coenzyme q10
Coenzyme Q10 St. John’s Wort”

  • 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 St. John’s Wort”

  • 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 St. John’s Wort”

  • Induces sleep if plasma levels are low

  • Shift workers

  • Jet Lag

  • 0.1 – 10 mg qhs

Insomnia St. John’s Wort”

Consumers Report 2004

Fish oils omega 3 fatty acids
Fish Oils & Omega 3 fatty acids St. John’s Wort”

  • 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 St. John’s Wort”(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... St. John’s Wort”

  • 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 St. John’s Wort”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 ?? St. John’s Wort”

  • 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.... St. John’s Wort”

  • Loose fat

  • Boost energy

  • ... no published support for such effects

Weight loss health foods
Weight loss St. John’s Wort” ….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?…. St. John’s Wort”

  • Associated Press5/22/00 …Herbalife Founder Mark Hughes dies at the age of 44 of ...

    .. Naturalcauses!

Ma huang or ephedra
Ma-Huang or Ephedra St. John’s Wort”

  • 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

Herbs supplements

“I’m taking you off wine, women and song St. John’s Wort”

and putting you on broccoli”

A clinician s perspective varying approaches
A Clinician’s Perspective ..... St. John’s Wort” 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 St. John’s Wort”

  • 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 St. John’s Wort”

…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 . . . St. John’s Wort”

  • 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….. St. John’s Wort”

  • 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!