1 / 62

Herbs & Supplements

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

baka
Télécharger la présentation

Herbs & Supplements

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Herbs & Supplements Did you remember to take your Gingko today ? Robert Baldor, MD Professor Family Medicine & Community Health

  2. 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

  3. A Clinician’s Perspective • What’s available • Efficacy • Safety

  4. 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

  5. Gingko Extracts • Ancient Chinese herbal treatment • Maidenhair tree leaves • Effects from flavonoids - antioxidant • Reduces capillary fragility, vasodilator

  6. 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)

  7. Marketed For ... • Memory enhancement • Improved concentration • No evidence for improved memory/concentration in normal, healthy individuals (NEJM 2002)

  8. 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

  9. St. John’s Wort • Outsells Prozac in Germany 7:1 • Meta-analysis - appears effective as low doses of standard antidepressants • Phototoxicity

  10. Depression Consumers Report 2004

  11. 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

  12. 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!

  13. 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)

  14. 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

  15. 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

  16. 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.

  17. 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)

  18. 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 ?

  19. 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

  20. AnxiolyticsGABA Binding Activity • Valerian (insomnia) • Kava kava (anxiety) • Chamomile (insomnia)

  21. 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

  22. 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

  23. 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

  24. Relief of Hot Flashes Consumers Report 2004

  25. 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

  26. “Not much - just flushing out my arteries.” The NewYorker

  27. 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

  28. “It’s a B-complex. Didn’t they used to put chocolate on the pillow?”

  29. 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)

  30. 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)

  31. “Michael has had an interesting side-effect from taking St. John’s Wort”

  32. FDA Approval • Drugs must be safe and effective • Average $230 million & 12 years • No patent to recoup costs for herbs

  33. 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

  34. Health Foods?….L-Trypthophan • An amino acid - assumed safe • Used for insomnia • Eosinophilia myalgia syndrome developed • 38 deaths!! • Banned by FDA in 1990

  35. 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)

  36. “Something from the supplement cart?” The NewYorker

  37. Common Supplements • Glucosamine/ chondroitin • CoQ-10 • Melatonin • Amino Acids • Fish Oils/omega FA • DHEA • Acidophilus • Chromium • Sports enhancement

  38. 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

  39. Consumers Report 2004

  40. 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

  41. Melatonin • Modified amino acid (tryptophan) • Released from pineal gland by diminishing light levels • Role in humans not fully elucidated • Small, conflicting sleep studies

  42. Melatonin for Sleep • Induces sleep if plasma levels are low • Shift workers • Jet Lag • 0.1 – 10 mg qhs

  43. Insomnia Consumers Report 2004

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

  49. Marketed To.... • Loose fat • Boost energy • ... no published support for such effects

More Related