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Complementary therapies

Complementary therapies. Matthew A Bartlett , M.B., B.Ch ., BAO Assistant Professor of Medicine General Internal Medicine Department of Internal Medicine. Disclosures. Relevant financial relationships: None Off label usage: Everything I am not a liver or PSC specialist. Objectives.

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Complementary therapies

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  1. Complementary therapies Matthew A Bartlett, M.B., B.Ch., BAO Assistant Professor of Medicine General Internal Medicine Department of Internal Medicine

  2. Disclosures • Relevant financial relationships: None • Off label usage: Everything • I am not a liver or PSC specialist

  3. Objectives • Discuss CAM/Integrative Medicine use in U.S. • Very brief overview of common CAM therapies • Develop practical approach to assessing risks/benefits of CAM (and other!) therapies • Discuss how CAM can be incorporated in patients with PCS

  4. Why am I here? • Complementary therapies are common • 1 in 3 adults use some form of “alternative” medicine • 20-60% of patients with IBD • $28.3 billion spent in the US in 2012 • One of the fastest growing fields in healthcare • Clinical practice is moving much faster than research NCHS, National Health Interview Survey, 2012

  5. Complementary and alternative medicine therapies

  6. Types of complementary therapies • Mind-body therapies • Herbs and dietary supplements • Manipulation and touch • Energy therapies • Alternative medical systems • Martial arts

  7. Mind-body approaches Expressive therapy • Art therapy • Journaling Sensory therapy • Aromatherapy • Guided imagery • Music therapy • Pet therapy Meditation/Relaxation • Meditation • Paced breathing • Hypnosis • Spirituality Other • Biofeedback • Yoga

  8. Herbs and dietary supplements • Typically products that you take by mouth • Often micronutrients aimed towards • Correcting a deficiency • Increase body function (e.g. immune booster)

  9. Manipulation and touch • Chiropractic Osteopathy • Massage Rolfing • Acupressure • Acupuncture • Healing touch • Reiki

  10. Alternative medical systems • Complete systems of theory and practice make up alternative medical systems • Ayurveda • Traditional Chinese medicine • Naturopathy • Homeopathy

  11. Practical approach to CAM therapies

  12. Practical approach to CAM therapies Our approach to any CAM intervention (or any therapy!) A. Safety first B. Suggestion of Benefit C. Worth Trying D. Determination of Benefit E. Continuation F. Healthy lifestyle as the ultimate therapy

  13. Practical approach to CAM therapies A. Safety first. • Are there concerns overall or specific to the condition treated? • Is the product considered high-quality & free of contaminants? https://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/ https://well.blogs.nytimes.com/2015/02/12/107141/

  14. Our Therapeutic approach B. Suggestion of Benefit. • Is it scientifically plausible that intervention will have a benefit? (reliable sources) • Are there formal studies for the conditions and symptoms the patient is facing?

  15. Our Therapeutic approach C. Worth Trying • The patient and provider weigh • Risks • Benefits • Costs • Inconvenience • Opportunity costs (trying one thing versus another)

  16. Our Therapeutic approach D. Determination of Benefit • Set SMART goals to determine if therapy is "working“ • Specific • Measurable • Attainable • Relevant • Timely • Example • Lower Alkaline phosphatase by 30% by 3 months • Improve sleep by 15% (ie. sleep one hour longer) by 3 mo

  17. Our Therapeutic approach E. Continuation? • Once product is tried • Did we achieve goals? • Any safety concerns? • It is worth it?

  18. Our Therapeutic approach F. Lifestyle as the therapy • Supplements are truly only supplements • Cannot replace a healthy lifestyle

  19. CAM and PSC

  20. No alternative medicine treatments have been found to treat primary sclerosing cholangitis. But some complementary and alternative therapies may help you cope with the signs and symptoms of the disease.

  21. A. Safety first • Supplements account for 20% reported hepatotoxicity • Tripled in the last decade • Products most commonly associated with liver damage: • Herbal products (16%): Green tea extract, kratom, black cohosh, Garcinia • Botanic mixtures (8%): Ayurvedicmedcations • Vitamins and minerals (8%): Niacin, multivitamins • Others (68%): Glucosamine chondroitin sulfate? Navarro V, Khan I, Björnsson E, et al. Liver Injury from Herbal and Dietary Supplements.  Hepatology. 2016. doi: 10.1002/hep.28813.

  22. B. Suggesting of benefit? • Clear role for dietary supplementation in the context of malabsorption or bone loss • Follow the advice of your liver specialist • Commonly used supplements in PSC/Liver disease • Curcumin / Turmeric • Milk thistle • Antioxidants

  23. Curcumin • Yellow-colored molecule derived from the turmeric plant • Used in traditional Asian medicine to treat upset stomach, arthritic pain, & "low energy." • Promising results in other liver diseases such as non-alcoholic fally liver disease (NAFLD)

  24. Conclusion: “While curcumin was well tolerated, it was not associated with significant improvements in cholestasis or symptoms. Moreover, this study also illustrates that a low SAP is common among those with PSC.” Scandinavian Journal of Gastroenterology: https://doi.org/10.1080/00365521.2019.1611917

  25. Milk thistle • Plant native to Europe, brought to the US by colonists • Used for over 2 millennia, liver/gallbladder disorders • Safe • Safely used in studies lasting 3 months – 4 years • Watch for medication interactions • Benefits: • Studies inconclusive spanning several liver diseases

  26. Antioxidants • Free radicals - byproduct of natural cell function • Found in environment: sunlight, pollution, tobacco • Trigger cell and tissue damage through oxidation • Antioxidants believed to minimize effects of free radicals • Unknowns • Test tube benefit = Human benefit? • Antioxidant supplements = Antioxidant foods? • Unclear what role antioxidants play in PSC • Safety – Vitamin E?

  27. Supplements – Take home points • Very little research on supplements in PSC • Legitimate concern about risks • All supplements need careful scrutiny • If a supplement is considered • Discuss with your primary care clinician or liver specialist and consider the ABCDE approach • Ensure that the supplement has had some outside quality assurance

  28. So what can I do? • Integrative medicine therapies can be helpful for common issues seen with chronic medial illness • Stress • Insomnia • Pain

  29. CAM therapy for stress, insomnia and pain + efficacy/ low risk • Acupuncture • Massage • Biofeedback • Hypnosis • Meditation • +/- efficacy/ low risk • Guided imagery • Qi gong • Tai chi • Yoga

  30. Back to the basics • A healthy lifestyle is always going be beneficial • Balanced, whole-food, plant-based diet • Physical activity • Regular mindfulness practice • Social support

  31. Back to the basics • A healthy lifestyle is always going be beneficial • Balanced, whole-food, plant-based diet • Physical activity • Regular mindfulness practice • Social support

  32. Conclusion • No complementary therapy found to treat PSC • As part of integrative management program, may: • Reduce stress • Reduce insomnia • Reduce muscle tension and pain

  33. Thank you!

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