WHMC311. Session 12. Respiratory System Disease Part II. Naturopathic Medicine Department. Endeavour College of Natural Health endeavour.edu.

Transcription

1 WHMC311 Session 12 Respiratory System Disease Part II Naturopathic Medicine Department 1

2 Topic Overview o Identify specific herbal medicines, drawing upon relevant literature, used in the support and modulation of colds, flu, sinusitis, tonsillitis, allergic rhinitis and asthma. o Discussion of relevant drug interactions and potentiations through an understanding of mechanisms of action of interactions. 2

3 Upper Respiratory Tract Infection o A collective term for infections, mostly viral, that affect the structures of the upper respiratory tract (URTI) o These infections usually have a brief duration, and usually recovery occurs without medical intervention o More severe cases should be referred for testing (Boon, Colledge & Walker, 2006) 3

4 Upper Respiratory Tract Infection o Acute coryza (common cold) o Acute laryngitis o Acute laryngotracheobronchitis (croup) o Acute epiglottitis o Acute bronchitis and tracheitis o Influenza (Boon, Colledge & Walker, 2006) 4

5 Cold & Influenza 5

6 Acute Coryza o Catarrhal inflammation of the mucous membrane in the nose, caused by a cold or hayfever. o Self limiting viral infection spread by droplet and infected mucous in the early stages of the condition. o Incubation is between 12 hours and 5 days & lasts between 7 to 14 days o Symptoms include: Tiredness & malaise Sore, swollen mucous membranes & lymph tissue Discharge that can vary from thin & watery to thick & purulent (Kumar & Clark, 2005) 6

7 Influenza Orthomyxovirus virus of either influenza A or Influenza B spread by droplets. Incubation of 1-3 days. Signs & symptoms o Sudden onset of fevers (39 C), shivering and aching o Headaches, throat pain and cough o The infection can last for weeks with a stage of debility that can present post infection. Mortality can occur in sensitive individuals usually through the contraction of opportunistic infections such as pneumonia. (Kumar & Clark, 2005,Merck online - Influenza) 7

8 Flu or Cold? Typical Symptoms Influenza Common cold Onset Sudden Gradual Fever High & lasting Uncommon Exhaustion Early & prominent Not a feature Muscle aches & pains Usual & often sever Slight Chest discomfort Prominent & can be severe Headache Prominent Rare Mild to moderate Cough Can become severe Not always Sore throat Sometimes Common Blocked nose Sometimes Common Complications Bronchitis, pneumonia Sinus congestion, earache (Sarris & Wardle, 2010, p.105) 8

9 Pharmaceutical Management: Common Cold o Due to the viral, self-limiting cause, pharmaceutical drug intervention is limited. o Symptomatic relief may be utilised. These over the counter drugs would include: Decongestants Expectorants Cough suppressants Non-steroidal anti-inflammatory drugs (NSAID s) o Antibiotics may be used if secondary bacterial infections present (Bryant & Knight, 2007) 9

10 Pharmaceutical Management: Common Cold Decongestants (Pseudoephedrine, Phenylephrine, Oxymetazoline) o Mode of Action Stimulate alpha receptors causing subsequent vasoconstriction and a reduction in mucus production. o Side Effects Systemic alpha receptor stimulation constipation, hypertension. CNS stimulation feelings of uneasiness, irritation, insomnia, euphoria. (Bryant & Knights, 2007;Bullock et.al, 2007;Kumar & Clark, 2005) 10

11 Pharmaceutical Management: Expectorants o Mode of Action Common Cold Dilute thickened mucus by mildly irritating the gastric mucosa to stimulate the production of thinner mucus (liquorice, senega, ammonia). Inhalation of volatile oils activate mucous glands on contact. Create dilution of mucus (Guaifenesin). o Side Effects Can be irritating to the gastric mucosa nausea & vomiting, diarrhoea. Other symptoms include rash, headache, dizziness. (Bryant & Knights, 2007;Bullock et.al, 2007;Kumar & Clark, 2005) 11

12 Pharmaceutical Management: Cough Suppressants o Mode of Action Common Cold Interruption of the nerve response to the medulla. Narcotic agents directly supress the medullary cough centre (codeine, dextromethorphan, pholcodine) o Side Effects Narcotic effect can create emesis, drowsiness and sedation. Only to be used on a non-productive cough. (Bryant & Knights, 2007;Bullock et.al, 2007;Kumar & Clark, 2005) 12

13 Pharmaceutical Management: Common Cold Non-Steroidal Anti-inflammatory Drugs (NSAID s) o Mode of Action Anti-inflammatory via inhibition of prostaglandins through the reduced release of cyclo-oxygenase enzymes (aspirin, ibuprofen). o Side Effects Dyspepsia, nausea, vomiting, diarrhoea/constipation, gastritis due to inhibition of mucous productive prostaglandins. (Bryant & Knights, 2007;Bullock et.al, 2007;Kumar & Clark, 2005) 13

14 Pharmaceutical Management: Common Cold Antibiotics (may be used if secondary bacterial infections present) Beta-lactams Bactericidal action in susceptible bacteria by inhibiting cell wall synthesis. Broad spectrum. Macrolides Bacteriostatic action to inhibit RNA protein synthesis in bacteria. Mainly used for respiratory tract infections, useful because they have slightly different spectrum to that of penicillin. Tetracyclines Bacteriostatic action to inhibit RNA protein synthesis in bacteria. Mainly used for respiratory tract infections Please review session 2.3 for a more thorough exploration of antibiotics. (Bryant & Knights, 2007) 14

15 Pharmaceutical Management: Influenza o This is the same protocol for Acute coryza. Due to the viral, self-limiting cause, pharmaceutical drug intervention is limited. o Symptomatic relief may be utilised. These over the counter drugs would include: Decongestants Expectorants Cough suppressants Non-steroidal anti-inflammatory drugs (NSAID s) o Antibiotics may be used if secondary bacterial infections present (Bryant & Knight, 2007) 15

16 Pharmaceutical Management: Influenza Influenza Antiviral drugs - (amantadine, oseltamivir, zanamivir) o Mode of Action Inhibits the replication of specific influenza viruses. These drugs are only useful within the first 2 days of symptom presentation for specific viral strains o Side Effects Amantadine has been found to cause neuromuscular disturbances & acute psychoses. (Bryant & Knights, 2007) 16

17 Pharmaceutical Management: Influenza Vaccination o Mode of action Influenza Inactive viral strains are injected to stimulate an antibody response which harbour some protection against infection. o Side Effects Injection site reaction, fever, malaise. Less commonly neurological reactions. o Warnings / Contra-indications If fever is present at time of vaccination. Allergies to neomycin, polymyxin or gentamycin or egg proteins (Bryant & Knight, 2007) 17

18 Information Gathering o Address acute presentation Treat symptoms, improve immunity and enhance recovery, reduce microbial presence, tonify the immune system o Are there signs of chronic immune dysregulation? Recurrent acute illness, chronic low-level symptoms (post-nasal drip), allergies o Stress? Support adrenal function/nervous system o Digestive dysfunction? Improve digestion, reduce gut permeability, rebalance microflora (Casteleijn & Finney-Brown 2014, p.174)

19 Treatment Considerations o Treatment approaches for common cold and influenza are similar with influenza treatment more vigorous (e.g. higher or more repeated doses) o Diaphoretics and heating remedies promote a mild fever and sweating both of which are useful for fighting infection. Circulatory stimulants: Zingiber off, Cinnamomum verum (cinnamon) in hot water More gentle: Mentha piperita (Peppermint), Eupatorium perfoliatum (Boneset), Nepeta cataria (catmint), Achillea millefolium (Yarrow) (Bone & Mills 2013, p ) 19

20 Treatment Considerations o Immune-modulation or enhancing Echinacea purpurea/angustifolia, Andrographis paniculata, Picrorrhiza kurroa, Uncaria tomentosa o Anti-catarrhals for upper respiratory Euphrasia (eyebright), Sambucus (elder), Hydrastis (golden seal) o Anti-viral for influenza Hypericum perforatum (St Johns Wort) o Symptomatic relief, such as for sore throat Emollient, topical astringent, lymphatic, topical antiseptic, antiinflammatory, anaesthetic (Bone & Mills 2013, p ; Casteleijn & Finney-Brown, 2014, p.162) 20

21 Herb Drug Interactions NSAIDs Capsicum spp. o May be protective against ulceration side effects of oral therapy Harpagophytum procumbens, Tanacetum parthenium Zingiber off, Curcuma longa Anti-inflammatory that may reduce the requirements for the drug and reduce side effects (Stargrove et al. 2008) 21

22 Sinusitis 22

23 Sinusitis o Acute inflammation of the para-nasal sinuses with a preceding event that inflames the sinuses (colds, influenza, allergic rhinitis) o Inflammation of the mucous membranes reduces the sinuses ability to properly drain allowing opportunistic bacteria from the throat and nose (occasionally fungal infections) to multiply and overgrow in this environment. o Chronic sinusitis progresses from acute and leads to thickening of the mucous membranes. o Implicating factors in this condition include asthma, environmental / airborne allergies, food intolerances (Kumar & Clark, 2005;National institute of allergy and infectious disease, 2010) 23

24 Signs and Symptoms o Pain in the forehead & cheekbones, jaw & teeth may present as tender o Swelling around the eyes, nose and puffiness of the cheeks o Thick mucous present may be yellow, green or blood streaked. There may be a post nasal drip o Congestion or a feeling of fullness in the nose o Other symptoms may include lethargy, coughs, sore throat, bad breath (Bryant & Knights, 2007)(National institute of allergy and infectious disease, 2010) 24

25 Clinical Presentation o Generally is very amenable to treatment - herbal/ acupuncture, face packs all work well. o Complications from inadequate treatment include osteomyelitis of the frontal bone, though very rare, and can lead to a brain abscess o Nasal polyps can develop o Tumours need to be ruled out 25

26 Pharmaceutical Management Antibiotics are utilised to control bacterial infections. Over the counter medication for symptomatic treatment would include: NSAID s to reduce inflammation and control pain Decongestants to reduce sinus congestion Saline sprays to aid drainage and thin mucus Nasal corticosteroids spray (Beclomethazone, Budesonide, Mometasone) administered for allergic sinusitis Side effects include nose bleeds, itching, sore throat (Bryant & Knight, 2007) (National institute of allergy and infectious disease, 2010) 26

27 Naturopathic Treatment 1. Avoidance or reduced exposure to offending antigens 2. Reduce sensitivity by improving integrity of mucosa and reducing inflammatory response 3. Support the immune system with immune enhancing herbs 4. Mucolytic herbs to clear stasis 5. Upper respiratory tract anti-catarrhals 6. Steam inhalation with antimicrobial essential oils 7. Grass pollen contains a protein that causes allergies (Bone & Mills 2013, p.246) 27

28 Herbal Actions o Support immune system Echinacea purpurea/angustifolia, Andrographis paniculata, Picrorrhiza kurroa o Anticatarrhal and decongestant Euphrasia off, Sambucus nigra, Hydrastis canadensis o Mucolytic herbs to clear the stasis Allium sativum, Armoracia rusticana (Bone & Mills 2013, p.246) 28

29 Hydrastis canadensis o Common name: Goldenseal o Particularly indicated for sinusitis due to properties: Antimicrobial Anticatarrhal Mucous membrane trophorestorative (Bone & Mills 2013, p.246) 29

30 Treatment of Chronic Sinusitis o Considered chronic when episodes of Acute Sinusitis continue for at least 3 months o Consider vicarious elimination Alteratives Galium aparine, Trifolium Lymphatics Phytolacca americana, Echinacea purpurea/angustifolia (Bone & Mills 2013, p.246) 30

31 Drug-Herb Interaction Antibiotics o Gelidium spp (algae), Thallus (Agar), Plantago psyllium Soluble fiber may inhibit absorption of oral drugs if administered concurrently (Brinker 2010, p. 33) o Cyamopsis tetragonolobus seeds (Guar gum) Concurrent consumption may inhibit oral absorption due to slower gastric emptying and viscosity of gum (Brinker 2010, p. 194) 31

32 Tonsillitis 32

33 Tonsillitis o The tonsils are comprised of lymphatic tissue and has a significant role in the bodies defence system o Inflammation of the tonsils demonstrates that they are fulfilling their role of protecting the body o Acute tonsillitis can become a medical emergency where the tonsils swell to the point of severe obstruction of the airway (Kumar & Clark, 2005;National institute of allergy and infectious disease, 2010) 33

34 Pharmaceutical Management o Antibiotics are utilised to control bacterial infections. o Over the counter medication for symptomatic treatment would include: Analgesic lozenges or throat sprays for topical pain relief. NSAID s to reduce fevers and aid with headaches, ear & jaw pain. o Some people who have repeated infections may need surgery to remove the tonsils. (Bryant & Knight, 2007;National institute of allergy and infectious disease, 2010) 34

35 Treatment Considerations Chronic Tonsillitis o Immune enhancing herbs o Lymphatic and depurative herbs o Local treatment such as a throat spray or lozenge. Gargling of Thymus vulgaris and Salvia officinalis Squirting lemon juice on to the tonsils with an eye dropper (Bone & Mills, 2013, p.247) 35

36 Herbal Treatment o Specific herbs for local treatment: Glycyrrhiza glabra (Licorice) soothing Salvia officinalis (Sage) - astringent and antiseptic Piper methysticum (Kava) anaesthetic Echinacea purpurea/angustifolia (Echinacea) Hydrastis canadensis (Golden seal) Althaea officinalis (Marshmallow) Commiphora myrrha (Myrrh) (Bone & Mills, 2013, p.247) 36

37 Allergic Rhinitis 37

38 Allergic Rhinitis o Allergic response mediated by IgE antibodies. Eyes, nasal mucous membranes and the throat are sensitised to inhaled allergenic agents. These include dust, dander, or pollen. o Initial Symptoms include: Itching, sneezing, running eyes and / or nose o Subsequent symptoms include: Nasal congestion Sore throat, coughing Blocked ears Puffy eyes lids & dark circles under the eyes Fatigue, irritability, reduced memory and concentration (Kumar & Clark, 2005;National institute of allergy and infectious disease, 2010) 38

39 Pharmaceutical Management o Saline sprays Wash of inhaled allergens, aid drainage and thin mucus. o Antihistamines Reduces the histamine-induced vasodilation, blood vessel permeability, erythema and oedema. Side Effects include: older classes can cause severe drowsiness. o Decongestants to vasoconstrict the blood flow to the nose. o Nasal corticosteroids sprays to reduces inflammation and mucous production (Kumar & Clark, 2005;National institute of allergy and infectious disease, 2010) 39

40 Treatment Considerations 1. Diet 2. Immune-enhancing herbs 3. Anti-allergy herbs 4. Upper respiratory anti-catarrhal herbs 5. Mucous membrane trophorestorative 6. T cell function dampener 7. Stress can exacerbate rhinitis and should be treated if it is considered to be a factor 40

41 Treatment Considerations o The use of 50mg of Pyconogenol b.i.d. by 30 subjects with allergic rhinitis to birch pollen led to only 36.7% relying on antihistamines compared to 50% of the 30 taking matching placebo. o Compared to placebo, hay fever nasal and eye symptoms were lower in those taking extract for 5 weeks or more (Wilson et al 2010) 41

42 Asthma 42

43 Asthma o A chronic inflammatory disorder of the airways characterised by reversible airflow obstruction causing Wheeze and/or cough Chest tightness/difficulty exhaling Shortness of breath Or very subtle (e.g. children with recurrent respiratory tract infection, seasonal asthma, night-time cough etc.) 43

44 Risk Factors o The strongest pre-disposing risk factor to asthma is atopy which is a genetic tendency for developing an immune-mediated (IgE) response to common allergens. o Other risks include: Atopic at an early age Exposure to high levels of allergens Family history of asthma Severe respiratory illness before the age of 2 years 44

45 Pathophysiology Haber,

46 Pharmaceutical Management o Controlling environmental stimuli or triggers o Anti-inflammatory drugs to promote relaxation of the bronchial smooth muscle o Bronchodilator drugs to stimulate the beta2-adrenergic agonist receptors during an attack o Antibiotics, when precipitated by bacterial infection o Combination of these treatments for severe attacks, in addition to oxygen and injected epinephrine in emergencies 46

47 Pharmaceutical Management B2-Adrenoreptor Agonists Relievers & Preventers Mode of Action o Stimulate B2 receptors on airway smooth muscle which results in broncho-dilation, mast cell membrane stabilization, thus inhibiting the release of inflammatory mediators & skeletal muscle stimulation. o Can be short-acting (most effective bronchodilators) and long-acting agents and in any severity of asthma. Side Effects o Can cause irritability, anxiety, heart palpitations & skeletal muscle tremor. o Chronic administration of short-acting B2-agonists can lead to tolerance by means of down-regulation and a decreased binding affinity of the B2-receptors. (Bryant & Knights, 2007) 47

48 Pharmaceutical Management Theophylline Relievers & Preventers Mode of Action o Unclear but believed to inhibition of phosphodiesterase increasing cellular camp, smooth muscle relaxation and bronchodilation. Side Effects Nausea, vomiting, epigastric pain, intestinal bleeding Irritability, nervousness, tremor, insomnia Warnings / Contraindications o Narrow therapeutic index with wide inter-patient variability in metabolism and clearance may result in adverse effects and toxicity even within this range o Only given orally, intravenously or rectally. They are unable to reach the bronchi via inhalation (Bryant & Knights, 2007) 48

49 Pharmaceutical Management Inhaled Corticosteroids (Beclomethasone, budesonide, fluticasone, ciclesonide) - Preventer Mode of Action o Anti-inflammatory action inhibiting phosphodiesterase production. This reduces prostaglandin & leukotriene production which in turn reduces the migration & function of neutrophils and eosinophils into tissues. o Corticosteroids also inhibit the synthesis, but not the release, of histamine from mast cells reducing airway reactivity o Improving the number of receptors & their response to B2-agonists o Reduce mucous production and hyper-secretion o Their efficacy is dose-dependent and duration-dependent (Bryant & Knights, 2007) 49

50 Pharmaceutical Management Inhaled Corticosteroids Side Effects o Oral candidiasis - rinse mouth and throat with water after use o Dysphonia - difficulty in speaking, hoarseness o High doses can cause suppression of the adrenal cortex occurs. This can result in skin thinning, purpura, bone thinning & potential for osteoporosis in adults. o Concern over the use of high dose corticosteroids and growth retardation in pre-pubertal children. o Generally the adverse effects of high doses of inhaled corticosteroids outweigh the risks of not controlling severe asthma adequately. (Bryant & Knights, 2007) 50

51 Pharmaceutical Management Systemic Corticosteroids (Prednisone) o Used to treat acute severe asthma, when a patient s condition declines or when starting long-term therapy. o Serious side effects so used in short bursts of therapy (1-3 weeks). Very short courses (3-5 days) have been used to reduce hospitalization due to acute exacerbations Side effects Skin thinning, impaired wound healing, immuno-suppression Growth retardation, skeletal muscle myopathy, osteoporosis Obesity Hypothalamic-pituitary-adrenal suppression (Bryant & Knights, 2007) 51

52 Information Gathering o Reduce symptoms and modulate disease progression Reduce inflammation, enhance bronchodialation, promote expectoration, reduce damaging airway remodelling o Are there signs of general allergy and sensitivity? Recurrent acute illness, chronic low-level symptoms (post-nasal drip), allergies o Address pertinent risk factors or comorbidities? Reduce exposure (environmental, diet, allergens), reduce hypersensitivity o Chronic infection, GORD, intestinal dysbiosis, stress? Address appropriately (Casteleijn & Finney-Brown 2014, p.196)

53 Treatment Aims o Identify allergic triggers & enhance patient understanding o Reduce airway hypersensitivity & reduce longer term remodelling o Modulate immune response o Enhance bronchodilation o Promote expectoration o Correct underlying digestive dysregulation GIT dysbiosis Increased intestinal permeability o Support nervous system to reduce stress response (Casteleijn & Finney-Brown 2014, p.187) 53

54 Treatment Considerations Dampen the inflammatory cascade o Boswellia serrata inhibits 5-lipoxygenase, a key cytokine in asthmatic inflammation. o Curcuma longa may interrupt NF-κB and reduce Th2 responses o Glycyrrhiza glabra lowers plasma levels of inflammatory cytokines o Zingerber officinale inhibits the release of prostaglandins, suppresses Th2-mediated immune responses, inhibits airway contractions. o Astragalus membranaceus may reduce lung inflammation, airway responsiveness and modulate some of the pathological processes involved in chronic asthma (Casteleijn & Finney-Brown in Sarris & Wardle 2014,pg 188) 54

55 Treatment Considerations Dampen the inflammatory cascade o PAF, a potent bronchoconstrictor, is released in response to allergen exposure = inflammatory airway response. Ginkgo biloba has shown activity as a PAF antagonist. Glycyrrhizin has demonstrated PAF inhibition Allium cepa shows anti-asthmatic and anti-paf effects due to it s thiosulfinate content 55

56 Treatment Considerations Immune modulation o Immune dysregulation is a key feature of atopic asthma. Strengthening immune resistance, rebalancing T-cell levels and restoring immune homeostasis in the lung may decrease sensitisation to allergens and triggers. o Echinacea angustifolia effective in prophylaxis/treatment of URTIs o Andrographis paniculata may inhibit the NF-κB pathway o Astragalus membranaceus immune enhancing + dampens inflammatory responses. 56

57 Cordyceps sinensis o Cordyceps is an effective anti-inflammatory herb. It has been shown to reverse asthma in many animal models, and it use should be considered (Skowron 2009, p.304) o The fungus germinates in living larva, kills and mummifies it, and then the stalk-like fruiting body emerges from the corpse and is used as herbal medicine from both Chinese and Tibetan traditions. 57

58 Cordyceps sinensis o Use of 3 gm/day for 10 days of cordyceps fermented mycelial product with astemizole and ketotifen for asthmatic cough in 81% improvement in 32 patients, compared with 61% improvement in 18 control subjects using just the pharmaceutical medications (Zhu Jet al 1998) 58

59 Treatment Considerations Manage allergies o Albizzia lebbek stabilised mast cell membranes in murine models, suggesting inhibition of histamine release. o Scutellaria baicalensis contains flavonoids which suppress eotoxin, a chemokine associated with recruitment of eosinophils to sites of allergic inflammation. o Panax ginseng may have the ability to modulate biochemical pathways involved in atopic asthma. o Immunosuppressive herbs, Tylophora indica or Hemidesmus indicus may be considered if necessary, but caution is urged re dosage. 59

60 Treatment Considerations Enhance bronchodilation o Justicia adhatoda considered specific for asthma and safe for log-term treatment. Contains alkaloids have been compared to theophylline for their bronchodilation and anti-asthmatic actions. o Euphorbia spp allays cough & has anti-proliferative properties = a reliable anti-asthmatic in spasmodic forms. o Coleus forskohlii (forskolin) is a natural bronchodilator as it increases camp levels in cells. o Zingerber officinale modulates intracellular calcium balance in airway smooth muscle, promoting rapid bronchodilation. o Other traditional bronchodilators include Grindelia camporum and Glycyrrhiza glabra. 60

61 Tylophora indica o Particularly useful for acute flare-ups of asthma or other allergic conditions o Used for short periods Up to 4 weeks at a time 2mls of 1:5 tincture for the first 10 days of each calendar month o Adverse effects Nausea and vomiting (even at low doses) 61

62 Tylophora indica 62

63 Treatment Considerations Consider the digestive link o Asthma development has been linked to increased digestive permeability, oesophageal reflux and dysbiosis. o Herbal bitters improve digestive capacity e.g. Gentiana luteum o Warming digestives associated with enzyme therapy e.g. Zingerber officinale, Cinnamomum cassia 63

64 Treatment Considerations o Discerning and eliminating triggers are key in treating asthma (check food allergy if asthma develops in childhood) o Exercise may be an issue o Hypersensitivity reactions may be associated with stress and anxiety. Mind-body techniques such as diaphragmatic breathing, meditation, tai chi, yoga, and stress management may help reduce frequency, duration, and severity of symptoms. 64

65 Drug-Herb Interactions o A standardisd CO2 extract of Petasites officinalis (butterbur) with a minimum of 15% petasins given for 2 months in doses from mg daily to children and adults with asthma. o Petasites officinalis extract was found to decrease number, duration and severity of asthma attacks. o More than 40% of those using asthma medications reduced their intake. Including 43% of those using steroids by an average reduction of 16%. (Brinker 2010, p.263) 65

66 Theophylline-Herb Interactions o Hypericum perforatum Reduced drug effects due to reduces serum levels Monitor for signs of drug effectiveness and adjust dose if necessary Drug has narrow therapeutic index (Braun & Cohen, 2010) o Cayenne spp. In animal trials, cayenne was found to increase theophylline absorption and bioavailability Higher doses or regular doses of cayenne may potentially increase the risk of theophylline toxicity (Bouraoui et al. 1988) 66

67 Corticosteroids-Herb Interactions o Glycyrrhiza glabra Concurrent use may potentiate effects of corticosteroids. Licorice can be used to minimise requirements for corticosteroids and aid withdrawal (applies more to oral drug). Reduced side effects observed, possibly due to lower drug dose. 67

68 Pre-reading for next session o. o Reading 1: Braun, L Cohen, M 2010, Herbs and Natural Supplements: An evidence based guide, 3 rd edn, Churchill Livingstone, Australia pp Reading 2: Dhawan, K Sharma, A 2002, Antitussive activity of the methanol extract of Passiflora incarnata leaves Fitoterapia, vol. 73, no. 5, pp (Via science direct) o Reading 3: Zakay-Rones, Z Thom, E Wollan, T & Wadstein, J 2004, Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment of Influenza A and B Viral Infections The Journal of International Medical Research, vol, 32, no. 2, pp

69 Pre-reading for next session o o o Reading 4a: Amit, A.; Saxenna, V.S.; Pratibha, N.; Bagchi, M.; Bagchi, D.; Stohs, S.J.. Safety of a Novel Botanical Extract Formula for Ameliorating Allergic Rhinitis Toxicology Mechanisms & Methods, Oct 2003, Vol. 13 Issue 4, p253, 9p. =112&sid=303e10c1-57bb f6d- 903da8dda504%40sessionmgr114&vid=4 Reading 4b: Amit, A.; Saxenna, V.S.; Pratibha, N.; Bagchi, M.; Bagchi, D.; Stohs, S.J.. Safety of a Novel Botanical Extract Formula for Ameliorating Allergic Rhinitis Part II Toxicology Mechanisms & Methods; May/Jun2005, Vol. 15 Issue 3, p , 12p =112&sid=303e10c1-57bb f6d- 903da8dda504%40sessionmgr114&vid=4 69

70 References o Adis International, 1997, Avery s Drug Treatment 4 th edn o Bone, K Mills, S, 2013, Principles and Practice of Phytotherapy: A Modern Herbal Medicine, 2 nd Edn, Churchill Livingstone, Edinburgh o Boon, N Colledge, N & Walker, B 2006, Davidson s Principles and Practice of Medicine, 20 th edn, Churchill Livingston o Braun, L Cohen, M 2005, Herbs and Natural Supplements. An Evidence-based Guide, Elsevier Mosby o Bryant B et al Pharmacology for Health Professionals. Mosby o Di Piro, J et al. 1997, Pharmacotherapy, A Pathophysiological Approach, 3rd edn, Appelton Lange, USA o Goodman, Gilman, 1996, The Pharmacological Basis of Therapeutics, 9 th edn, McGraw-Hill o Kumar & Clark, 2005 o Mills, S Bone, K 2005, The Essential Guide to Herbal Safety, Elsevier Churchill Livingstone. o MIMS Desk Reference April/May 2006 o Pizzorno, J Murray, M 2006, Textbook of Natural Medicine, 3rd edn, Churchill Livingstone Elsevier o Haber, 2008, Asthma 101, Texas Occupational Medicine Institute, viewed o o Wilson D, Evans M, Guthrie N, Sharma P, Baisley J, Schonlau F, Burki C, 2010 A randomized, double-blind, placebo-controlled exploratory study to evaluate the potential of pycnogenol for improving allergic rhinitis symptoms. Phytotherapy Research, Aug, Vol 24, Issue 8, pp Zhu J, Halpern, G Jones, K 1998 The Scientific Rediscovery of an Ancient Chinese Herbal Medicine: Cordyceps sinensis (Part 2) The Journal of Alternative and Complementary Medicine, Volume 4, Number 4, 1998, pp