An Introduction to Herbs for Wound Healing Professionals

Transcription

1 An Introduction to Herbs for Wound Healing Professionals Dina Ranade, RD; and Nancy Collins, PhD, RD, LD/N, FAPWCA, FAND Medicinal plants have played an important therapeutic role throughout history. Records of herbal remedies date back 5,000 years and document the evolution of ethnobotanical therapies from regional availability of plants and trade commerce to highly developed medical practice. Systems such as Ayurveda and Traditional Chinese Medicine use herbs extensively and are established facets of healthcare in India and China, respectively. In Europe and the United States, herbalism declined in the early 1900s as the pharmaceutical industry expanded. Today, uneasiness with drug side effects along with the desire for natural options has catalyzed a resurgence in herbal use. As scientific research validates efficacy, interest and use continue to rise. This article provides wound care professionals a review of the common herbs patients may report taking and important facts to keep in mind, such as drug interactions and side effects. Definition of Herb An herb is any plant whose leaf, stem, flower, root, or seed is used for flavoring, food, medicine, or perfume. 1 Herbs, classified as over-the-counter dietary supplements, are frequently purchased and managed without consulting a healthcare professional. When asked to list medications, people often forget or intentionally omit vitamin and mineral supplements as well as herbs. 2 Clients fear physicians may not endorse botanicals and will recommend discontinuation. Physicians hold to their skepticism about herbal safety due to uncertainties, such as case reports citing nephrotoxicity and hepatotoxicity. 3 Regardless of belief in plant medicine, it is critical for healthcare practitioners to have complete information on herbal supplementation in order to make informed plan-of-care decisions. Herbal Therapy in Wound Care New approaches incorporating use of medicinal herbs and botanicals have the potential to positively impact patient care. Botanicals address all objectives of wound healing through both topical and internal applications. Honey, a botanical known for its antibacterial and antifungal properties, has gained acceptance as a treatment to accelerate wound healing. Aloe vera, a plant with a long tradition of topical use for burns and wounds, decreases inflammation, soothes itching and burning, provides antimicrobial effects, and promotes overall healing. Numerous other plants contain chemical constituents that provide benefit for wounds. The astringent properties of herbs such as witch hazel help dry oozing and bleeding wounds. Mucilage, a constituent in herbs such as slippery elm and plantain, provides a soothing and protective coating. The vulnerary herb calendula contains multiple beneficial components that are antiseptic, anti-inflammatory, and stimulate the immune responses and collagen formation. Topical use of herbs has little risk of adverse effect, but occasional allergic contact dermatitis reactions warrant the use of skin testing before application. When taken internally, the effects of herbs are far-reaching, offering additional benefit for common concerns such as digestive disturbances or emotional imbalances. When seeing patients for chronic or nonhealing wounds, it is important to specifically inquire if the patient is consuming any herbal products or using any topical preparations in addition to what has been prescribed by the wound healing professional. Today s Herbal Commerce Herbs are sold in different forms, including teas, liquid extracts or tinctures, capsules and pills, syrups, oils, salves, and lotions. They can be purchased in mainstream markets such as Wal-Mart and health food stores and also are available on the Internet. In 2012, total herbal and botanical dietary supplement sales in the United States increased by 5.5%, continuing a steady growth trend over the past 9 years. This equates to 36 million adults who use herbal supplements, contributing to industry sales revenue of $5.6 billion. 4 In 2013, 13% of consumers taking herbs reported increasing their usage; additionally, 23% of consumers reported herbs serve an important role in maintaining their well-being and health. 5 Economic hardship coupled with high medical costs seems to lead people, especially women and younger generations, to make more independent decisions about personal health. The trend toward increased self-medication with herbal supplements is not without concerns. Consumers must be aware of product safety and purity, proper dosing recommendations, and reputable manufacturers and distributors. Table 1 lists some of the most commonly purchased herbs. Dina Ranade, RD, has practiced as a clinical dietitian in the healthcare setting for the past 24 years. She has completed formal studies in herbal medicine and now merges herbal and nutritional therapeutics. Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of Nutrition411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com. This article was not subject to the Ostomy Wound Management peer-review process. 16 ostomy wound management june

2 Table 1. The 10 top-selling herbal dietary supplements in the United States in Mainstream Retail Market Natural and Health Foods Market 1. Cranberry 1. Flax seed and/or oil 2. Garlic 2. Wheat and barley grass 3. Saw Palmetto 3. Turmeric 4. Soy 4. Aloe vera 5. Ginkgo 5. Spirulina/blue green algae 6. Milk thistle 6. Milk thistle 7. Black cohosh 7. Elderberry 8. Echinacea 8. Saw Palmetto 9. St. John s wort 9. Echinacea 10. Ginseng 10. Cranberry Table 2. Herbs for improved circulation and wound healing Herbs for improved circulation and wound healing Turmeric Aloe vera leaf gel Goldenseal Cayenne pepper Plantain Specific indications Antioxidant, antiinflammatory, antimicrobial; stimulates immune response Enhances wound healing by increasing blood circulation through the wound area; antimicrobial Antimicrobial, increases wound granulation and healing Enhances blood circulation to extremities, improves vascular integrity, relieves pain with topical application Antioxidant, antiinflammatory, antibacterial; promotes wound healing Herbal Regulation and Quality As herbalism gains impetus, the need for safety information and quality control measures increases. Herbal products categorized as dietary supplements are subject to regulation by the Food and Drug Administration (FDA) under the Dietary Supplement Health and Education Act of 1994 (DSHEA). 6 Dietary supplements do not require FDA approval before marketing. The FDA authorizes only any label claim of prevention, treatment, or cure for a disease or condition. The responsibility for ensuring safety and prevention of false or misleading claims falls to the supplement manufacturers who must comply with the Dietary Supplement Current Good Manufacturing Practices (CGMPs). These regulations are meant to prevent adulteration and contamination of herbal products and to ensure quality, consistency, and authentication of botanicals. 7 In 2011, three nonprofit organizations joined to address concerns about adulteration of herbal ingredients: the American Botanical Council, Contraindications Drug interactions Avoid internal use in presence of diarrhea; avoid commercial products that combine aloe gel and latex Avoid in pregnancy and lactation Avoid use in or near eyes; topically avoid use for more than 2 days; internally use in drop doses only May decrease absorption of medications. Take 1 hour before or 2 hours after medications May inhibit drug metabolizing enzymes from the CYP3A4 and CYP2D6 pathways Adverse events Reports of adverse events involve the use of the aloe latex (juice), not the inner leaf gel, which has no adverse events reported; aloe latex may cause diarrhea, stomach cramps, and skin irritation Topical use can irritate mucous membranes and broken skin or cause burning sensation; internal use may cause gastrointestinal irritation or heartburn in sensitive individuals Propolis Antiseptic, antioxidant; enhances wound healing topically and internally Avoid use in people with allergies to bees Contact dermatitis and allergic reactions; apply skin patch test before use 18 ostomy wound management june

3 Table 3. Herbs to aid mental function Herbs to aid mental function St. John s wort Lemon balm Holy basil Gingko Black cohosh Ginseng Specific indications Contraindications Drug interactions Adverse effects Depression accompanied by gastro-intestinal distress, nervous anxiety, seasonal affective disorder Mood elevator, especially for seasonal affective disorder Mental fog; chronic depression Enhances memory, especially for elderly Hormonal depression (doom and gloom) Enhances cognitive function; relieves fatigue Avoid in combination with phototherapy (laser or ultraviolet) the American Herbal Pharmacopoeia, and the University of Mississippi s National Center for Natural Products Research focus on the accidental adulteration occurring due to poor quality control procedures as well as intentional adulteration with cheaper products for financial gain. Written reports are available on the adulteration of black cohosh, skullcap, bilberry, and grapefruit seed extract. 8 A reliable and authoritative reference on the safety of botanicals is the American Effects the drug metabolizing CYP450 enzyme system, decreasing blood levels and therapeutic activity of drugs metabolized through this pathway. Avoid use with cyclosporine, warfarin, digoxin, nifedipine, verapamil, indinavir, clopidogrel bisulfate, oxycodone, omeprazole, and statins (for full list refer to Botanical Safety Handbook); also may affect oral contraceptive pills Discontinue use 7 days before undergoing surgery Careful glucose monitoring for persons with diabetes on insulin or oral hypoglycemic agents due to blood glucose lowering activity Concomitant use with anti-coagulants should be under healthcare practitioner supervision only; may lower plasma concentrations of nifedipine; should not be used with MAO inhibitors Fair-skinned people should avoid sun exposure while taking due to photosensitizing properties Pregnancy Adulterants have been identified and linked to liver toxicity; links to hepatotoxicity have not been confirmed; larger doses may cause gastrointestinal discomfort Avoid concomitant use with warfarin or use only under the supervision of a healthcare professional. Careful glucose monitoring in persons with diabetes Allergic reactions have been reported; may be over-stimulating if used with caffeine or other stimulants Herbal Products Association s Botanical Safety Handbook 9 ; a second edition was recently published. Herb-Drug Interactions Herb-drug interactions are less common than drug-drug interactions; however, they do occur. Navigating the evidence is confounded by study errors, conflicting information, and reporting of adverse events with little clinical significance ostomy wound management june

4 Table 4. Herbs to support urinary function Herbs supporting urinary function Cranberry Parsley leaf Uva-ursi Saw Palmetto Stinging nettle leaf Specific indications Antibacterial, prevention and treatment of urinary tract infection (UTI) Anti-inflammatory, diuretic Antimicrobial to urinary tract for treatment of UTI, cystitis, and mild nephritis Treatment of benign prostatic hyperplasia and interstitial cystitis; urinary antiseptic Mild, potassiumsparing diuretic; strengthens kidney function The more knowledge and experience with botanicals, especially for appropriate dose and indication, the better able the clinician to tackle these challenges. Natural does not equate with safe, but the effect and interaction of an herb is difficult to predict due to lack of regulation and standardization of products, as well as consumer selfprescribed usage. 11 Taking herbs and drugs separately by at least 2 to 3 hours decreases likelihood of interaction. 12 Particular caution should be used if taking herbs known to cause either increased or decreased blood values of medications. The top three herbs causing this type of response are St. John s wort, gingko, and kava-kava. Warfarin is by far the medication with which the most interactions may occur, but any medication that has a cardiovascular or central nervous system effect should be a red flag for possible interactions. 10 Side Effects Botanicals are essentially safe and nontoxic, but not all herbs work gently, and if used in the wrong way or at the wrong dose there can be negative outcomes. Despite the growing volume of research and history of long traditional use, much remains unknown. Discerning the truth from the abundant information in the media and Internet is challenging. Research studies and case reports must be evaluated for accuracy, specifically with regard to proper Contraindications Drug interactions Adverse effects Avoid in pregnancy, lactation, and in young children Due to increase in potassium excretion, avoid use with lithium, digoxin, or lanoxin; take 2 hours before or after iron supplements In large doses or prolonged use may cause nausea and gastric irritation; may turn urine a greenish-brown color; however, no problems are associated with this ; concerns with liver toxicity and drug interactions have not been confirmed in clinical trials Careful glucose monitoring for persons with diabetes on insulin or oral hypoglycemic agents due to serum glucoselowering activity Fresh nettle may cause skin irritation on contact and should not be consumed unless cooked; no reaction occurs with ingestion of dried, powdered, extracted, or cooked nettle leaf botanical identification. Part of the problem is that in our age of abundance and technical advances, herbs now are sold in concentrated forms, either as capsules or standardized to a certain amount. This creates greater potential for overdosing than if herbs are taken in more traditional forms such as teas or tinctures. With plants, the concept more is better does not apply. Overall, in comparison to pharmaceuticals, risk of herbal side effects is mild. Toxicity In 2010, more than 22,000 deaths occurred from overdose of pharmaceuticals, 74% of which were unintentional. 13 In contrast, the US National Poison Data System reported zero deaths from dietary supplements, including herbs. 14 Because toxic, poisonous plants exist, self-collection of herbs must be done with botanical knowledge and confirmation the proper plant has been identified. In manufactured supplements, toxicity is often a result of contamination with adulterants. Risk of this occurrence is higher for herbs imported from other countries or from suppliers more concerned with lower costs who may compromise purity. Dose is the essential consideration. A strong-acting herb can be toxic if taken at a higher dose than recommended. Effective dosing is based on age and body weight, criteria not often reflected on product package recommendations ostomy wound management june

5 Table 5. Herbs to aid digestion Herbs for digestion Specific indications Contraindications Drug interactions Adverse effects Peppermint Chamomile Fennel seed Digestive aid, anti-spasmodic, relieves gas Acute and chronic digestive distress; anti-spasmodic, calming Prevention and treatment of gas, reflux, bloating, constipation; stimulates appetite May decrease esophageal pressure, exacerbating gastroesophageal reflux, or hiatal hernia Take 2 hours before or after iron supplements Allergic reaction possible Estrogenic activity reported in infants, although has been used safely for treatment of colic Ginger Nausea, motion sickness Cinnamon Stimulates gastric hydrochloric acid secretion, relieves gas, nausea, and low-grade diarrhea Pregnancy in high doses (>2 g) Careful glucose monitoring for persons with diabetes on insulin or oral hypoglycemic agents due to blood glucose-lowering activity Dandelion root Digestive aid, bitter tonic Licorice Anti-inflammatory to gastric mucosa, benefits for treating gastritis, ulcers, and inflammatory bowel disease In pregnancy, use only under supervision of qualified healthcare practitioner; avoid in hypertension, liver disease, edema, severe kidney insufficiency, low serum potassium, congestive heart failure; not recommended for use >6 weeks or in high doses at therapeutic dose (1 to 5 g, three times a day); at high dose or prolonged use, may cause potassium depletion with diuretics, laxatives, corticosteroids; may potentiate cardiac glycosides such as digoxin at doses used as a spice in cooking Note: Cautions do not apply to deglycyrrhizinated licorice (DGL) products Commonly Used Herbs There is a vast number of medicinal plants and an herb or several herbs to cure or relieve every possible ailment. Many references offer extensive herbal Materia Medica lists. 12,15,16 Most herbals provide information on all aspects of use for a specific herb; however, for concerns regarding safety, the Botanical Safety Handbook 9 is the most comprehensive. Additionally, herbal databases are available on the Internet and include the American Botanical Council s herbmed.org 17 and the Natural Medicines Comprehensive Database. 18 Improved circulation and wound healing. Botanicals help reduce the risk of delayed wound healing, enhance the healing process, and decrease incidence of infections. Plant chemical constituents are classified into broad categories that assist with skin integrity such as antimicrobial, anti-inflammatory, antioxidant, cytotoxic, and immune stimulant. For support of circulation, herbs stimulate blood flow to better deliver oxygen and nutrients to the wound area as well as provide cleansing to prevent contamination. Herbs fight specific wound-compromising bacteria and aid in treatment of diabetic foot ulcers, pressure ulcers, and venous leg ulcers (see Table 2). Aid to mental function. Botanicals influence cognition in two ways. The biochemical constituents of plants provide specific therapy for anxiety, depression, stress reduction, improving memory, and hormone-related imbalances. Plants also address the mind-body connection, offering energy that nourishes the spirit (see Table 3). Support urinary function. Botanicals often act as mild diuretics, providing benefit to kidney function by decreasing excess accumulation of fluid. Many herbs are specifically 24 ostomy wound management june

6 anti-inflammatory, antimicrobial, and soothingly demulcent to the urinary tract, providing treatment for infections and irritations (see Table 4). Aid to digestion. Botanicals provide a multitude of healing qualities for digestive imbalances, including heartburn, nausea, bloating, gas, diarrhea, and constipation. They act as adjunctive therapy for inflammatory bowel disease, gastroesophageal reflux, leaky gut syndrome, and treatment of food allergies. Herbs often are calming, relieving stress-induced or emotion-related digestive responses (see Table 5). Practice Points As today s healthcare transforms, holistic medicine continues to gain wider acceptance. The intricate science of herbalism is growing as a specialized field and has far-reaching benefits in the area of wound care. With rising popularity of alternative approaches, the clinician who takes the time to review existing herbal supplementation and then educate patients on safety, appropriate dosing, pure product availability, and the potential risks of mixing with prescription or nonprescription pharmaceuticals has made an important contribution to patient autonomy and supported an all-inclusive approach to healthcare. Although the following list of considerations can help with safe herbal use, consultation with a qualified herbal practitioner is recommended for complex issues and concerns. Detailed information on herbal products includes the dose, form (tea, extract, capsule, topical salve or liniment), brand, and length of time the herb has been used. Compare dose taken to recommended doses. The concept that if a small amount is beneficial, more is better does not apply. Use wild-crafted or organic herbal products only from reputable sources that clearly advertise purity. Apply patch testing on skin before topical application of a botanical. Consult reliable references such as the Botanical Safety Handbook for efficacy, interactions, side effects, and contraindications, as well as safety during pregnancy and lactation. Red-flag medications for potential interactions include warfarin, digoxin, lithium, cyclosporine, and protease inhibitors. Avoid use of herbs reported to cause hepatotoxicity (black cohosh, kava kava, chaparral) with hepatotoxic medications (tetracycline, acetaminophen, statins), or with excessive alcohol intake. The more prescription medications a patient takes, the greater the likelihood of an herb-drug interaction. Risk is substantially increased if taking more than six medications and is highest in the elderly population. n References 1. Oxford Dictionary. Oxford University Press; Available at: Accessed April 12, Mehta DH, Gardiner PM, Phillips RS, McCarthy EP. Herbal and dietary supplement disclosure to health care providers by individuals with chronic conditions. J Altern Complement Med. 2008;14(10): Bent S. Herbal medicine in the United States: review of efficacy, safety, and regulation. J Gen Intern Med. 2008;23(6): Lindstrom A, Ooyen C, Lynch ME, Blumenthal M. Herb supplement sales increase 5.5% in 2012: herbal supplement sales rise for 9th consecutive year; turmeric sales jump 40% in natural channel. Herbalgram. 2013;99: Natural Marketing Institute. Consumer and Market Trends of Botanicals. Engredea News & Analysis; March Available at: com/consumer/consumer-and-market-trends-botanicals. Accessed April 25, Commission on Dietary Supplement Labels. Dietary Supplement Health and Education Act of US Department of Health and Human Services; November 24, Available at: Accessed April 20, US Food and Drug Administration. Dietary Supplements. US Department of Health and Human Services; March Available at: Food/Dietarysupplements/default.htm. Accessed April 18, Smith T. Nonprofit Collaboration Addresses Adulteration of Botanical Dietary Ingredients. HerbalGram. 2011;92: Gardner Z, McGuffin M (ed). American Herbal Products Association s Botanical Safety Handbook 2nd ed. Boca Raton, FL: CRC Press: Tsai HH, Lin HW, Simon Pickard A, Tsai HY, Mahady GB. Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements. Int J Clin Pract. 2012;66(11): Ulbricht C. What every clinician should know about herb-supplement-drug interactions. Altern Complement Ther. 2012;18(2): Winston D. Herbal Therapeutics, 10th ed. Herbal Therapeutics Research: Broadway, NJ: Library; Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, JAMA. 2013;309(7): Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL Annual Report of the American Association of Poison Control Centers National Poison Data System (NPDS): 27th Annual Report. Clinical Toxicology (2010). 48, Available at: Accessed April 22, Hoffmann D. Medical Herbalism. Rochester, NY: Healing Arts Press; PDR for Herbal Medicine, 4th ed. Montvale, NJ: Thomson Healthcare, Inc; American Botanical Council. Available at: html#param.wapp?sw_page=index. Accessed April 18, Natural Medicines Comprehensive Database. Therapeutic Research Faculty; Available at: home.aspx?cs=&s=nd. Accessed April 18, june 2014 ostomy wound management 25