Herbal Medicine: What You Should Know. Alexandra Cruz, PharmD Senior Pharmacy Manager Healthfirst

Transcription

1 Herbal Medicine: What You Should Know Alexandra Cruz, PharmD Senior Pharmacy Manager Healthfirst

2 Purpose and Objectives PURPOSE To gain an understanding of commonly used herbal medicines and the potential risks associated with use OBJECTIVES Define traditional, complementary, and alternative medicine Review the history of herbal medicine Describe the benefits and risks of consumption of herbal medicine Discuss commonly used herbal medicines in both Haiti and the developed world Understand uses, adverse reactions, and drug interactions with commonly used herbals FINANCIAL DISCLOSURE None

3 About Healthfirst Founded in 1993 on the simple idea that we can be a different kind of health insurance plan and improve healthcare in our communities The only not-for-profit health insurance company sponsored by local hospitals and healthcare systems in New York Insures more than 1.3 million members (1 in 8 NYC residents) through a comprehensive risk-sharing model Mission: Our members are our North Star and our mission is guided by their needs and preferences in ensuring a superior experience and access to the highest quality healthcare when and where they need it.

4 Definitions Traditional Medicine The sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures Used for the maintenance of health as well as for the prevention, diagnosis, improvement or treatment of physical and mental illness Complementary and Alternative Medicine (CAM) A broad set of healthcare practices that are not part of that country s own tradition or conventional medicine and are not fully integrated into the dominant healthcare system Used interchangeably with traditional medicine in some countries Herbal Medicines Include herbs, herbal materials, herbal preparations and finished herbal products, that contain parts of plants, plant materials, or a combination as active ingredients World Health Organization Traditional Medicine Strategy Available at: Accessed April 4, 2018.

5 History and Use of Herbals Herbal medicine for the treatment, control and management of a variety of conditions has been used since pre-historic times An estimated four billion people (80% of world s population) in the developing world use herbal medicine for primary healthcare Use in developed countries has been increasing since the 1970s. In the United States, over 30% of adults and 12% of children use herbals 70% of people taking herbal medications were reluctant about telling their doctors that they were using them 1. Ekor M. The growing use of herbal medicines: issues relating to adverse reactions and challenges in monitoring safety. Front Pharmacol. 2013;4(4): World Health Organization Traditional Medicine Strategy Available at: Accessed April 4, 2018.

6 Herbal Products: Pros and Cons Reasons for use Perception that natural = safe More affordable Believed to have less side effects than modern medicine More accessible Concerns with herbal products Cultural and religious beliefs Lack of regulation and standardization Lack of knowledge drug interactions, adverse drug reactions Optimal dosage is unknown Inappropriate use or misleading claims 1. Ekor M. The growing use of herbal medicines: issues relating to adverse reactions and challenges in monitoring safety. Front Pharmacol. 2013;4(4): World Health Organization Traditional Medicine Strategy Available at: Accessed April 4, 2018.

7 Commonly Used Herbals in Haiti

8 Bitter Melon/Asowosi (Momordica Charantia) Common Uses (insufficient evidence) Diabetes HIV/AIDS Kidney stones Liver disease Skin conditions (psoriasis, abscesses, wounds) Stomach and intestinal disorders Contains active insulin-like compound, polypeptide-p, which is proposed to have glucoselowering effects Charantins or insulin-like peptides which may have effects on carbohydrate metabolism GI side effects (abdominal pain, diarrhea), headache Antidiabetic agents hypoglycemia may occur Avoid caused menstrual bleeding and abortions in animal studies 1. Natural Medicines Comprehensive Database Consumer Version [Internet]. Stockton (CA): Therapeutic Research Faculty; Bitter Melon; [reviewed 2017 Nov 7; cited 2018 Apr 4]. Available from: 2. Bitter Melon. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: December Accessed April 4, 2018.

9 Cinnamon/Canell (Cinnamomum cassia) Common Uses (insufficient evidence) Diabetes Hyperlipidemia Inflammation Candidiasis Several polyphenols have been isolated from cinnamon showing insulin like activity Various proposed mechanisms demonstrate the protective effects of cinnamaldehyde on the cardiovascular system mainly due to peripheral vasodilation Raw cinnamon can be an irritant to mucosal membranes. Always dilute with liquid or food if ingesting Cassia cinnamon may cause or worsen liver disease in those who ingest large quantities. Avoid use in those with history or active liver disease Antidiabetic agents hypoglycemia may occur Avoid- unknown effects on fetus 1. Rao PV, Gan SH. Cinnamon: a multifaceted medicinal plant. Evid Based Complement Alternat Med. 2014;2014: Cinnamon. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: January Accessed April 4, 2018.

10 Aloe Vera/Lalwa Common Uses (insufficient evidence) Dermatologic and wound healing conditions (topical) Constipation (oral) Diabetes (oral) Metastatic Cancer (oral) Ulcers and Inflammation of GI tract (oral) A number of potentially active ingredients have been identified Hypersensitivity (topical) Diarrhea or vomiting (oral) Reported cases of acute hepatitis (oral) Thiazide diuretics, corticosteroids altered electrolyte balance Cardiac glycosides possible hypokalemia-related arrhythmias Antidiabetic agents possible hypoglycemia Avoid oral consumption topical use is believed to be safe 1. Foster M, Hunter D, Samman S. Evaluation of the Nutritional and Metabolic Effects of Aloe vera. In: Benzie IFF, Wachtel-Galor S, editors. Herbal Medicine: Biomolecular and Clinical Aspects. 2nd edition. Boca Raton (FL): CRC Press/Taylor & Francis; Chapter 3. Available from: 2. National Center for Complementary and Integrative Health. Aloe Vera Available at: Accessed April 4, 2018.

11 Castor Oil/L huile palma christi (Ricinus Communis) Common Uses Constipation (FDA approved, oral) Inflammatory conditions (topical) Acts primarily in the small intestine; hydrolyzed to ricinoleic acid which reduces net absorption of fluid and electrolytes and stimulates peristalsis Abdominal cramps, diarrhea, nausea Dehydration Do not use for longer than 1 week None reported Avoid- may induce labor

12 Senna/Ti sanit (Cassia acutifolia) Common Uses Constipation (FDA approved) Hemorrhoids Irritable bowel disease Weight loss Contains sennosides which irritate the lining of the bowel causing a laxative effect Dehydration Hypokalemia Diarrhea, abdominal pain, cramping Digoxin, diuretics- hypokalemia Possibly safe (short term) Small amounts of active metabolites are excreted in breast milk 1. Senna. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: August Accessed April 4, Natural Medicines Comprehensive Database Consumer Version [Internet]. Stockton (CA): Therapeutic Research Faculty; Senna; [reviewed 2015 Feb 16; cited 2018 Apr 4]. Available from:

13 Sage/Lachoy (Salvia officinalis, Salvia lavandulaefolia) Common Uses (insufficient evidence) Digestive problems Sore mouth or throat Alzheimer s Disease Depression Restlessness, vomiting, vertigo, rapid heart rate, tremors, seizures, kidney damage Inhibition of acetylcholinesterase, and rosmarinic acid has been shown to exert neuroprotective, antioxidant, and antiapoptotic effects against amyloid beta fibrils None well documented Safety and efficacy is unknown 1. National Center for Complementary and Integrative Health. Sage Available at: Accessed April 4, Senna. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: August Accessed April 4, 2018.

14 Soursop/Corossol (Annona muricata) Common Uses (insufficient evidence) Diabetes Antimicrobial Cancer Ethanolic bark extract has been shown to possess antidiabetic effects Adverse reaction information is lacking None well documented Avoid- information lacking 1. Soursop. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: August Accessed April 4, 2018.

15 Other Commonly Used Herbals

16 Garlic (Allium sativum) Common Uses (insufficient evidence) Dyslipidemia Hypertension Diabetes Common Cold Cancer Prevention Breath and body odor, mild GI adverse reactions (bloating, flatulence, nausea) Contains allinase enzyme which converts to allicin, believed to be responsible for some pharmacologic properties Anticoagulants- increased risk of bleeding Protease Inhibitors- may decrease serum concentrations Safe in pregnancy and breastfeeding 1. National Center for Complementary and Integrative Health. Garlic Available at: Accessed April 4, Garlic. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: February Accessed April 4, 2018.

17 Ginseng (Panax ginseng) Common Uses (insufficient evidence) Diabetes Hypertension Improve general well-being, physical stamina, concentration Ginseng saponins have been reported to act as selective calcium antagonists and enhance the release of NO2 from endothelial and neuronal cells Modulation of insulin sensitization and secretion based on cholinergic, dopaminergic, adrenergic, and nitric oxide actions found with ginsenosides Headaches, insomnia, and diarrhea, hypertension Anticoagulants- increased risk of bleeding Avoid - insufficient evidence 1. National Center for Complementary and Integrative Health. Ginseng Available at: Accessed April 4, Ginseng. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: March Accessed April 4, 2018.

18 Red Rice Yeast (Monascus purpureus) Common Uses (insufficient evidence) Hyperlipidemia Contains monacolin K which is chemically identical to active ingredient in lovastatin. Inhibits HMG-CoA reductase, the enzyme that catalyzes HMG-CoA to mevalonate and then to cholesterol, which results in decreased VLDL-C and plasma triglycerides, as well as LDL-C. Myopathy, rhabdomyolysis Liver toxicity Amiodarone, antacids, macrolide antibiotics, phenytoin, sildenafil- may decrease metabolism of red rice yeast CCBs, CYP3A4 inhibitors (strong), fluconazole, grapefruit juice, PPIs may increase serum concentrations of red rice yeast St. John s Wort increases metabolism of red rice yeast Avoid due to potential teratogenicity 1. National Center for Complementary and Integrative Health. Red Rice Yeast Available at: Accessed April 4, Red Rice Yeast. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: Feb Accessed April 4, 2018.

19 Milk Thistle (Silybum marianum) Common Uses (insufficient evidence) Liver disease (alcohol related hepatitis, cirrhosis) Diabetes Brief GI disturbances Avoid use in women with hormone sensitive conditions Silymarin stabilized hepatocyte and other cell membranes and stimulated macromolecular and protein synthesis Anti-inflammatory action with inhibition of neutrophil-mediated histamine release, lipoxygenase and prostaglandin synthetase, and leukotriene synthesis Weak CYP3A4 inhibition Moderate CYP2C9 inhibition Avoid- limited data exists 1. National Center for Complementary and Integrative Health. Milk Thistle Available at: Accessed April 4, Milk Thistle. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: October Accessed April 4, 2018.

20 Gingko biloba Common Uses (insufficient evidence) Alzheimer s and other dementias Hypertension Intermittent Claudication Antioxidant properties have been described and may account for observed protective effects of ginkgo in conditions of oxidative stress Headache, Dizziness, Heart palpitations GI and dermatologic reactions Anticoagulants increased risk of bleeding NNRTIs reports of virologic failure Avoid due to lack of information 1. National Center for Complementary and Integrative Health. Gingko biloba Available at: Accessed April 4, Gingko biloba. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: March Accessed April 4, 2018.

21 Hawthorn (Crataegus monogyna) Common Uses (insufficient evidence) Heart failure Hypertension Hyperlipidemia Angina Arrhythmia Cardiovascular actions include positive inotropic effects, peripheral vasodilation, increased myocardial perfusion, as well as stroke volume and decreased afterload Also increases the refractory period, an action thought to be one reason for observed antiarrhythmic activity Dizziness, headache, rash, palpitation, nausea Antihypertensives may enhance hypotensive effects Digoxin Avoid due to lack of information 1. National Center for Complementary and Integrative Health. Hawthorn Available at: Accessed April 4, Hawthorn. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc: Sept Accessed April 4, 2018.

22 Cranberry/seriz (Vaccinium macrocarpon) Common Uses (insufficient evidence) Urinary tract infections Cardiovascular disease Suggested mechanisms include increased resistance of low-density lipoprotein to oxidation, inhibition of platelet aggregation, and reduced blood pressure May decrease UTI symptoms by suppressing inflammatory processes in response to bacteria Diarrhea, GI symptoms Warfarin may enhance anticoagulant effect Minimal risk in pregnancy generally considered safe 1. National Center for Complementary and Integrative Health. Cranberry Available at: Accessed April 4, Gingko biloba. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc. Sept Accessed April 4, 2018.

23 Oats (Avena sativa) Common Uses (insufficient evidence) Hypertension Hyperlipidemia Diabetes Prevention of cardiovascular disease FDA recognizes that beta-glucan may play a role in reducing the risk of coronary heart disease GI discomfort, abdominal distention, flatulence May decrease absorption of medications Generally recognized as safe when used as food 1. Oats. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc. Oct Accessed April 4, 2018.

24 St. John s Wort (Hypericum perforatum) Common Uses (insufficient evidence) Depression It is assumed that hyperforin is the active component Mechanism remains unclear but amentoflavone has shown potent GABA receptor activity Photosensitivity, anxiety, dry mouth, nausea, fatigue, headache MANY! Antidepressants, contraceptives, cyclosporine, digoxin, antiretrovirals, antineoplastics, warfarin decreased effectiveness Avoid due to lack of evidence 1. National Center for Complementary and Integrative Health. St. John s wort Available at: Accessed April 4, St. John s wort. Review of Natural Products. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc. March Accessed April 4, 2018.

25 Summary Herbal medicines are commonly used worldwide and use is seldom reported to providers Natural does not mean safe Herbal medicines are not without adverse reactions and drug interactions Although reliable sources of herbal medicine do exist, majority of recommendations are NOT evidence based Information on use by patients must be specifically obtained and education is critical 25

26 Contact Information Alexandra Cruz, PharmD Senior Pharmacy Manager Healthfirst