Herbs & Supplements

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Herbs & Supplements

Did you remember to takeyour Gingko today ?

Robert Baldor, MDProfessor

Family Medicine & Community Health

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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

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A Clinician’s Perspective

• What’s available• Efficacy • Safety

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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

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Gingko Extracts

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

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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

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((2002 Cochrane)2002 Cochrane)

Marketed For ...

• Memory enhancement • Improved concentration

• No evidence for improved memory/concentration in normal, healthy individuals (NEJM 2002)

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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

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St. John’s Wort

• Outsells Prozac in Germany 7:1• Meta-analysis - appears effective as low

doses of standard antidepressants • Phototoxicity

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Depression

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Depression

Consumers Report 2004

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

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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!

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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)

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• 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 RDVand……– As much caffeine as a cup of premium coffee

• A cup (8oz) of Starbucks has 180mg of caffeine

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

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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

17Tidsskr Nor Laegeforen. 1994 Dec 10;114(30):3583-6.

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)

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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 ?

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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

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Anxiolytics GABA Binding Activity

• Valerian (insomnia) • Kava kava (anxiety)• Chamomile (insomnia)

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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)

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AFP 2003AFP 2003

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

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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

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Relief of Hot Flashes

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WHAT RELIEVED HOT FLASHES?

Consumers Report 2004

Milk Thistle

• Flavonoid complex called silymarin • Used for improving liver function in hepatitis,

cirrhosis• Meta- analysis – appears safe but no clear

benefit….

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Am J Med 2002

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“Not much - just flushing out my arteries.”

The NewYorker

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

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

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)

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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)

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

FDA Approval

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

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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

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Health Foods?….L-Trypthophan

• An amino acid - assumed safe• Used for insomnia• Eosinophilia myalgia syndrome developed

– 38 deaths!!• Banned by FDA in 1990

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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)

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“Something from the supplement cart?”

The NewYorker

Common Supplements

• Glucosamine/ chondroitin• CoQ-10• Melatonin• Amino Acids

• Fish Oils/omega FA• DHEA• Acidophilus• Chromium• Sports enhancement

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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

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Cochrane Review 2005

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Consumers Report 2004

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)

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AFP 2005

Melatonin

• Modified amino acid (tryptophan)• Released from pineal gland by diminishing

light levels• Role in humans not fully elucidated• Small, conflicting sleep studies

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

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Insomnia

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Insomnia

Consumers Report 2004

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

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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

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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

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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

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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

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The Medical Letter 2006

Marketed To....

• Loose fat • Boost energy

• ... no published support for such effects

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Weight loss ….Health Foods??

• Metabolife contains Ma Hung • Bitter orange extract contains synephrine• Chomper is a natural laxative, contains

digitalis - induces arrhythmias • Tryptophan & phenylalanine - amino acids ?

efficacy

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Health Foods?….

• Associated Press 5/22/00 …Herbalife Founder Mark Hughes dies at the age of 44 of ...

.. NaturalNatural causes!

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Ma-Huang or Ephedra

• MetaboLife, Herbal Ecstasy• Contains Ephedrine• Linked to 155 deaths & strokes• Banned by NFL, NCAA after heat stroke

deaths while using the supplement• FDA Ban in 2004• Ban overturned, FDA overstepped authority

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“I’m taking you off wine, women and song

and putting you on broccoli”

A Clinician’s Perspective ..... varying approaches

• Acceptance Acceptance - ask about & tolerate use of herbal products by patients

• EndorsementEndorsement - accept patient use of natural products as initial therapy, monitor for effects

• Integration Integration - prescribe herbs with advice on use, dosing, etc.

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Resources• www.NaturalStandard.com• NIH CAM Center (nccam.nih.gov)• NIH Office of Dietary Supplements

(odp.od.nih.gov/ods/)• Food & Drug Administration (fda.gov)• www.consumerlab.com• Medical Letter• Published studies

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Current Consensus …the best nutritional strategy for promoting

optimal health & reducing the risk of chronic disease is to choose wisely from a wide variety of foods, with emphasis on anti-oxidant rich fruits, vegetables & whole grains .

AHA 2002 ADA 2002AHA 2002 ADA 2002

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Best Advice . . .

• Buy from well-known national companies• Label includes:

– Herbs common & scientific name– Manufacture’s name & address– Dosing guidelines– Potential side effects– Batch & Lot number and expiration date

• US Pharmacopoeia verification seal

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A Final Thought…..

• The Japanese eat very little fat and suffer fewer heart attacks than the British or Americans

• However, the French eat a lot of fat and also suffer fewer heart attacks than the British or Americans

• The Germans drink very little red wine and suffer fewer heart attacks than the British or Americans

• While the Italians drink excessive amounts of red wine & suffer fewer heart attacks than British or Americans

• Conclusion: Eat and drink what you like. Speaking English is apparently what kills you!

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