54
WHAT IS THE ROLE, IF ANY, OF ALTERNATIVE MEDICINES IN MODERN CARDIOLOGY? Thomas F. Whayne, Jr, MD, PhD, FACC Professor of Medicine (Cardiology) Division of Cardiovascular Medicine University of Kentucky February, 2010 (Whayne T: review article scheduled for April issue of E-mail: [email protected]

CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

  • Upload
    simon23

  • View
    667

  • Download
    2

Embed Size (px)

DESCRIPTION

 

Citation preview

Page 1: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

WHAT IS THE ROLE, IF ANY, OF ALTERNATIVE MEDICINES IN

MODERN CARDIOLOGY?Thomas F. Whayne, Jr, MD, PhD, FACCProfessor of Medicine (Cardiology)Division of Cardiovascular MedicineUniversity of Kentucky

February, 2010

(Whayne T: review article scheduled for April issue of Cardiovascular Therapeutics; just published: Tachjian A, et al. J Am Coll Cardiol 2010;55:515-525.)

E-mail: [email protected]

Page 2: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

CNN, March 17, 2007 Gambian president serves up AIDS Cure out of a pancake syrup bottle containing a murky brown concoction with seven herbs and spices.

Page 3: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Definition of Alternative Medications• Outside of mainstream medicine.• Available over-the-counter.• Does not require prescription.• Generally derives from a natural fruit,

vegetable, tree or root. Herb defined as plant or plant product and regarded as food product. Because of this, frequently called dietary supplements.

• Minimal supervision by FDA.• Awareness important due to potential for

interaction with prescription medications.

Page 4: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Prevalence of Alternative Medications

• Dietary supplements reported in 45% of 458 patients but high percentage may be due to inclusion of vitamins and minerals.*

• In 1997, an estimated 15 million adults took alternative medications and this was estimated to involve 18% of all prescription medication users.#

• A multibillion dollar industry.

*Peng CC et al. Arch Intern Med 2004;164:630-636.#Eisenberg DM et al. JAMA 1998;280: 1569-1575

Page 5: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Society of Holistic Medicine of United Kingdom

Page 6: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

From the British Medical Association

Page 7: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Journal of Holistic Healthcare

Page 8: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA
Page 9: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

The University is accredited by The Higher Learning Commission • www.ncahlc.orgMaharishi University of Management • Fairfield, Iowa 52557 • (641) 472-7000Office of Admissions: (800) 369-6480 or (641) 472-1110Copyright and Service Mark Notice • Disclosures and Consumer Information • Contact the webmaster; Claims NIH Grants.

Alternative medication degree programs are available.

Page 10: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Maharishi University of ManagementFairfield, Iowa

Alternative medication degree programs are available.

Page 11: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Kentucky Southwestern College - Florence

Lexington Healing Arts Academy - Lexington Lexington Healing Arts Academy - Lexington

US Career Institute – ONLINE MASSAGE PROGRAM - ONLINE with 4 weeks in Ft. Collins, CO

Fowler Wainwright International Institute of Professional Coaching

- Training Online Institute for Integrative Nutrition - Distance Learning and NYC Programs - Distance Learning and NYC Programs

Palmer College of Chiropractic - Training in Port Orange, FL

Logan College of Chiropractic/University Programs - Training in St. Louis, MO

Kaplan University - Online - Training Online PCI Online - Web-Based, Online Programs

Clayton College of Natural Health - With Distance Learning Programs

Natural Health Institute of Bowling Green - Bowling Green Northern Kentucky School of Medical Massage - Burlington

Southern Graduate Institute of Natural Medical Science - Falcon

Page 12: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Dietary Supplement Health and Education Act (DSHEA)*

• Includes vitamins, minerals, herbs, botanicals, amino acids and combinations of these.

• By 2010, manufacturers must evaluate the identity, purity, strength and composition.

• Firms making or supplying source ingredients are not subject to these regulations.

• Other loopholes: manufacturers, not the FDA, determine, their quality specifications.

• FDA has minimal resources for dietary supplement oversight.

*Ashar BH. Arch Intern Med 2010;170:261-263.

Page 13: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

ACAI BERRY*• Components of Acai Berry: polyphenols, anthocyanidins

(potent antioxidant, purple color), phytosterols, monounsaturated and polyunsaturated fatty acids, vitamin E and dietary fiber.

• Natives along the Amazon River have used the Acai Berry for nutrition, healing and wellness properties.

• Sold by an ever-expanding network (MonaVie®).• Pushed for antioxidant, antibacterial, antiinflammatory

antimutagenic properties, especially for the CV system.

*http://www.acaiberryjuice.org/.

Page 14: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Antioxidant Vitamins: Vitamin A, Vitamin E and Beta-Carotene

• Do not decrease CV mortality.

• May actually increase CV mortality and certainly were established as having no cardiovascular value in the otherwise impressive results of the Heart Protection Study with Simvastatin.*

*Heart Protection Study Collaborative Group. Lancet. 2002;360:23-33.

Page 15: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

ASPIRIN• Nurses’ Health Study* (NHS; observational) of 80,000

middle-aged and older women reported significant in CV mortality from aspirin use.

• Five pooled primary prevention trials of aspirin use showed no mortality benefit.+

• Women’s Health Study# (WHS; primary prevention) of 40,000 women: no in CV or other mortality in women randomized to aspirin.

• Both NHS and WHS suggested ASA of CV events more pronounced in women 65 or older.

• Prescribe aspirin if definite CV disease regardless of age.

*Chan AT, et al. Arch Intern Med 2007;167:562-572.+Eidelman RS, et al. Arch Intern Med 2003;163:2006-2010.#Ridker PM, et al. N Engl J Med 2005;352:1293-1304.

Page 16: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

ASPIRIN AND PRIMARY PREVENTION IN WOMEN

Women’s Health Study* (WHS-39,876 women):

477 MACE with ASA over 10 years vs. 522 events with placebo (a nonsignificant 9% ↓ MACE).Stroke rate 19% lower with ASA (p=0.04).Small but insignificant increment in MI risk with ASA, not seen

with placebo.Meta-analysis of ASA# in women and men:

Composite of MACE decreased due to effect of ASA in decreasing ischemic stroke in women and MI in men.

Platelet reactivity:Women retain modestly more platelet reactivity but total

suppression of aggregation in direct COX-1 pathway, putative mechanism for cardioprotection by ASA^.

*Ridker PM et al. N Engl J Med. 2005;352:1293-1304.# Berger JS et al. JAMA. 2006;295:306-313.^Becker DM et al. JAMA. 2006;295:1420-1427.

Page 17: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

AYURVEDIC MEDICINE• Ayurveda is an alternative traditional medicine system

native to India. From Sanskrit, āyus means life and veda means science. Medicinal preparations and surgical procedures are involved.

• Ayurvedic medicines involve herbal-only and rasa shastra (combines herbs with metals such as gold, copper, arsenic, lead and mercury). Therefore, risk of lead and mercury toxicity has been described in U.S.*

• Vegetable/herbal components include cardamom, cinnamon, guggul (resin from tree native to India), et al.

• Medicinal components may also include animal products such as milk, bones and gallstones.

*Saper RB, et al. JAMA 2008;300:915-923.

Page 18: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

AYURVEDIC MEDICINE

• Ventricular tachycardia reported in an East Indian patient in Los Angeles after ingestion of an ayurveda herbal antidiarrheal medication containing aconitum.*

• Aconitum napellus (common Monkshood) is most common of the plant species. Aconitum contains the alkaloid pseudaconitine, a deadly neurotoxin and cardiotoxin which has been used as an arrow poison.* Blocks sodium current.# Aconitum can be a garden plant with blue or yellow flowers.*

*Dhesi P, et al. Arch Intern Med 2010;170:303-305.#Tachjian A, et al. J Am Coll Cardiol 2010;55:515-525.

Page 19: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

B VITAMINS AND HOMOCYSTEINE

• Increased plasma homocysteine is associated with an increased incidence of CHD and stroke.*

• Unfortunately, B vitamins (folic acid and vitamins B/B) have not been shown to decrease CV disease and in some studies (NORVIT), a harmful trend from the full B vitamin combination has been shown.#

*Lonn E, et al. N Engl J Med 2006;354:1567-1577.#Bonaa KH et al. N Engl J Med 2006;354:1578-1588.

Page 20: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

BLACK COHOSH*• Contains triterpene glycosides.

• May bind to estrogen and serotonin receptors.

• Used for relief of symptoms of menopause, pre-menstrual tension and other gynecologic problems.

• Available supplements inhibit CYP3A4.

• Hepatotoxicity has been reported.

*Tachjian A, et al. J Am Coll Cardiol 2010;55:515-525.

Page 21: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

CHELATION THERAPY• Ethylenediaminetetraacetic acid (EDTA).

• Intended for heavy metal toxicity, e.g. lead.

• Involves EDTA plus minerals and vitamins, given IV and in theory, improves plaques by removing Ca++, LDL oxid., Fe and in platelet aggregation.

• EDTA is potentially toxic by complexing cations.

• Placebo controlled trials show no benefit*+.

• Readily available in Kentucky ($100/infusion).*Knudtson ML, et al. JAMA 2002;287:481-486.+Anderson TJ, et al. J Am Coll Cardiol 2003;41:420-425.

Page 22: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

CINNAMON

• Cinnamon has been studied as a dietary supplement to improve lipid and glucose levels.

• Some glucose reduction suggested* but there appears to be no benefit in decreasing lipids.*#

*Mang B, et al. Eur J Clin Invest 2006;36:340-344.#Vanschoonbeek K, et al. J Nutr 2006;136:977-980.

Page 23: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

COENZYME Q-10 • UNCERTAIN BENEFIT/RISK RATIO.• MITOCHONDRIAL ENERGY TRANSDUCTION.• FUNCTIONAL ELEMENT IN ALL CELL

MEMBRANES.– ANTIOXIDANT ACTION.– REGENERATION OF REDOX CAPACITY.

• CONTROL OF MEMBRANE CHANNELS.• BIOSYNTHESIS OF CoQ IN MITOCHONDRIA

AND ENDOPLASMIC RETICULUM.• BIOSYNTHESIS of CoQ INHIBITED BY STATINS.• DOSE: 200 mg once daily (to risk of statin

myositis).

*Crane F. J Am Col Nutr 2001;20:591-598.Kelly P. Amer Col Cardiol Sci Sessions 2005 (used 100 mg once daily).

Page 24: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Coenzyme Q: Additional Effects?

• Lowering of blood pressure?

• Studies have shown decreased endothelial dysfunction with improved function by means of increased brachial artery flow-mediated vasodilatation.*– This could play a role in blood pressure

control.

*Kuettner A, et al. Int J Cardiol 2005;98:413-419.

Page 25: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Cordyceps Sinensis

• A mushroom extract.

• Marketed to increase aerobic capacity and endurance exercise performance.*

• No evidence of benefit.

*Parcell AC, et al. Int J Sport Nutr Exerc Metab 2004;14:236-242.

Page 26: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

DIETARY FIBER• Soluble fiber, 5-10 grams/day, can reduce

LDL approximately 5%*# and 10-12 grams/day may be beneficial.

• Sources of soluble fiber include oats, oat bran, barley, flaxd, pectin (fruits), root vegetables, legumes, guar gum and psyllium (in some cereals and Metamucil®).

• Insoluble fiber generally does not LDL.

*US Dept Health Human Serv. FDA. Fed Register 1998;63:8103-8121.#Chen J, et al. Eur J Clin Nutr 2006;60:62-68.

Page 27: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

PHYTOESTROGENS^ IN PLACE OF ESTROGEN AS A VIABLE ALTERNATIVE?

(CAN CAUSE MILD ESTROGENIC AND ANTIESTROGENIC EFFECTS)

ESTROGEN EFFECTS: HDL, LDL, endothelial stabilization (good).• Increase in CRP; occasional marked increase in triglycerides;

thrombogenesis [oral estrogens and not transdermal estrogens] (bad).

• Heart Estrog/Prog Replacement Study (HERS)*.– Mean age 67. No CV benefit and in 1st year: ↑CHD, ↑MI.

• Trend toward CHD risk when estrogen started closer to menopause# and < age 60 as compared to CHD risk in women more distant from menopause.

• Decreased coronary calcified-plaque burden in a trial in women with estrogen+.

^http://en.wikipedia.org/wiki/Phytoestrogens (Feb. 5, 2010)*Hully S, et al. JAMA 1998;280:605-613.#Rossouw JE, et al. JAMA 2007;297:1465-1477.+Manson JE, et al. N Engl J Med 2007;356: 2591-2602.

Page 28: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

FERRITIN REDUCTION• VA randomized trial* compared iron via

phlebotomy vs no iron in patients with stable peripheral arterial disease (PAD).

• One half of patients had CV disease other than PAD.

• There was no in CV events with phlebotomy.

• The iron-heart hypothesis appears very weak.

*Zacharski LR, et al. JAMA 2007/297:603-610.

Page 29: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

GARLIC• Raw garlic and garlic supplements have been

touted as natural cholesterol-lowering agents.• A component in garlic, ajoene, inhibits collagen-

induced platelet aggregation.#

• Stanford University performed a randomized trial of 192 patients in 1 of 4 treatment arms: raw garlic, powdered garlic, aged garlic extract or placebo.*– No form of garlic had any effect on LDL or other

plasma lipid concentrations in adults with moderate hypercholesterolemia.

#Tachjian A, et al. J Am Coll Cardiol 2010;55w:515-25.*Gardner CD, et al. Arch Intern Med 2007;167:346-353.

Page 30: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

GINSENG*• Supposed to function as an immune system

stimulant that increases vigor, sexual potency, longevity and as an antidiabetic agent.

• Reported to have both hypertensive and hypotensive effects ( nitric oxide).

• Decreased pro time/INR with warfarin.• Used in Chinese medicine for MI, CHF and angina

but no proof of CV benefit.• Some estrogen-like effects. • Wide product variations and effects.

*Tachjian A, et al. J Am Coll Cardiol 2010;55:515-525.

Page 31: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

Gingko Biloba• Reports of benefit have not been consistent; both

positive as well as negative studies have been published.

• Improved cognitive function in patients suffering from dementia is a major claim for Gingko.*

• Prolongation of walking distance in patients with intermittent claudication has been reported.#

• Decreased severity of acute mountain sickness upon rapid ascent to altitude has been reported.+

*Kanowski S, Hoerr R. Pharmacopsychiatry 2003;36:297-303.# Peters H, et al. Vasa 1998;27:106-110.+ Gertsch JH, et al. High Alt Med Biol 2002;3:29-37.

Page 32: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

GUGGUL (GUGGULIPID)• Stereoisomers E and Z guggulsterone (collectively

known as guggulipid) appear to be the active ingredients in the resin of the guggul tree in India and Pakistan.

• Function as antagonist ligands for the bile acid farnesoid X receptor, which is an important regulator of cholesterol homeostasis.

• Slight rise in LDL in a controlled US trial.* Therefore, no proven benefit was demonstrated.

• More benefit reported in the Indian population, suggesting environmental/genetic differences.

*Szapary PO, et al. JAMA 2003;290:765-772.

Page 33: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

HAWTHORN EXTRACT*• Used to treat angina, CHF, bradyarrhythmia

and cerebral insufficiency.• Positive inotropic and vasodilatory effects.• Reported to enhance activity of digitalis.• Inhibits synthesis of thromboxane A2 so there

is a potential bleeding risk on antiplatelet agents or anticoagulants.

• Data insufficient and cannot be recommended.

*Tachjian A, et al. J Am Coll Cardiol 2010;55:515-525.

Page 34: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

KAVA• Kava or kava kava, is also known as Piper

methysticum.• Has been reported to be a potent anxiolytic

agent and also to facilitate cognitive function and cause a positive affective state as well as benefit sleep disorders.*

• Effect of kava on the heart may be important in its anxiolytic effect. Kava may exert a favorable effect on reflex vagal control of heart rate.

*Thompson R, et al. Hum Psychopharmacol 2004;19:243-250.#Watkins LL, et al. J Psychopharmacol (Oxford, Eng) 2001;15:283-286.

Page 35: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

L-CARNITINE• L-Carnitine stimulates fatty oxidation at the

mitochondrial level (administered orally).• Potential moderate (minus 7-12%) benefit for reducing

Lipoprotein (a).*• Some reduction in fasting glucose reported.#

• Improved exercise tolerance suggested in chronic stable angina.+

• No performance benefit in endurance athletes; also no improved LV function post myocardial infarction.^

*Sirtori CR, et al. Nutr Metab Cardiovasc Dis 2000;10:247-251.# Rahbar AR, et al. Eur J Clin Nutr 2005;59:592-596.+ Iyer RN, et al. J Assoc Physicians India 2000;48:1050=1052.^Iyer R, et al. J Postgrad Med 1999;45:38-41.

Page 36: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

LECITHIN

• Claims that lecithin breaks down fat and cholesterol through function as a fat emulsifier.

• There is no proof of benefit.*

*McGowan M, et al. The Lipid Spin 2007;4:1-18.

Page 37: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

LICORICE*

• Used as an expectorant and some cough syrups contain licorice extract.

• Can cause hypokalemia (especially a problem), hypertension and edema.

• Can cause hyperglycemia.

• Can inhibit thrombin and platelet aggregation.

*Tachjian A, et al. J Am Coll Cardiol 2010;55:515-525.

Page 38: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

NUTS

• Tree nuts include walnuts, almonds, pistachios, macadamias and pecans.

• Peanuts are ground nuts (legumes).• Walnuts and almonds studied most.• A few small studies*#+ report 12-13% LDL

reductions with ½ to 1 cup per day but the patient must be able to burn the additional calories from ingestion of the nuts.

*Sabate J, et al. N Engl J Med 1993;328:603-607.#Abbey M, et al. Am J Clin Nutr 1994;59:995-999.+Zambon D, et al. Ann Intern Med 2000;132:538-546.

Page 39: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

OLIVE OIL• High content of oleic acid, an omega-6 monounsaturated

fatty acid, with some cardioprotection suggested.*• Olive oil phenolic compounds exert potent biologic

activities such as: antioxidant, anti-inflammatory and antithrombotic effects.*

• High-phenolic virgin olive oil has been shown to improve ischemic reactive hyperemia in hypercholesterolemic patients.#

• Olive oil use associated with 47% less likelihood of having acute coronary syndrome.+

*Visioli F, et al. Cardiovasc Res Reports 2002;23:389-392.#Ruano J, et al. J Am Coll Cardiol 2005;46:1864-1868.+Kontogianni MD, et al. Clin Cardiol 2007;30:125-129.

Page 40: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

OMEGA FATTY ACIDSFor hypertriglyceridemia: TG > 500 mg/dl when

using Lovaza®*.Other beneficial effects:

Vasodilatation.Decreased thrombosis.Possible decrease in ventricular^ and atrial arrhythmias,+ especially postop.

Lovaza®*:Maximum dose 2,000 mg twice daily

*Davidson MH et al. Clin Ther 2007;29:1354-1367.^Leaf A et al. Circulation 2005;112:2762-2768.+Calo L et al. J Am Coll Cardiol 2005;45:1723-1728.

Page 41: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

POLICOSANOL* (from sugarcane)[Reported benefit not consistent+]

REPORTED POSSIBLE BENEFITS: PLATELET AGGREGATION. LDL OXIDATION. THROMBOXANE PRODUCTION.• STABILIZES ENDOTHELIUM. FOAM CELL PRODUCTION. BLOOD PRESSURE.• DOSE IS 10 mg twice daily (obtain from health

food store or the internet).• A major critique is the dominance of studies

from Cuba. However, Wright, Zielke and Whayne found a 17% decrease in LDL.^

*Gouni-Berthold I, et al. Amer Hrt J. 2002;143:356-365.+Berthold H, et al. JAMA. 2006;295:2262-2269.^Wright CM, et al. Int J Angiol 2005;13:173-175.

Page 42: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

RED WINE• BENEFIT FROM ALCOHOL

– ALCOHOL MAY DECREASE INSULIN RESISTANCE*– ALCOHOL HAS AN ANTI-PLATELET EFFECT#

• BENEFIT FROM POLYPHENOLS (WHICH INCLUDES RESVERATROL)#

• BENEFIT FROM NITRIC OXIDE (ONE SUGGESTED POLYPHENOL EFFECT)#

• BENEFIT FROM FLAVONOIDS WHICH INHIBIT LDL OXIDATION+

RED WINE, DARK CHOCOLATE, GREEN TEA ARE MAIN SOURCES OF FLAVONOIDS

*Howard A et al. Ann Intern Med. 2004;140:211-219#Wallerath T et al. J Am Col Cardiol. 2003;41:471-478+Maron D. Curr Ath Reports. 2004;6:7378

Page 43: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

RED YEAST RICE• Red yeast rice is the fermented product of rice on

which red yeast has been grown.

• Active ingredient: Monacolin K (reported to be identical to lovastatin. Consistency problematic.

• Cholestin®, a proprietary red yeast rice, is definitely effective, lowering LDL 21% in a dose of 2.4 gm/day.*#

• Cholestin® is available in Canada, Europe and Asia but in the US, it no longer contains the active ingredient.

*Heber D, et al. Am J Clin Nutr 1999;69:231-236.#Rippe J, et al. Circulation 1999;8:1123.

Page 44: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

RESVERATROL*• Polyphenol.

• Nonflavonoid.

• Sources.– Especially from Red Wine (highest content in

Spanish red wines).– Grape skin only (esp. red grapes) and amount

increased by fermentation time in contact with skin.– Other sources: grape juice, peanuts, berries.

• Partial explanation of the French Paradox?

*http://lpi.oregonstate.edu/infocenter/phytochemical/resveratrol; Jan 29, 2010

Page 45: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

RESVERATROL*

• Antioxidant.– Decreased LDL oxidation.

• Free radical scavenger.

• Inhibits several enzymes involved in inflammation.

• Stimulates nitric oxide synthase.

• Inhibits platelet aggregation

*http://lpi.oregonstate.edu/infocenter/phytochemical/resveratrol; Jan 29, 2010

Page 46: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

RESVERATROL• Cancer cells: Resveratrol can inhibit proliferation of

cancer cells and induce apoptosis.• Structure of resveratrol is similar to the synthetic

estrogen agonist: diethylstilbestrol.– Extra care with breast cancer patient since could stimulate

some types of breast cancer cells.

• Value of supplements not proven.– Most supplements from root of Polygonum cuspidatum (also

known as Hu Zhang of Kojo-kon).– Red wine appears preferable.

• Reported to inhibit Cytochrome P450 3A4 (CYP3A4); therefore, could statin toxicity et al.

*http://lpi.oregonstate.edu/infocenter/phytochemical/resveratrol, Jan 29, 2010

Page 47: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

SAW PALMETTO*• Used for treatment of BPH.• Also used as a diuretic and a urinary antiseptic.• Mechanism of action not clear.• Inhibits cyclooxygenase and increases bleeding with

warfarin.• Can cause cholestatic hepatitis and acute

pancreatitis.• Possible intraoperative floppy iris syndrome during

cataract removal.

*Tachjian A, et al. J Am Coll Cardiol 2010;55:515-525.

Page 48: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

SOY PROTEIN• Soy protein does not offer a practical means

of lowering LDL since large amounts of soy are required.

• Half of daily protein as soy protein may only LDL approximately 3%.*

• Nevertheless, an increase in soy rich food may be beneficial by saturated fat intake.#

*Sacks FM, et al. Circulation 2006;113:111034-1044.# McGowan M, et al. The Lipid Spin 2007;4:1-18.

Page 49: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

ST. JOHN’s WORT• Reported to be safe and more effective than placebo for the

treatment of mild to moderate depression in some studies.*

• St. John’s Wort shown to decrease plasma concentrations of simvastatin because CYP 3A4 system is induced by St. John’s Wort (this would not occur with pravastatin and rosuvastatin which are not metabolized through that system).# Also can see decreased pro time/INR with warfarin due to induction of CYP3A4 system.

• Amplifies effect of platelet inhibitor, Clopidogrel+ since CYP3A4 converts Clopidogrel to its active metabolite, 2-oxyclopidogrel. In ACS, however, Mukherjee et al found no difference in benefit between CYP3A4 vs non CYP3A4 statins used with clopidogrel.^

*Lecrubier Y, et al. Am J Psychiatry 2002;159:1361-1366.# Sugimoto K, et al. Clin Pharmacol Ther 2001;70:518-524.+Zhou SF and Lai X. Curr Drug Metab 2008;9:394-409. ^Mukherjee D, et al. Heart 2005;91:23-26.

Page 50: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

STANOLS (PLANT STEROLS)

• Displace cholesterol from micelles and prevent its uptake at the brush border membrane.*

• Optimal intake probable 2,000 mg/day.*

• Lowers LDL 6-20%.#

• Minimal side effects.

• Probably the most valuable of available alternative dietary supplements.

*Katan MB, et al. Mayo Clin Proc 2003;78:965-978.#Amundsen AL, et al. Am J Clin Nutr 2002;76:338-344.

Page 51: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

VITAMIN C• Classed as an antioxidant vitamin.• No decrease in progression of coronary

calcification.*• No improvement in lipid profile and

possibly even some adverse affect on some blood lipids: TG in both sexes and cholesterol in women.#

• Apparent benefit in frequency of the common cold but not duration or severity.+

*Arad Y, et al. J Am Coll Cardiol 2005;46:166-172.# Hercberg S, et al. Lipids 2005;40:335-342.+ Sasazuki S, et al. Eur J Clin Nutr 2006;60:9-17.

Page 52: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

VITAMIN D• Forms of vitamin D: D2 (UV irradiation of

ergocalciferol); D3 (UV irradiation of dehydrocholesterol, transiently through pre D3).*

• Vitamin D refers to D2 and D3. Both are used in OTC supplement but prescription form is D2.

• Active form is 1,25(OH)2D. Plays role in multiple genes including insulin prod. and vasc. smooth muscle cells. Widespread receptors including endothelium. Can see possible CV effects.

• In severe deficiency (<25 nmol/l) can Rx 50,000 IU for several and then 2,000 IU daily. Incidence of deficiency is high (up to 47% in one Scottish practice).^

*Holick MF. N Engl J Med 2007:357:266-281.^Rhein HM. BMJ 2008:336:1451.

Page 53: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

YOHIMBINE*

• Marketed for treatment of sexual disorders and exhaustion.

• Some of effects attributed to activity as an alpha2-adrenergic antagonist.

• Increases release of norepinephrine, complicating control of hypertension.

*Tachjian A, et al. J Am Coll lCardiol 2010;55:515-525.

Page 54: CUÁL ES EL PAPEL, SI EXISTE, DE LA MEDICINA ALTERNATIVE EN LA

CONCLUSIONS REGARDING ALTERNATIVE MEDICATIONS

• Some are of definite value, some of no value and others are dangerous (especially chelation therapy).

• Unfortunately, due to the lack of financial incentive, there is no pharmaceutical company support for large placebo controlled trials to guide the clinician and bring effective alternative medications into clinical practice while incenting physicians/patients not to use ineffective/ dangerous Rx. Also, the NIH has not supported trials.

• Alternative Rx with apparent value:Aspirin, Coenzyme Q, Nuts, Olive Oil, Omega Fatty Acids, Policosanol, Red Wine, Red Yeast Rice, Soluble Dietary Fiber, Soy, Stanols (plant sterols).