What do we know What do we know about alternative about alternative

treatments of treatments of epilepsy"epilepsy"

Enrique Feoli MDEnrique Feoli MDNorth East Regional EpilepsyNorth East Regional Epilepsy

20142014

Alternative TreatmentsAlternative Treatments

Complementary and Alternative Complementary and Alternative medicines (CAM)medicines (CAM)

Non conventional therapiesNon conventional therapies

Herbs and EpilepsyHerbs and EpilepsyCAMCAM

Complimentary and Complimentary and AlternativeAlternative

CAMCAM On the riseOn the rise 42% US42% US 65% Germany65% Germany 20% UK20% UK 1/6 people taking Rx also take Herbal1/6 people taking Rx also take Herbal > 50 y.o.: 2.66 herbals and 2.26 Rx> 50 y.o.: 2.66 herbals and 2.26 Rx

CAMCAM

< 40% share their use with Drs.< 40% share their use with Drs. Legislation requiring Legislation requiring

regulation/licensing of Herbs in regulation/licensing of Herbs in Germany, France, Sweden, Germany, France, Sweden, Australia.Australia.

In US the Dietary Supplement In US the Dietary Supplement Health and Education Act of 1994 Health and Education Act of 1994 removed these products from FDA removed these products from FDA jurisdictionjurisdiction

Herbs for EpilepsyHerbs for Epilepsy Valerian rootValerian root SkullcapSkullcap European MistletoeEuropean Mistletoe MarijuanaMarijuana Black cohoshBlack cohosh LobeliaLobelia KavaKava HyssopHyssop Blue vervainBlue vervain YarrowYarrow GeraniumGeranium KelpKelp BupleurumBupleurum Passion flowerPassion flower Carline thistleCarline thistle ElderberryElderberry MugwortMugwort

Lady’s slipperLady’s slipper AloeAloe BetonyBetony European PeonyEuropean Peony GinsengGinseng Flax seed oilFlax seed oil GingerGinger LindenLinden ChrysanthemumChrysanthemum ForskolinForskolin BehenBehen Burning bushBurning bush CalotropisCalotropis Gotu KolaGotu Kola GroundselGroundsel Lily of the ValleyLily of the Valley Tree of HeavenTree of Heaven YewYew

How often do people take How often do people take herbs?herbs?

Overall use of complementary and Overall use of complementary and alternative medicines (CAM) in U.S. 1990-alternative medicines (CAM) in U.S. 1990-1997.1997.

Herbal product use increased 4xHerbal product use increased 4x In 1997, adults - 33 million office visits regarding In 1997, adults - 33 million office visits regarding

herbal products & high-dose vitamins; spent ~$8 herbal products & high-dose vitamins; spent ~$8 billionbillion

In 1997, ~15 million adults took prescription In 1997, ~15 million adults took prescription medications with herbs and/or high-dose vitaminsmedications with herbs and/or high-dose vitamins

Eisenberg et al. JAMA 1998;280:1569-75.

How often do people How often do people take herbs?take herbs?

Herb U.S. sales ($ millions)

Gingko biloba 150

Echinacea 70

Garlic 50

Ginseng 40

Soy 35

Saw palmetto 30

St. John’s wort 30

Valerian 16

Top 10 selling herbs and dietary supplements: 2002

How often do persons with How often do persons with epilepsy take herbs?epilepsy take herbs?

U.S. and England studies:U.S. and England studies: Up to 1 in 3 persons with epilepsy use CAM Up to 1 in 3 persons with epilepsy use CAM Most do not discuss their CAM use with doctorsMost do not discuss their CAM use with doctors Herbs taken include ginseng, St. John’s wort, Herbs taken include ginseng, St. John’s wort,

melatonin, gingko biloba, garlic and black cohoshmelatonin, gingko biloba, garlic and black cohosh Treat seizures (<10%), other symptoms (20%), and Treat seizures (<10%), other symptoms (20%), and

general health (>70%)general health (>70%)

Peebles et al. Epilepsy Behav 2000;1:74-7

Easterford et al. Epilepsy Behav 2005;6:59-62

Federal regulation of Federal regulation of herbsherbs

Herbal products are classified by the Herbal products are classified by the government as dietary supplements.government as dietary supplements.

Dietary supplements are regulated by Dietary supplements are regulated by the 1994 Dietary Supplement and the 1994 Dietary Supplement and Health Education Act (DSHEA); Health Education Act (DSHEA); prescription drugs - much more prescription drugs - much more rigorous requirements of the Federal rigorous requirements of the Federal Food, Drug, and Cosmetic Act.Food, Drug, and Cosmetic Act.

Federal standards by Federal standards by DSHEADSHEA

Claim -- an effect on bodily Claim -- an effect on bodily structure or function, not structure or function, not against a specific disease.against a specific disease.

Label must include a disclaimer Label must include a disclaimer that FDA has not evaluated the that FDA has not evaluated the productproduct

Federal regulation of Federal regulation of herbsherbs

Not required to be produced under Good Not required to be produced under Good Manufacturing Process standards, like drugsManufacturing Process standards, like drugs

No government agency (eg, FDA) No government agency (eg, FDA) independently verifies the quality/productionindependently verifies the quality/production

Could be contaminated with microbes, Could be contaminated with microbes, pesticides, toxic metals, or adulterated (eg, pesticides, toxic metals, or adulterated (eg, herbs or drugs) herbs or drugs)

Potency and amount per pill/capsule may Potency and amount per pill/capsule may vary significantly within the same bottle or vary significantly within the same bottle or from batch to batch, or from one branded from batch to batch, or from one branded product to anotherproduct to another

Federal regulation of Federal regulation of herbsherbs

Standards set forth by the DSHEA:Standards set forth by the DSHEA: Manufacturers are responsible for the Manufacturers are responsible for the

truthfulness of labeling claimstruthfulness of labeling claims No government agency independently No government agency independently

reviews and verifies the claims and reviews and verifies the claims and supporting evidencesupporting evidence

Only manufacturers control product Only manufacturers control product quality and verify safety quality and verify safety

StandardizationStandardization

How much of the active ingredient? How much of the active ingredient? For example, bottle says “carbamazepine 200 For example, bottle says “carbamazepine 200

mg”mg” This is a major problem for herbal products This is a major problem for herbal products

becausebecause the active ingredient (s) are usually not known the active ingredient (s) are usually not known the amount of the assumed active ingredient may vary the amount of the assumed active ingredient may vary

from pill to pill and product to productfrom pill to pill and product to product it is usually not possible to measure levels in the it is usually not possible to measure levels in the

blood to guide dosageblood to guide dosage

? The active ingredient? The active ingredient

St. John's wort standardized by its content of St. John's wort standardized by its content of hypericin (typically to 0.3% hypericin) hypericin (typically to 0.3% hypericin)

Hypericin not confirmed as the active Hypericin not confirmed as the active ingredient ingredient

Case Case

40 y/o woman with epilepsy well controlled on CBZ40 y/o woman with epilepsy well controlled on CBZ

Was feeling depressed and began to take St John’s wort.Was feeling depressed and began to take St John’s wort.

She had multiple recurrent seizures and came to the office for a follow up. She had multiple recurrent seizures and came to the office for a follow up.

She did disclose that she began a over he counter tx.She did disclose that she began a over he counter tx.

Problem; St john’s W, decreases the effectiveness of Problem; St john’s W, decreases the effectiveness of CBZCBZ

You wonder whether St. John’s wort could affect your carbamazepine or You wonder whether St. John’s wort could affect your carbamazepine or birth control pill, and whether it is safe and actually helps depressionbirth control pill, and whether it is safe and actually helps depression

Herbal Anticonvulsants: Herbal Anticonvulsants: MechanismsMechanisms

Sedative effect/improved sleep: Sedative effect/improved sleep: Valerian, Kava, Lobelia, passion Valerian, Kava, Lobelia, passion flower.flower.

Increase in brain GABA/GABA Increase in brain GABA/GABA receptors (Valerian, Kava)receptors (Valerian, Kava)

Agonist of benzodiazepine receptors Agonist of benzodiazepine receptors (Passion flower).(Passion flower).

Antioxidants (TJ-960)Antioxidants (TJ-960)

Herb/AED InteractionsHerb/AED Interactions Don’t use Valerian or Kava with Don’t use Valerian or Kava with

alcohol, barbiturates, benzos- alcohol, barbiturates, benzos- sedation/coma.sedation/coma.

Hemorrhagic complications with Hemorrhagic complications with Gingko and St. John’s wort.Gingko and St. John’s wort.

St. John’s wort can lower St. John’s wort can lower carbamazepine levels.carbamazepine levels.

Shankapulshpi (Ayurvedic formula) Shankapulshpi (Ayurvedic formula) decreases 1/2 life of phenytoin and decreases 1/2 life of phenytoin and decreases its efficacy.decreases its efficacy.

Tell your physician about herb use; Tell your physician about herb use; anticipate potential for interactions.anticipate potential for interactions.

Herbs and Seizure Herbs and Seizure MedicationsMedications

Increase Side effectsIncrease Side effects Valerian RootValerian Root Kava KavaKava Kava Passion FlowerPassion Flower ChamomileChamomile

Herbs that cause Herbs that cause SeizuresSeizures Kava KavaKava Kava: GTC from toxicity and withdrawal.: GTC from toxicity and withdrawal.

MarijuanaMarijuana: intoxication or withdrawal.: intoxication or withdrawal. SkullcapSkullcap: confusion and convulsions with high : confusion and convulsions with high

doses.doses. Ma HuangMa Huang: has ephedrine, pseudoephedrine, : has ephedrine, pseudoephedrine,

lowers threshold.lowers threshold. Gamolenic acidGamolenic acid lowers seizure threshold: lowers seizure threshold:

evening primrose oil, borage (starflower). evening primrose oil, borage (starflower). GoldensealGoldenseal: hydrastine lowers threshold.: hydrastine lowers threshold. GinsengGinseng: lowers threshold.: lowers threshold. Ginkgo bilobaGinkgo biloba: GTCs reported. Neurotoxin 4’-: GTCs reported. Neurotoxin 4’-

o-methylpyridoxine.o-methylpyridoxine. Thujone-containing herbsThujone-containing herbs: wormwood, sage; : wormwood, sage;

lower threshold.lower threshold.

Herbs and seizuresHerbs and seizures

Worsen seizuresWorsen seizures EphedraEphedra Ma HuangMa Huang MateMate GuaranaGuarana Borage oilBorage oil ? Ginkgo? Ginkgo ? Ginseng? Ginseng

BadBad

Effects on Serum Concentration of Effects on Serum Concentration of AED’s (Herb-Drug interactions) P450 AED’s (Herb-Drug interactions) P450 enzymes:enzymes: St. John’s wortSt. John’s wort GarlicGarlic EchinaceaEchinacea Pine bark extractPine bark extract PygenolPygenol Milk thistleMilk thistle American helleboreAmerican hellebore GingkoGingko MugwortMugwort PipissewaPipissewa

Side-Effects of HerbsSide-Effects of Herbs Natural doesn’t equal safe!Natural doesn’t equal safe! Herbs and herbal preparations Herbs and herbal preparations

contain many compounds.contain many compounds. Black cohosh, Valerian, green tea Black cohosh, Valerian, green tea

have tannins - can affect have tannins - can affect absorption of Ca, Cu, Fe, Mg.absorption of Ca, Cu, Fe, Mg.

Black cohosh can cause Black cohosh can cause miscarriage via uterine miscarriage via uterine stimulation.stimulation.

Lobelia - respiratory paralysis and Lobelia - respiratory paralysis and death.death.

Samuels et al, 2008

What are the Ingredients?What are the Ingredients? Epi-StillEpi-Still is a 100% herbal formula  is a 100% herbal formula

and contains the following and contains the following ingredients in therapeutic dosage: ingredients in therapeutic dosage: Passion flower, Skullcap, Cicuta Passion flower, Skullcap, Cicuta virosa (30C), and Cuprum virosa (30C), and Cuprum metallicum (30C).metallicum (30C).

Hello. I was just wondering if anyone has heard of the herbal medication for seizures called Epistill? I 

Synergy 02Synergy 02

More than 70 mineralsMore than 70 minerals More than 18 amino acidsMore than 18 amino acids Plant source silica Plant source silica

Active ingredient?Active ingredient? Is it just water and minerals?Is it just water and minerals? No trails/tests indicating thatNo trails/tests indicating that is useful is useful

Take HomeTake Home In any given person herbs may be helpful, In any given person herbs may be helpful,

but in most they likely are notbut in most they likely are not In any given person herbs may worsen In any given person herbs may worsen

epilepsyepilepsy Herbs definitely can effect AED levelsHerbs definitely can effect AED levels No good studiesNo good studies Communication between doctors and Communication between doctors and

patients is crucialpatients is crucial PerspectivePerspective

Part IIPart II

Non Conventional Non Conventional TherapiesTherapies

YogaYoga BiofeedbackBiofeedback Aromatherapy Aromatherapy AcupunctureAcupuncture

Non Conventional Non Conventional TherapiesTherapies

YogaYoga BiofeedbackBiofeedback Aromatherapy Aromatherapy Acupuncture Acupuncture

How effective are alternative How effective are alternative or complementary approaches or complementary approaches

to epilepsy?to epilepsy? No scientific research in epilepsy and there No scientific research in epilepsy and there

is very little evidence of their effectivenessis very little evidence of their effectiveness

Some people who have tried Some people who have tried complementary treatments have felt that complementary treatments have felt that these have helped their epilepsy and these have helped their epilepsy and improved their quality of life. improved their quality of life.

Certainly, reducing stress can reduce Certainly, reducing stress can reduce seizures in some people, and or improve seizures in some people, and or improve quality of life.quality of life.

Can relaxation, yoga Can relaxation, yoga control epilepsy?control epilepsy?

Some people have found that yoga Some people have found that yoga or meditation helps them prevent or meditation helps them prevent stress-induced seizures and stress-induced seizures and improves their quality of life improves their quality of life

Can epilepsy be controlled Can epilepsy be controlled by acupuncture?by acupuncture?  

the goal is to bring the person's the goal is to bring the person's health into a better mental, physical health into a better mental, physical and emotional balance. and emotional balance.

Acupuncture has been used in Acupuncture has been used in patients with epilepsy with mixed patients with epilepsy with mixed results. results.

Can epilepsy be controlled Can epilepsy be controlled using aromatherapy?using aromatherapy?

Aromatherapy uses pure aromatic Aromatherapy uses pure aromatic oils from plants for stimulation and oils from plants for stimulation and relaxation and to aid the healing relaxation and to aid the healing process. Dr. Tim Betts, a British process. Dr. Tim Betts, a British researcher, has had some success researcher, has had some success using oils on patients with epilepsy using oils on patients with epilepsy who can predict an imminent who can predict an imminent seizure. seizure.

Can epilepsy be controlled Can epilepsy be controlled through biofeedback?through biofeedback?

Biofeedback for epilepsy uses EEG Biofeedback for epilepsy uses EEG machines to help people identify and machines to help people identify and alter their own seizure-related brain alter their own seizure-related brain activity. The person with epilepsy is activity. The person with epilepsy is trained over time to use relaxation trained over time to use relaxation or other biofeedback techniques to or other biofeedback techniques to generate a more normalized brain generate a more normalized brain wave pattern, which may in turn wave pattern, which may in turn reduce their seizures. reduce their seizures.

Take Home Take Home

There are no scientific studies that There are no scientific studies that support the use of non conventional support the use of non conventional therapies to control seizures.therapies to control seizures.

Some has shown to improve quality Some has shown to improve quality of life (yoga)of life (yoga)

Discuss with your doctor before Discuss with your doctor before starting any non conventional starting any non conventional therapies therapies

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