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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)
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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
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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
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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.
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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
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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
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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
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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?”
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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”
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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
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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
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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
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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
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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
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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
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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”
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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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