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Herbal Prescribing Basicsfor nurse practitioners

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Why Herbs?

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Today’s presentation

-Herbal preparations and dosing-Herbal actions-Indications for herbal actions-Herb-drug interactions-Recommended resources-Questions

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Herbal Preparations

Liquid extract, or tincture, is a method of preserving herbs in a base of water and alcohol, making it convenient to dispense and consume.

Liquid Extract or Tincture

Capsules

An herbal capsule is convenient but not as easy to absorb as a liquid extract. The powders in the capsule should be freshly powdered prior to placing in the capsule. Damage from exposure to oxygen and light can be reduced by encapsulating the powders quickly and placing in an opaque container.

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Infusion

Infusions are a type of tea made by pouring hot water over dried or fresh plant material, usually leaves and flowers, in order to extract volatile oils, vitamins and enzymes.

Decoction

Another type of tea usually used for barks, roots and seeds which require more time and heat for extraction of constituents.

Herbal oil

Made by soaking a fresh or dried herb in oil (most commonly olive oil) for a period of time and then pressed and filtered.

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Salve

A salve is made with herbal oils and typically beeswax to give it solidity.

Elixir

An elixir contains the herb, water, a sweetener such as honey or glycerin and a small amount of alcohol. It is generally better tasting than a tincture or liquid extract and often helpful when treating children.

Dosage

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-strength of the herbal product-quality of the herbal product-age of the individual-weight of the individual-sensitivity of the individual-acute or chronic condition

Things to consider

Strength of the herbal product

The form of the herb can alter its strength.

standardized cap--------tincture---------elixir---------tea

Strongest-------->------------>------------weakest

Quality of the herbal product

-Less herb is needed if it is made with high quality raw ingredients.-Herbal products that have been carefully grown and processed retain the vital force of the plants.

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Age of the individual using the product

-The very young and the very old usually need to take less of an herbal product.

Weight of the individual using the product

-Doses should always be calculated on the weight of the individual.

Sensitivity of the individual

-Everyone has different levels of sensitivity and individuals with the same body weight may need different doses.

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Acute or chronic conditions

-A person presenting with an acute condition often needs higher physiologic doses of herb than a person presenting with a chronic condition.

Dosages are usually based upon a 150 pound person.

Tinctures-10-60 drops 1-4 times per dayTeas-1tsp-1T herb per cup water.Capsule-generally, the label will have a dosage on the lower side. Most capsules are standardized to a specific constituent.

General Guidelines for Dosing

Dosages for seniors

Over 63 yrs 5/6ths of full doseOver 77yrs 2/3rds of full dose

Kings American Dispensatory http://www.henriettes-herb.com/eclectic/kings/index.html

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Children’s Dosing

Clark’s RuleChild’s weight in pounds ÷ 150 pounds = fraction of the adult dosage

Herbal Actions

Enhances the process of nutrition and repair to the bodily tissues and promotes healthy changes in the organism. Also known as a blood and lymph cleanser.

Example: arctium, urtica, mahonia

Alterative

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Anti-inflammatory

Reduces inflammation by various methods.

Example: calendula, glycyrrhiza, matricaria, populus

Antiseptic

Prevents the growth of microbes. Usually refers to use on the skin.

Example: calendula, thymus, achillea

Bitter

Increases the tone of the gastric mucosa and stimulates digestion. Also called a digestive tonic.

Examples: gentiana, humulus, achillea, scutellaria

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Cathartic

Causes bowel evacuation due to stimulatory nature or bulking nature. Also called a laxative.

Examples: bulking -linum, althea, plantago, ulmusstimulating - taraxacum, mahonia, rumex

Cholegogue

Stimulates bile flow from the gall bladder. Most bitter herbs are cholegogues.

Examples: mahonia, arctium, taraxacum, chelidonium

Demulcent

A bland, mucilaginous agent that soothes and heals mucous membranes by forming a protective coating over the irritated mucosa.Examples: althea, ulmus, plantago, zea mays, calendula, linum

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Nervine

Soothes and quiets the nervous system.

Examples: matricaria, scutellaria, leonorus

Tonic

Nourishes tissues and restores normal function or tone to an organ or system.

Examples: crataegus, gentiana, rubus

Vulnerary

Promotes healing of wounds or irritated tissues.

Examples: calendula, aloe, plantago

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Indications

61 yo female PTC with wet wound on left middle finger, lateral surface near distal phalangeal joint. It is crater-like and very tender. Two months duration. Will not heal. Never has had anything like this. Usually heals wounds well. Lives w/partner, active, gardener, good diet, healthy lifestyle habits.

Case #1

Herbal actions to consider

antisepticanti-inflammatoryvulneraryanodyne

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Herbs with those actions

antiseptic - calendula, mahonia, commiphora, achilleaanti-inflammatory -matricaria, glycyrrhiza, populus, calendulavulnerary -aloe, calendula, symphytum, plantagoanodyne - valeriana, populus

Treatment plan

1) Epsom salt soaks daily.2) Calendula succus applied bid.3) Keep bandaged w/breathable gauze to keep clean throughout day (and some air circulation). Unbandage when at rest to allow air circulation.

Case #2

69yo female complaining of bloating and hard stools. Her bowels do not move regularly. She reports being sensitive to various foods, experiencing bloating. She reports not having a regular appetite. She brings recent labs with her and results are unremarkable. BP 125/78. Pulses very tight, constricted. Tongue coated white/yellow.

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Herbal actions to consider

bitternervinecholegogue

Herbs with those actions

bitter (digestive tonic) - arctium, gentiana, scutellaria, humulusnervine -scutellaria, humulus, matricariacholegogue -chelidonium, mahonia, taraxacum

Treatment plan

Tincture (1oz):gentiana 3 dr scutellaria 3 drchelidonium 2 dr

Sig: Take ¼ tsp in small amount water 10min before each meal. Swish in mouth before swallowing.

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Case #3

3yo female presents with Mom, complaining of year long history of hard stools with multiple episodes of small, but painful, external hemorrhoid due to straining at stool. Miralax has been prescribed by pediatrician for the past yr and parents don’t want daughter dependent upon it. They’ve tried weaning her off the miralax but always the stool becomes hard and difficult to pass. Their daughter is afraid to push since she associates pushing w/eventual pain due to hemorrhoid.

Herbal actions to consider

catharticdemulcent

Herbs with those actions

cathartic-bulking-althea, ulmus, linumstimulating-taraxacum, mahonia

demulcent-althea, ulmus, glycyrrhiza

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Treatment plan

1) Hydrate, hydrate, hydrate2) Tea (decoction)-mahonia, taraxacum, althea, ulmus, cinnamonum, glycyrrhiza. Equal parts of the first 4 and ½ the amount of the last 2. Use 1tsp herb per cup water. Simmer 10min and strain. Drink 1-2 cups each day. Can mix w/juice or nut milk or use special cup or funny straw. Drink warm or cold.

Case #4

36 yo female complaining of heart “fluttering”and “beating hard”. SOB, feels dizzy. No pain. Had one episode x20min few days ago. But upon further questioning the episodes started about a month ago. She is having challenge in her marriage, her 7yo daughter’s school is not working for them and stress level at her job has been high. Her diet has not been good and sleep has been of poor quality and lacking quantity. Exercise has been non-existent.

On exam her heart rhythm is irregular irregular and rate is 80bpm. BP is 138/88. Her color is slightly pale. Lungs are clear. Pulses: ki deep, ht small and thin, st tight. Tongue is dry with a thin white coat.

She states she is better with rest and is worse after meals. She has had hx of GERD but if avoiding wheat and dairy has no symptoms. She’s been eating wheat and dairy recently. There is no fm hx of heart disease.

I send her that afternoon for an EKG and it is determined she has frequent unifocal PVC’s with no other abnormalities.

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Herbal actions to consider

nervinecardiotonicanti-inflammatoryalterative

Herbs with those actions

nervine-melissa, tilia, scutellaria, matricaria, leonoruscardiotonic-crataegusanti-inflammatory-glycyrrhiza, mahonia, curcuma, matricariaalterative-taraxacum, mahonia, urtica

Treatment plan1) Tincture (2oz):

crataegus 7 drleonurus 7 drglycyrrhiza 2 dr

Sig:1½ tsp daily in divided doses.2)Tea (infusion)-

Equal parts melissa, scutellaria, tilia, taraxacum leaf, urtica, aloysia. Use heaping tsp herb per cup water. Steep 10min. Strain. Drink 3 cups each day.

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Herb-Drug Interactions

Reviews

From a 2013 systematic review of four databases, only 46 articles (out of over 4000) were deemed qualified drug-herb interactions. Of those, two herbs were found to have serious drug interactions and five herbs were found to have moderately severe drug interactions.Br J Clin Pharmacol. 2013 March; 75(3): 603–618.

More Reviews

Another review, done in 2011, discussed the mechanisms and clinical implications of herb-drug interactions by reviewing published human studies. Drugs that have a high potential to interact with herbal medicines usually have a narrow therapeutic index. This review reported on five herbs that might likely interact with drugs.

Curr Med Chem. 2011;18(31):4836-50.

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And one more review

A third review, done in 2009, reviewed the literature to determine the possible interactions between seven popular herbal medicines and conventional drugs. They found one herb, of the seven, had no drug interactions, and the rest had varying interaction.

Drugs. 2009;69(13):1777-98

Ways herbs interact with drugs

The most common herb-drug interaction is pharmacokinetic. The herb interferes with the elimination/absorption of the drug.

CYP3A4 is a member of the cytochrome p450 super family of enzymes that catalyze many reactions in the liver and in the gut involved in drug metabolism. Herbs and drugs can induce or inhibit these enzymes affecting down-regulation or up-regulation of another drug or herb. It is estimated that CYP3A4 is responsible for oxidizing 50% of conventional drugs. Any herb that induces or inhibits this enzyme’s activity affects these drugs.

Cytochrome p450

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Hypericum perforatum

Hypericum (St. John’s Wort) ranks #1 in herb-drug interactions. There are many compounds present in Hypericum; one of those compounds, hyperforin, increases the activity of CYP3A4, thereby decreasing the level of many drugs that are substrates for this enzyme. Examples: alprazolam, amitriptyline, atorvastatin, chlorzoxazone, cyclosporin, debrisoquine, digoxin, erythromycin, fexofenadine, gliclazide, imatinib, indinavir, irinotecan, ivabradine, mephenytoin, methadone, midazolam, nifedipine, omeprazole, oral contraceptives, quazepam, simvastatin, tacrolimus, talinolol, verapamil, voriconazole and warfarin

Pol Merkur Lekarski. 2013 Nov;35(209):309-12. Drugs. 2009;69(13):1777-98.

Ginkgo biloba

At a dose of above 240mg standardized Ginkgo appears to also interfere with cytochrome p450 system, specifically inducing CYP2C19 and inhibiting CYP3A4 resulting in down-regulating omeprazole and up-regulating midazolam.

Drug Metab Rev. 2013 Aug;45(3):353-85.

More on Ginkgo biloba

From a review done in 2008: There is scant information from case reports or controlled trials to support the suggestion that Ginkgo potentiates the effects of anticoagulant or antiplatelet drugs. More study is necessary.

Mol Nutr Food Res. 2008 Jul;52(7):764-71

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Bottom Line

-We know herbs interact with drugs.-We know little of the significance of the interactions.-More study is needed.

Be a responsible practitioner

-educate yourself; patients will use herbs -know your patient’s sensitivity, vitality-be honest w/your patient-err on the conservative side

1) Tilgner, Sharol, ND. (1999). Herbal Medicine from the Heart of the Earth. Creswell, OR:Wise Acres Press.2) http://www.henriettes-herb.com/3) http://www.herbmed.org/index.html#param.wapp?sw_page=index4) http://www.ncbi.nlm.nih.gov/PubMed/

Recommended Resources

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Summary

-preparations and dosing-actions of herbs-indications of herbs-drug-herb interactions-resources

Contact Info

Lori von der Heydt, ND4445 NE FremontPortland, OR 97213503-249-7752vonderheydt@beaumonthealthcare.com

Thank you for your attention.