Herbs-Safety in Use - Caribbean Poison Information Network

CARIBBEAN POISON CARIBBEAN POISON INFORMATION NETWORKINFORMATION NETWORK

THE THIRD ANNUAL SCIENTIFICTHE THIRD ANNUAL SCIENTIFICTHE THIRD ANNUAL SCIENTIFIC THE THIRD ANNUAL SCIENTIFIC CONFERENCE CONFERENCE

UHWI KINGSTON JAMAICAUHWI KINGSTON JAMAICAUHWI KINGSTON, JAMAICA UHWI KINGSTON, JAMAICA MAY 31MAY 31--JUNE 1,2008JUNE 1,2008

HERBSHERBSHERBSHERBSSafety In UseSafety In UseSafety In UseSafety In Use

Winsome B. Christie N.D. Rph Bpharm.Winsome B. Christie N.D. Rph Bpharm.CARPIN 3rd Scientific ConferenceCARPIN 3rd Scientific Conference

UHWI Main Medical Lecture TheatreUHWI Main Medical Lecture TheatreMay 31May 31-- June 1, 2008June 1, 2008

ObjectivesObjectivesObjectivesObjectivesUpon completion the participants should be able to Upon completion the participants should be able to p p p pp p p pdefine a herbdefine a herbKnow the presentations of herbal formulationsKnow the presentations of herbal formulationsBecome familiar with herbs which have resulted in toxicBecome familiar with herbs which have resulted in toxicBecome familiar with herbs which have resulted in toxic Become familiar with herbs which have resulted in toxic episodesepisodesUnderstand current legislations internationally and Understand current legislations internationally and l lll lllocallylocallyFactors in assessing the efficacy and safety of herbsFactors in assessing the efficacy and safety of herbsUnderstand general factors in the consideration of takingUnderstand general factors in the consideration of takingUnderstand general factors in the consideration of taking Understand general factors in the consideration of taking herbsherbsBecome familiar with potential herb/drug interactions of Become familiar with potential herb/drug interactions of several popular herbsseveral popular herbsseveral popular herbs.several popular herbs.

HerbologyHerbologyHerbologyHerbologyHerbal Medicine is the therapeutic use of plants, Herbal Medicine is the therapeutic use of plants, p p ,p p ,and is the most ancient form of health care and is the most ancient form of health care known to humankind. A herb is a plant or plant known to humankind. A herb is a plant or plant part valued for its medicinal savory or aromaticpart valued for its medicinal savory or aromaticpart valued for its medicinal, savory or aromatic part valued for its medicinal, savory or aromatic qualities. qualities. Herb plants produce and contain a Herb plants produce and contain a variety of chemical substances that act upon variety of chemical substances that act upon y py pthe body.the body. Herbs have been used to treat Herbs have been used to treat virtually every disease and condition. ...virtually every disease and condition. ...www tlccenter com/glossary ivnuwww tlccenter com/glossary ivnuwww.tlccenter.com/glossary.ivnuwww.tlccenter.com/glossary.ivnu

H b lH b l di i idi i iHerbologyHerbology divisionsdivisions

Western HerbsWestern HerbsChi H bChi H bChinese HerbsChinese HerbsAyyurvedicAyyurvedic HerbsHerbsHomeopathyHomeopathy

W B Christie ©W B Christie ©

Homeopathy Homeopathy

Mineral remedies including elements metals compounds Mineral remedies including elements metals compounds and salts etc.and salts etc.Vegetable remediesVegetable remediesVegetable remediesVegetable remediesAnimal remediesAnimal remediesThe The NosodesNosodes (Morbid tissues and secretions)(Morbid tissues and secretions)SarcodesSarcodes ((e.ge.g uric acid and uric acid and thyrothyro--iodine also endocrine iodine also endocrine remediesremediesImponderabiliaImponderabilia incldincld. Positive and negative force. Positive and negative forceelectricity sun etcelectricity sun etc

W B Christie ©W B Christie ©

Herbal MedicineHerbal MedicineHerbal MedicineHerbal Medicine

Use of crude plant material such as Use of crude plant material such as leaves, leaves, flowers,fruitflowers,fruit, seed, stems, , seed, stems, woods,barkwoods,bark, roots, rhizomes or other plant , roots, rhizomes or other plant parts which may be entire, fragmented or parts which may be entire, fragmented or po deredpo deredpowdered.powdered.Refers to the long historical use of these Refers to the long historical use of these medicines to support the healing functionmedicines to support the healing functionmedicines to support the healing function medicines to support the healing function of the body.of the body.

Herbal medicineHerbal medicine

The use of herbal medicine is wellThe use of herbal medicine is well--established established and widely acknowledged to be safe and and widely acknowledged to be safe and

ff ti d b t d b ti lff ti d b t d b ti leffective and may be accepted by national effective and may be accepted by national authorities authorities

(WHO, 2000).(WHO, 2000).

Definitions cont’dDefinitions cont’d

Traditional Medicine: sum total of Traditional Medicine: sum total of k l d kill d ti b dk l d kill d ti b dknowledge, skills and practices based on knowledge, skills and practices based on the theories, beliefs and experiences the theories, beliefs and experiences indigenous to different cultures whetherindigenous to different cultures whetherindigenous to different cultures, whether indigenous to different cultures, whether explicable or not, used in the maintenance explicable or not, used in the maintenance of health as well as in the prevention,of health as well as in the prevention,of health as well as in the prevention, of health as well as in the prevention, diagnosis, improvement or treatment of diagnosis, improvement or treatment of physical and mental illness.physical and mental illness.p yp y

(WHO 2000).(WHO 2000).

Herbal PropertiesHerbal PropertiesHerbal PropertiesHerbal Properties

AphrodisiacsAphrodisiacs EmeticsEmeticsAphrodisiacsAphrodisiacsAstringentsAstringentsCarminativesCarminatives

EmeticsEmeticsEmmenagoguesEmmenagoguesEmollientsEmollientsCarminativesCarminatives

CholagoguesCholagoguesDemulcentsDemulcents

EmollientsEmollientsExpectorantsExpectorantsGalactogoguesGalactogoguesDemulcentsDemulcents

DiaphoreticsDiaphoreticsdiureticsdiuretics

GalactogoguesGalactogoguesHemostaticsHemostaticslaxativeslaxativesdiureticsdiuretics laxativeslaxatives

LithotriphicsLithotriphics SialogoguesSialogoguesLithotriphicsLithotriphicsNervinesNervinesOxytocicsOxytocics

SialogoguesSialogoguesStimulantsStimulantsStomachics (tonics)Stomachics (tonics)OxytocicsOxytocics

ParasiticidesParasiticidesPurgatives (laxatives)Purgatives (laxatives)

Stomachics (tonics)Stomachics (tonics)TonicsTonicsVulnerariesVulnerariesPurgatives (laxatives)Purgatives (laxatives)

RubefacientsRubefacientssedativessedatives

VulnerariesVulneraries

sedativessedatives

Types of Herbal PreparationsTypes of Herbal Preparations

Teas (infusions, decoctions)Teas (infusions, decoctions)Bolus (suppository)Bolus (suppository)

Poultice and plasterPoultice and plasterSalveSalve( pp y)( pp y)

Electuary (unpalatable herbs)Electuary (unpalatable herbs)EnemaEnemaFomentation(compress)Fomentation(compress)

SalveSalveSmokingSmokingSyrupsSyrupsTi t ( l h l f )Ti t ( l h l f )

o e tat o (co p ess)o e tat o (co p ess)Gelatin capsuleGelatin capsuleLinimentLinimentOilOil

Tinctures ( alcohol free)Tinctures ( alcohol free)Herbal WinesHerbal WinesStandardisedStandardised ExtractsExtractsOilOil

PillPillDoucheDouche

Standardized productsStandardized products

Specific amount of one active constituent in an herb is artificially Specific amount of one active constituent in an herb is artificially manipulated to be at a certain level.manipulated to be at a certain level.Based on an orthodox pharmaceutically driven industryBased on an orthodox pharmaceutically driven industryWhere doctors are feeling more comfortable to recommend products Where doctors are feeling more comfortable to recommend products that have active constituents in measurable and consistent amounts.that have active constituents in measurable and consistent amounts.Also in response to pressure from medical doctors to bring herbs in Also in response to pressure from medical doctors to bring herbs in line with how drugs are standardized herb companies are line with how drugs are standardized herb companies are developing such products.developing such products.H i li th i i i t f idH i li th i i i t f id ff t dff t dHere in lies the increase in some instances of sideHere in lies the increase in some instances of side--effects and effects and interactions interactions

H b l f tH b l f tHerbal use safety Herbal use safety issuesissues

Traditional UseTraditional Use Clinical trialsClinical trialsTraditional UseTraditional UsePersonal anecdotePersonal anecdoteCase studiesCase studies

Clinical trialsClinical trialsSystematic reviewSystematic reviewMetaMeta--analysisanalysisCase studiesCase studies

InIn--vitrovitroA i l t tiA i l t ti

MetaMeta--analysisanalysis

Animal testingAnimal testing

Reasons for differencesReasons for differences

Experimental group and patient populationExperimental group and patient populationI l t d tit t diff f h lI l t d tit t diff f h lIsolated constituents differ from whole Isolated constituents differ from whole plantplantAnimal studies may not apply to humansAnimal studies may not apply to humansMethod of administration Method of administration Form of plant used in studyForm of plant used in study

Reasons for differences cont’dReasons for differences cont’d

Dose and duration may be differentDose and duration may be differentPlacebo effectPlacebo effectPlacebo effectPlacebo effect

Assessing safety of herbsAssessing safety of herbs

GMP (good manufacturing practices)GMP (good manufacturing practices)(g g p )(g g p )Proper identificationProper identificationCleanlinessCleanlinessCleanlinessCleanlinesspuritypurity

Complimentary or AlternativeComplimentary or AlternativeMedicineMedicine

Th Ad t ti f t diti l M di i t thTh Ad t ti f t diti l M di i t thThe Adaptation of traditional Medicine to the The Adaptation of traditional Medicine to the dominant medical system.dominant medical system.

History of herbal MedicineHistory of herbal Medicineyyin U.S.in U.S.

Native American, AfricanNative American, African--American, European influence. Native American, European influence. Native American use of local plants, American use of local plants, hygenichygenic practices, and pharmacopeia.practices, and pharmacopeia.Colonists, physicians, Colonists, physicians, indianindian doctors, frontier medicine, slave doctors, frontier medicine, slave , p y ,, p y , , ,, ,medicine, heroic medicine.medicine, heroic medicine.Food and Drug Act of 1906Food and Drug Act of 1906-- prohibiting shipment of adulterated or prohibiting shipment of adulterated or misbranded medicine across state linesmisbranded medicine across state linesShirleyShirley AmendementAmendement 1912 Prohibit fraudulent claims on a label1912 Prohibit fraudulent claims on a labelShirley Shirley AmendementAmendement 1912 Prohibit fraudulent claims on a label1912 Prohibit fraudulent claims on a labelFederal Food, Drug and Cosmetic Act 1938Federal Food, Drug and Cosmetic Act 1938Food Additives Amendment of 1958Food Additives Amendment of 1958KefauverKefauver--Harris Amendment 1962Harris Amendment 1962KefauverKefauver Harris Amendment 1962Harris Amendment 1962KefauverKefauver--Harris implementation of 1972Harris implementation of 1972Nutrition Labeling and Education Act 1990Nutrition Labeling and Education Act 1990Dietary Dietary SuppplementSuppplement Health and Education Act 1994 Health and Education Act 1994 yy pppppp

Traditional MedicineTraditional Medicinein Jamaicain Jamaica

Modalities include Modalities include Western MedicineWestern Medicine

AyurvedaAyurvedaTraditionalTraditionalWestern MedicineWestern Medicine

Folk MedicineFolk MedicineAfricanAfrican

Traditional Traditional Chinese MedicineChinese Medicine

AfricanAfrican

History Of Herbal Medicine inHistory Of Herbal Medicine inHistory Of Herbal Medicine in History Of Herbal Medicine in JamaicaJamaica

Food and drug act 1964 importation and Food and drug act 1964 importation and labeling labeling Pharmacy act 1966 which replaced the Pharmacy act 1966 which replaced the y py pDrug and poison law: conditions of saleDrug and poison law: conditions of salehas regulations since 1975 & 1976has regulations since 1975 & 1976has regulations since 1975 & 1976has regulations since 1975 & 1976Old Old galenicalsgalenicals

History of herbal History of herbal di i ’ddi i ’dmedicine cont’dmedicine cont’d

Pharmacy act List1Pharmacy act List1-- free salefree salePharmacy act List1Pharmacy act List1 free sale free sale (list committee)(list committee)Li t 2 ld d th i i fLi t 2 ld d th i i fList 2 sold under the supervision of a List 2 sold under the supervision of a Pharmacist/places appoved by pharmacy Pharmacist/places appoved by pharmacy

il l i t i l d h b l hil l i t i l d h b l hcouncil planning to include herbal shops council planning to include herbal shops (list committee)(list committee)List 3 poisons (ministry of health)List 3 poisons (ministry of health)List 4 prescriptions (ministry of health)List 4 prescriptions (ministry of health)p p ( y )p p ( y )

History of Herbal MedicineHistory of Herbal MedicineHistory of Herbal MedicineHistory of Herbal Medicinecont’dcont’d

Ministry of health also is working on Ministry of health also is working on reclassifying preparations based on reclassifying preparations based on claims claims 1. herbal remedies: no claim1. herbal remedies: no claim2 herbal medicine : claims2 herbal medicine : claims2.herbal medicine : claims2.herbal medicine : claimsto assist with the legislative requirements. to assist with the legislative requirements.

Current Health claimsCurrent Health claimsCurrent Health claimsCurrent Health claimson labelson labels

Three types of claims Three types of claims health claims,health claims,Structure/functionStructure/functionnutrientnutrientnutrientnutrient

Herbal LabelsHerbal LabelsHerbal LabelsHerbal Labels

Dosages, warnings, substantiated Dosages, warnings, substantiated structure and function claimsstructure and function claimsstructure and function claims,structure and function claims,Latin name not required if herb is listed Latin name not required if herb is listed i 2i 2ndnd diti f H b f fditi f H b f fin 2in 2ndnd edition of Herbs of commerce for edition of Herbs of commerce for those herbs listed the common name those herbs listed the common name sufficessuffices

Language of the herbal labelLanguage of the herbal label

SynergisticSynergisticy gy gBalancedBalancedNaturalNaturalNaturalNaturalPolypharmacyPolypharmacy or formulasor formulasstandardizationstandardization

Current useCurrent useCurrent useCurrent use

25 percent of all prescription medicines25 percent of all prescription medicines25 percent of all prescription medicines 25 percent of all prescription medicines are made form plants; 60 percent of all are made form plants; 60 percent of all over the counter medications containover the counter medications containover the counter medications contain over the counter medications contain some natural components; 74 percent of some natural components; 74 percent of all herbs used today are still used as theyall herbs used today are still used as theyall herbs used today are still used as they all herbs used today are still used as they have traditionally been used; 75 to 80 have traditionally been used; 75 to 80 percent of the world’s population usepercent of the world’s population usepercent of the world s population use percent of the world s population use herbs as primary medicine herbs as primary medicine

Current useCurrent useCurrent useCurrent use

Half of all Americans have tried orHalf of all Americans have tried orHalf of all Americans have tried or Half of all Americans have tried or currently use supplements. Up to 80 currently use supplements. Up to 80 percent of people in South Africa usepercent of people in South Africa usepercent of people in South Africa use percent of people in South Africa use traditional or complementary/ alternative traditional or complementary/ alternative medicine (TM/CAM) as part of primarymedicine (TM/CAM) as part of primarymedicine (TM/CAM) as part of primary medicine (TM/CAM) as part of primary health care.(WHO 2000) health care.(WHO 2000)

Current use inCurrent use inCurrent use in Current use in JamaicaJamaica

Surveillance unit of the Ministry of Health Surveillance unit of the Ministry of Health herbs are widely used in Jamaica in the herbs are widely used in Jamaica in the form of weight loss products no form of weight loss products no documented studies need more datadocumented studies need more datafirst aid,first aid,

Safety monitoringSafety monitoringSafety monitoringSafety monitoring

Under reporting of cases of adverseUnder reporting of cases of adverseUnder reporting of cases of adverse Under reporting of cases of adverse events.events.Need for more collaboration with privateNeed for more collaboration with privateNeed for more collaboration with private Need for more collaboration with private entities and government agenciesentities and government agenciesCl ifi ti f t d t f dCl ifi ti f t d t f dClassification of reported events foods,Classification of reported events foods,herbs e.g. ackeeherbs e.g. ackeemandrake root, 2007 physic nut root mandrake root, 2007 physic nut root 2007 isolated incidences2007 isolated incidences

MANDRAKEMANDRAKEMANDRAKEMANDRAKE

Physic nutPhysic nut JatrophaJatropha curcascurcasPhysic nut, Physic nut, JatrophaJatropha curcascurcas

Incidences of poisoningsIncidences of poisonings

AnticholinergicAnticholinergic effects:effects:tt b ll db ll datropaatropa belladonnabelladonna

daturadatura metelmetel species mixed up with species mixed up with campsiscampsis and and paulowniapaulownia speciesspeciesjimson weed jimson weed MandragoraMandragora officinarumofficinarumjj gg(mandrake)(mandrake)

Thorn AppleThorn AppleThorn AppleThorn Apple

DaturaDatura

Jimson WeedJimson WeedJimson WeedJimson Weed

KavaKava--kava (kava (Piper Piper methysticummethysticum ))(( pp yy ))PodophyllumPodophyllum emodiemodi and and PodophyllumPodophyllum peltatumpeltatum(mandrake and (mandrake and mayapplemayapple resp.)resp.)contaminated herbal preparations (contaminated herbal preparations (egeg, , GentianaGentiana and and clematis) in the 1980s and 1990s clematis) in the 1980s and 1990s StrychnosStrychnos nuxnux--vomicavomica (strychnine) has been found in(strychnine) has been found inStrychnosStrychnos nuxnux--vomicavomica (strychnine) has been found in (strychnine) has been found in imported herbal patent medicines and can cause imported herbal patent medicines and can cause abdominal distress. Although frequently formulated in abdominal distress. Although frequently formulated in h thi d t i t f t h ih thi d t i t f t h ihomeopathic doses, toxic amounts of strychnine cause homeopathic doses, toxic amounts of strychnine cause profound metabolic acidosis, profound metabolic acidosis, rhabdomyolysisrhabdomyolysis, and , and generalized "spinal seizures" in fully alert patients generalized "spinal seizures" in fully alert patients g p y pg p y p

Cardiovascular systemCardiovascular systemCardiac glycosides and other cardioactive steroid Cardiac glycosides and other cardioactive steroid contaminants may cause toxicity. contaminants may cause toxicity. Digitalis lanataDigitalis lanata was was mistaken for plantain and caused severe cardiotoxicity mistaken for plantain and caused severe cardiotoxicity ( l t h t bl k) i 1997 h d( l t h t bl k) i 1997 h d(eg, complete heart block) in 1997 when consumed as (eg, complete heart block) in 1997 when consumed as an internal cleansing product. An outbreak of digoxinlike an internal cleansing product. An outbreak of digoxinlike deaths occurred in New York City when a Chinese deaths occurred in New York City when a Chinese aphrodisiac called Chanaphrodisiac called Chan--Su was sold The labeling wasSu was sold The labeling wasaphrodisiac called Chanaphrodisiac called Chan--Su was sold. The labeling was Su was sold. The labeling was in in Chinese and stated that the product was meant to be Chinese and stated that the product was meant to be applied topically but several people ingested it Thisapplied topically but several people ingested it Thisapplied topically, but several people ingested it. This applied topically, but several people ingested it. This product contained an extract from the venom of product contained an extract from the venom of BufoBufotoads, which caused the deaths. These types of toads, which caused the deaths. These types of ingestions can be treated with digoxiningestions can be treated with digoxin--specific Fab.specific Fab.g gg g pp

Hepatic systemHepatic systemH ti t i it ith B ddH ti t i it ith B dd Chi iChi i d h b t d ithd h b t d ithHepatic toxicity with BuddHepatic toxicity with Budd--ChiariChiari syndrome has been reported with syndrome has been reported with pyrrolizidinepyrrolizidine alkaloids, which are metabolized to alkaloids, which are metabolized to alkylatingalkylating agents that agents that produce hepatic produce hepatic venoveno--occlusive disease, occlusive disease, hepatomegalyhepatomegaly, and cirrhosis. , and cirrhosis. These herbal products include These herbal products include HeliotropiumHeliotropium (heliotrope), (heliotrope), SenecioSenecio((gordolobogordolobo)) CrotalariaCrotalaria andand SymphytumSymphytum (comfrey)(comfrey) SenecioSenecio andand CrotalariaCrotalaria((gordolobogordolobo), ), Crotalaria,Crotalaria, and and SymphytumSymphytum (comfrey). (comfrey). SenecioSenecio and and CrotalariaCrotalariahave been used in Jamaica to make bush tea. Toxicity can affect the fetus have been used in Jamaica to make bush tea. Toxicity can affect the fetus as well.as well.MenthaMentha pulegiumpulegium ((ieie, pennyroyal oil, "squaw" mint) teas have been , pennyroyal oil, "squaw" mint) teas have been mistaken for other mint teas and have been used intentionally as mistaken for other mint teas and have been used intentionally as yyabortifacientsabortifacients. These teas contain the . These teas contain the hepatotoxinhepatotoxin, , pulegonepulegone, which causes , which causes hepatocellularhepatocellular necrosis. necrosis. PulegonePulegone toxicity can result in multisystem organ toxicity can result in multisystem organ failure.failure.

Plant Poisonings, Herbs 2006 Plant Poisonings, Herbs 2006 FerminFermin BarruetoBarrueto JrJr, MD, MD, Assistant Professor, Department of , Assistant Professor, Department of

Surgery, Division of Emergency Medicine, University of Maryland Surgery, Division of Emergency Medicine, University of Maryland

General ConsiderationsGeneral ConsiderationsGeneral ConsiderationsGeneral Considerations

Reports of herb/drug interactions areReports of herb/drug interactions areReports of herb/drug interactions are Reports of herb/drug interactions are confusing and accompanied by media confusing and accompanied by media hysteriahysteriahysteriahysteriaMost herbs are safe at normal therapeutic Most herbs are safe at normal therapeutic levelslevelslevelslevelsCare and caution should be used with Care and caution should be used with

i l l ti h ti l l ti h tspecial populations such as pregnant or special populations such as pregnant or lactating women, the extremely illlactating women, the extremely ill

General considerationsGeneral considerationsGeneral considerationsGeneral considerations

Older and younger personsOlder and younger personsOlder and younger personsOlder and younger personsPersons on ,multiple medications.Persons on ,multiple medications.M t f h b d i t tiM t f h b d i t tiMany reports of herb drug interactions areMany reports of herb drug interactions aresketchy and lack laboratory analysissketchy and lack laboratory analysisHerbal remedies have broad therapeutic Herbal remedies have broad therapeutic action. Synthetic drugs have a narrow action. Synthetic drugs have a narrow y gy gtherapeutic index. therapeutic index.

Efforts to identify all possible interactionsEfforts to identify all possible interactionsEfforts to identify all possible interactions Efforts to identify all possible interactions will lead to limitless investigations and to will lead to limitless investigations and to inconsistent decisions Pharmokinetic druginconsistent decisions Pharmokinetic druginconsistent decisions. Pharmokinetic drug inconsistent decisions. Pharmokinetic drug interactions are not only mediated by interactions are not only mediated by botanicals but also by certain foodsbotanicals but also by certain foodsbotanicals but also by certain foods, botanicals but also by certain foods, beverages and lifestyle products.beverages and lifestyle products.

(Planta Med 2004 Sep:70(9):784(Planta Med 2004 Sep:70(9):784 91)91)(Planta Med. 2004 Sep:70(9):784(Planta Med. 2004 Sep:70(9):784--91)91)

The greatest source of drug interactions isThe greatest source of drug interactions isThe greatest source of drug interactions is The greatest source of drug interactions is other drugs e.g. statins deplete COQ10,other drugs e.g. statins deplete COQ10,lower energy levels cause weight gainlower energy levels cause weight gainlower energy levels,cause weight gain, lower energy levels,cause weight gain, and led to heart failure. Several antibioticsand led to heart failure. Several antibioticsD l t f li id d it i b12 hi hD l t f li id d it i b12 hi hDeplete folic acid and vitamin b12 which Deplete folic acid and vitamin b12 which can increase homocysteine levels, can increase homocysteine levels,

t ib t t i d k it ib t t i d k icontribute to anemia, and cause cracks in contribute to anemia, and cause cracks in the corners of the mouth.the corners of the mouth.

Food interaction e g garlic onionsFood interaction e g garlic onionsFood interaction e.g. garlic, onions, Food interaction e.g. garlic, onions, broccoli contain sulfur compounds which broccoli contain sulfur compounds which encourage the liver to produceencourage the liver to produceencourage the liver to produce encourage the liver to produce detoxification enzymes resulting in speedy detoxification enzymes resulting in speedy clearance of drugs form the bodyclearance of drugs form the bodyclearance of drugs form the body.clearance of drugs form the body.What is acceptable public risk?What is acceptable public risk?Di t l t h ld t hi hDi t l t h ld t hi hDietary supplements are held to higher Dietary supplements are held to higher standards than prescription medicines.standards than prescription medicines.

Causes of Death by ComparisonsCauses of Death by Comparisons(Jim Duke PHD former head of USDA’S(Jim Duke PHD former head of USDA’S(Jim Duke PHD former head of USDA S (Jim Duke PHD former head of USDA S

Botanical division 1997)Botanical division 1997)

Herbs 1 in 1,000,000Herbs 1 in 1,000,000Supplements 1 in 1000,000Supplements 1 in 1000,000Mushrooms 1 in 100,000Mushrooms 1 in 100,000

Improper use of meds 1 in 2000Improper use of meds 1 in 2000Angiogram 1 in 1,000Angiogram 1 in 1,000Alcohol 1 in 500Alcohol 1 in 500,,

Food Food PoisoninPoisonin 1 in 25,0001 in 25,000NSAID 1 in 10,000NSAID 1 in 10,000Murder 1 in 10,000Murder 1 in 10,000

Cigarettes 1 in 500Cigarettes 1 in 500Prescription meds 1 in 333Prescription meds 1 in 333Medical mishap 1 in 250Medical mishap 1 in 250Murder 1 in 10,000Murder 1 in 10,000

Hospital Hospital surgsurg 1 in 10, 0001 in 10, 000Car Car accidaccid 1 in 5,0001 in 5,000

Medical mishap 1 in 250Medical mishap 1 in 250Iatrogenic HospitalIatrogenic HospitalInfections 1 in 80Infections 1 in 80By pass surge 1 in 20By pass surge 1 in 20By pass surge 1 in 20 By pass surge 1 in 20

Leading Cause of Deaths (CDC)Leading Cause of Deaths (CDC)Leading Cause of Deaths (CDC)Leading Cause of Deaths (CDC)

Heart Disease 700 142 deathsHeart Disease 700 142 deathsHeart Disease 700,142 deathsHeart Disease 700,142 deathsCancers 533,786 deathsCancers 533,786 deathsC b lC b l 163 538 d th163 538 d thCerebrovascularCerebrovascular 163,538 deaths163,538 deathsChronic respiratory dis. 123,013 deathsChronic respiratory dis. 123,013 deathsUnitentionalUnitentional injury 101,537 deathsinjury 101,537 deathsDaibetesDaibetes 71 372 deaths71 372 deathsDaibetesDaibetes 71,372 deaths71,372 deathsInfluenza and Influenza and PneuPneu 62,034 deaths 62,034 deaths

Leading Causes of Deaths (CDC)Leading Causes of Deaths (CDC)

Alzeimer’sAlzeimer’s disease 53,852 deaths disease 53,852 deaths Kidney 39,480 deathsKidney 39,480 deathsInfection/septicemia 32,238 deaths Infection/septicemia 32,238 deaths

Note: If adverse drug reaction wereNote: If adverse drug reaction wereNote: If adverse drug reaction were Note: If adverse drug reaction were tabulated as the cause of death, this would tabulated as the cause of death, this would be the fourth leading cause of death in thebe the fourth leading cause of death in thebe the fourth leading cause of death in the be the fourth leading cause of death in the United States. United States.

(Bates et. al JAMA 274:29, 1995 and JAMA 237:839(Bates et. al JAMA 274:29, 1995 and JAMA 237:839--841,1997)841,1997)

7,000 deaths per yr. Medication errors in hospitals7,000 deaths per yr. Medication errors in hospitals12 000 d h U12 000 d h U12,000 deaths per yr. Unecessary surgery12,000 deaths per yr. Unecessary surgery45,000 death per yr. Other errors in hospitals45,000 death per yr. Other errors in hospitals80,000 deaths per yr. Infections in hospitals80,000 deaths per yr. Infections in hospitals106 000 deaths per yr Non106 000 deaths per yr Non error adverse reactions toerror adverse reactions to106,000 deaths per yr. Non106,000 deaths per yr. Non--error, adverse reactions to error, adverse reactions to

medications or drug adverse eventsmedications or drug adverse events

JAMA 1998; 279:1200JAMA 1998; 279:1200--5; Annual Review Public Health 1992;5; Annual Review Public Health 1992;13:36313:363--383; and Lancet 1998; 351:643383; and Lancet 1998; 351:643--644644

General Considerations cont’dGeneral Considerations cont’dGeneral Considerations cont dGeneral Considerations cont d

Always check medication side effect information before Always check medication side effect information before yyassuming a herb/drug or food/drug interactionassuming a herb/drug or food/drug interaction

don’t automatically blame the herb.don’t automatically blame the herb.

Pharmaceutical comp. have a vested financial interest in Pharmaceutical comp. have a vested financial interest in continued market placement of a drug. Medication continued market placement of a drug. Medication

i l h ld b d b i d d ti l h ld b d b i d d tappraisals should be made by independent groupappraisals should be made by independent group

JAMA. 2004 Dec 1:292(21):2622JAMA. 2004 Dec 1:292(21):2622--31).31).JAMA. 2004 Dec 1:292(21):2622JAMA. 2004 Dec 1:292(21):2622 31).31).


A Concern is the ability of the physician orA Concern is the ability of the physician orA Concern is the ability of the physician or A Concern is the ability of the physician or practitioner to be able to discern side practitioner to be able to discern side effects or interactionseffects or interactions (JAMA 2003 D(JAMA 2003 Deffects or interactions effects or interactions (JAMA. 2003 Dec (JAMA. 2003 Dec 3;290(21):28383;290(21):2838--42) 42)

Some interactions the benefits outweigh the risks and as Some interactions the benefits outweigh the risks and as Pharmacists and also medical Doctors these interactions Pharmacists and also medical Doctors these interactions

i di dare ignored.are ignored.

The use of supplements poses onlyThe use of supplements poses onlyThe use of supplements poses only The use of supplements poses only minimal risks and interactions are not minimal risks and interactions are not serious(Arch Intern. Med. 2004 Mar 22;164(6):630serious(Arch Intern. Med. 2004 Mar 22;164(6):630--6).6).

Effective education of both conventional medical Effective education of both conventional medical practitioners and healers is the key to maximising public practitioners and healers is the key to maximising public safety Dietary supplementssafety Dietary supplementssafety. Dietary supplementssafety. Dietary supplementshave an excellent safety record. A qualified herbalist, have an excellent safety record. A qualified herbalist, trained in the use of botanicals, should be consulted trained in the use of botanicals, should be consulted about the use of herbs with other supplements orabout the use of herbs with other supplements orabout the use of herbs with other supplements or about the use of herbs with other supplements or medications. In the U.S. the American Herbalist Guild medications. In the U.S. the American Herbalist Guild offers professional membership to those herbalists who offers professional membership to those herbalists who have passed a stringent review process.have passed a stringent review process.have passed a stringent review process. have passed a stringent review process.


Pregnant or nursing women should consultPregnant or nursing women should consultPregnant or nursing women should consult Pregnant or nursing women should consult their physician or healthcare professional their physician or healthcare professional before taking any medications or herbsbefore taking any medications or herbsbefore taking any medications or herbsbefore taking any medications or herbsDiscontinue product if allergy, sideDiscontinue product if allergy, side--effects effects develops Take with food to avoiddevelops Take with food to avoiddevelops. Take with food to avoid develops. Take with food to avoid digestive upset.digestive upset.Di d td t d d tDi d td t d d tDiscard outdated productsDiscard outdated products


Do not self diagnoseDo not self diagnoseDo not self diagnoseDo not self diagnoseIf condition persists for more than a few If condition persists for more than a few days consult a healthcare professionaldays consult a healthcare professionaldays consult a healthcare professionaldays consult a healthcare professionalWaterWater--soluble plant fibers inhibit the soluble plant fibers inhibit the b ti f l t b t bb ti f l t b t babsorption of almost any substance by absorption of almost any substance by

delaying gastric emptying and creating a delaying gastric emptying and creating a il i i til i i tmucilaginous environment.mucilaginous environment.


Do not take prescription medications at the Do not take prescription medications at the p pp psame time with herbs allow 2 hours between same time with herbs allow 2 hours between them.them.B f f ddi h h b l d iB f f ddi h h b l d iBeware of faddish herbal adverts, instant Beware of faddish herbal adverts, instant weightloss formulas and guarantees of restored weightloss formulas and guarantees of restored healthhealthhealthhealthFind the correct scientific name of a herb. Herbs Find the correct scientific name of a herb. Herbs have more than one common name which have more than one common name which changes from region to region and country to changes from region to region and country to countrycountry


Never stop taking a prescription medication suddenly or without the Never stop taking a prescription medication suddenly or without the monitoring of a physicianmonitoring of a physicianmonitoring of a physicianmonitoring of a physicianPurchase the product from a reliable source.Purchase the product from a reliable source.Do not take botanicals for prolonged periods without proper Do not take botanicals for prolonged periods without proper supervision.supervision.ppDo not take mega doses of vitamins, minerals, or herbs without Do not take mega doses of vitamins, minerals, or herbs without supervisionsupervisionmore is not always better.more is not always better.

C lt k l d bl h b li t h i i b f iC lt k l d bl h b li t h i i b f iConsult a knowledgeable herbalist or physician before using Consult a knowledgeable herbalist or physician before using botanicals for a medical condition.botanicals for a medical condition.Never substitute a herbal for a botanical they Never substitute a herbal for a botanical they donotdonot work the same work the same waywayyyTake media hype about a herb /supplement or prescription medicine Take media hype about a herb /supplement or prescription medicine withwitha grain of salt investigate don’t chase headlinesa grain of salt investigate don’t chase headlines

B f l b t i f ti bt i d f th i t tB f l b t i f ti bt i d f th i t tBe careful about information obtained from the internet Be careful about information obtained from the internet

Types of InteractionsTypes of InteractionsTypes of InteractionsTypes of Interactions

Pharmacokinetic interactionsPharmacokinetic interactionsPharmacokinetic interactionsPharmacokinetic interactionsabsorption,distribution,metabolism, or absorption,distribution,metabolism, or eliminationelimination ↑or ↓in amt of herb or drug↑or ↓in amt of herb or drugeliminationelimination--------↑or ↓in amt. of herb or drug↑or ↓in amt. of herb or drugPharmacodynamic interactionsPharmacodynamic interactionsalteration in how herb or drug affects a alteration in how herb or drug affects a tissue or organ→synergistic/potentiation or tissue or organ→synergistic/potentiation or antagonism.antagonism.

Herb Drug interactions and reaction Herb Drug interactions and reaction concernsconcerns

AllergicAllergic-- very low most related to the ragweed familyvery low most related to the ragweed familyBlood pressure meds.Blood pressure meds.-- yohimbeyohimbe ginseng and licorice increase blood ginseng and licorice increase blood pressurepressureIntrinsicIntrinsic-- predictable and unpredictablepredictable and unpredictablep pp p

(idiosyncratic responses)(idiosyncratic responses)Extrinsic effects misidentification of the plant; impurities in productExtrinsic effects misidentification of the plant; impurities in productcontamination of product incorrect dosage or preparation;contamination of product incorrect dosage or preparation;contamination of product, incorrect dosage or preparation; contamination of product, incorrect dosage or preparation;

mislabeling; false advertising; substitution or adulteration or productmislabeling; false advertising; substitution or adulteration or product(GMP would clear most of these problems)(GMP would clear most of these problems)

DrugDrug--Supplement InteractionSupplement InteractionDrugDrug Supplement InteractionSupplement InteractionPharmaceuticalPharmaceutical Herb/supplementHerb/supplement

AnaestheticsAnaestheticsAction on the Gaba receptorsAction on the Gaba receptors

Kava, St John’s Wort,Kava, St John’s Wort,Valerian, passion flowerValerian, passion flowerskullcapskullcapskullcapskullcap

AnticoagulantsAnticoagulants Angelica root, arnica flower, anise, Angelica root, arnica flower, anise, gg g , , ,g , , ,asafoetida, bogbean, borage seed oil,asafoetida, bogbean, borage seed oil,

Anticoagulants cont’dAnticoagulants cont’dAdditive effect may increase orAdditive effect may increase or

BromelainBromelain, capsicum, celery , capsicum, celery chamomile, chamomile, clove,coenzymeclove,coenzyme Q10,Q10,

Additive effect may increase or Additive effect may increase or decrease the effect of a blood decrease the effect of a blood thinner and lead to either a thinner and lead to either a bleeding episode or the formation bleeding episode or the formation

DanshenDanshen, devil’s claw, dong , devil’s claw, dong quaiquai, , fenugreek, Feverfew, feverfew, fenugreek, Feverfew, feverfew, garlic, ginger, garlic, ginger, ginkobilobaginkobiloba, , gingsenggingseng goldenseal green teagoldenseal green tea

of a clot.of a clot.gingsenggingseng, goldenseal, green tea , goldenseal, green tea (in large amounts) horse chestnut, (in large amounts) horse chestnut, licorice root, licorice root, lovagelovage root, root, meadowsweet omega 3 fattymeadowsweet omega 3 fattymeadowsweet, omega 3 fatty meadowsweet, omega 3 fatty acids, onion, acids, onion, papainpapain, , parselyparsely, , passionflower herb, poplar, passionflower herb, poplar, quassiaquassia, red clover, rue, St John’s , red clover, rue, St John’s qq , , ,, , ,wortwort, sweet clover, turmeric, , sweet clover, turmeric, willowbarkwillowbark, vitamin E , vitamin E

ImmunosuppresImmunosuppres Echinacea, St Echinacea, St Digoxin, aloe Digoxin, aloe Foxglove& Foxglove& sants sants (corticosteroids (corticosteroids or cyclosporine)or cyclosporine)

John’s John’s WortWort, , alfalfa sprouts, alfalfa sprouts, ginseng and ginseng and

l t il t i

vera, laxatives, vera, laxatives, diuretics ↓ k diuretics ↓ k levelslevels

eleutherococcus eleutherococcus Have digoxin like Have digoxin like propertiesproperties

melatoninmelatoninlicorice root, licorice root, astralagasastralagas

Quinine may ↑ Quinine may ↑ levelslevels

Psylium fiber mayPsylium fiber may↓ levels↓ levels

Hawthorn berry Hawthorn berry may ↑actn and may ↑actn and y ↑y ↑eliminate useeliminate use

PharmaceuticalPharmaceutical Herb/supplement interactionHerb/supplement interaction

AntidepressantAntidepressant Gingobiloba, SGingobiloba, S--adenosylmethionine (SAMe) adenosylmethionine (SAMe) St. John’s WortSt. John’s Wort

hi bhi byohimbe yohimbe

AspirinAspirin Willow bark,(salicylates,)Willow bark,(salicylates,)Devil’s claw Devil’s claw

DiureticsDiuretics Aloe, goldenseal, licoriceAloe, goldenseal, licoriceCorn silk, urva ursi, dandelion, Corn silk, urva ursi, dandelion, celery seedscelery seeds

Cholesterol lowering drugsCholesterol lowering drugs Red yeast rice, pomegranate, Red yeast rice, pomegranate, ll li idli idguggulguggul lipids,lipids,

Seizure MedicationsSeizure Medications Evening primose oil, lower seizure Evening primose oil, lower seizure thresholdthreshold

Thyroid MedicationsThyroid Medications Horseradish lemon balmHorseradish lemon balmThyroid MedicationsThyroid Medications Horseradish, lemon balm, Horseradish, lemon balm, bugleweed, soy, decrease thyroid bugleweed, soy, decrease thyroid uptakeuptakeKelp increase thyroid outputKelp increase thyroid outputKelp increase thyroid output Kelp increase thyroid output

Prior to surgery (Based on theory Prior to surgery (Based on theory not research)not research)

Best case scenario discontinue Best case scenario discontinue herbs 10herbs 10--14 days before surgery14 days before surgeryN t l iblN t l iblNot always possible Not always possible

Cardiac stabilityCardiac stability Yohimbe ginsengYohimbe ginseng

Table To Show Use of Garlic/ Coconut WaterTable To Show Use of Garlic/ Coconut Waterand Cucumber Juiceand Cucumber Juice

to Control Hypertensionto Control HypertensionPatientPatient DATE & BP DATE & BP

readingreadingDate & BP Date & BP reading afterreading after

AntiAnti--HTN HTN Garlic addedGarlic added Coconut water Coconut water and cucumberand cucumberreadingreading reading afterreading after

InterventionInterventionand cucumber and cucumber juicejuice

11 14/9/0514/9/05 16/6/0516/6/05 YY NN YY11 14/9/0514/9/05150/70150/70

16/6/0516/6/05140/60140/60

YY NN YY

22 14/9/0514/9/05 16/9/0516/9/05 YY NN YY22 14/9/0514/9/05150/70150/70

16/9/0516/9/05130/70130/70

YY NN YY

33 16/9/0516/9/05 4/10/054/10/05 YY YY33 16/9/0516/9/05200/100200/100

4/10/054/10/05140/80140/80

YY YY

/ // / / // /44 6/10/056/10/05179/80179/80

10/10/0510/10/05140/70140/70

YY YY

Table To Show Use of Garlic/ String BeanTable To Show Use of Garlic/ String BeanJuice to Control HypertensionJuice to Control HypertensionJuice to Control HypertensionJuice to Control Hypertension

PatientPatient DATE & BP DATE & BP didi

AntiAnti--HTNHTN Garlic addedGarlic added Coconut Coconut t dt d

Date & BP Date & BP di ftdi ftreadingreading water and water and

cucumber cucumber juicejuice

reading afterreading afterInterventionIntervention

55 1/9/051/9/05180/140180/140

NN YY 8/9/058/9/05120/80120/80

66 26/11/0526/11/05140/50140/50

YY YY 15/12/0515/12/05120/70120/70

77 30/12/0530/12/05140/90140/90

YY YY 12/1/0512/1/05140/80140/80

88 12/1/0612/1/06170/100170/100

NN YY 19/1/0619/1/06140/90140/90

The use of Goats The use of Goats RhueRhue andandRed Clover as aids in controlling DiabetesRed Clover as aids in controlling Diabetes

PatientPatient Date and glucose Date and glucose levellevelmmmol/dlmmmol/dl

Date and level after Date and level after interventionintervention11stst readingreading

22NDND ReadingReading

11 5/09/055/09/05 17/09/0517/09/05 30/09/0530/09/0511 5/09/055/09/0510.510.5

17/09/0517/09/057.57.5

30/09/0530/09/057.97.9

22 12.112.1 3.73.7 16.716.7

33 8/09/058/09/0510.110.1

15/09/0515/09/058.28.2

44 9/09/059/09/0510.910.9

7/10/057/10/059.79.7

11/11/0511/11/056.36.3

55 13/09/0513/09/056.46.4

20/09/0520/09/055.25.2

The use of GoatsThe use of Goats RhueRhue andandThe use of Goats The use of Goats RhueRhue and and Red Clover as aids in controlling DiabetesRed Clover as aids in controlling Diabetes

PatientPatient Date and glucose Date and glucose levellevelmmmolmmmol/dl/dl

Date and level after Date and level after interventionintervention11stst readingreading

22NDND ReadingReading

66 19/09/0519/09/057.87.8

26/10/0526/10/056.16.1

4.64.6

77 20/09/0520/09/05 10/10/0510/10/05 22/10/0522/10/057710.910.9 9.19.1 6.86.8

88 30/09/0530/09/0511 611 6

10/10/0510/10/057 57 511.611.6 7.57.5

99 14/10/0514/10/0518.618.6

22/10/0522/10/0512.712.7

29/10/0529/10/0514.414.4

1010 16/09/0516/09/058.78.7

28/10/0528/10/055.65.6

ConclusionConclusion

Effective education of both conventional medical Effective education of both conventional medical practitioners and traditional healers is the key to practitioners and traditional healers is the key to maximisingmaximising public safety. Dietary supplements have an public safety. Dietary supplements have an excellent safety record. A qualified herbalist, trained in excellent safety record. A qualified herbalist, trained in y qy qthe use of botanicals, should be consulted about the use the use of botanicals, should be consulted about the use of herbs with other supplements or medications. In of herbs with other supplements or medications. In Jamaica there will soon be a professional body who will Jamaica there will soon be a professional body who will p yp yoffer membership to those herbalists/offer membership to those herbalists/traditonaltraditonal healers healers who have passed a stringent review process. To ensure who have passed a stringent review process. To ensure public safety.public safety.p yp y

AcknowlegementsAcknowlegementsAcknowlegementsAcknowlegements

Thanks toThanks toPhylisPhylis D. Light Director of Herbal Studies D. Light Director of Herbal Studies yy ggat the CCNH at the CCNH MrsMrs Ellen Campbell GrizzleEllen Campbell GrizzleMrsMrs Ellen Campbell GrizzleEllen Campbell GrizzleDirector of Information research NCDADirector of Information research NCDAM b f th Ph ilM b f th Ph ilMember of the Pharmacy councilMember of the Pharmacy councilMrMr Radcliffe Radcliffe GoulbourneGoulbourne Inspector Inspector

Acknowledgments cont’dAcknowledgments cont’d

Dr Erica Edmonds and her team inDr Erica Edmonds and her team inDr Erica Edmonds and her team in Dr Erica Edmonds and her team in particular Miss Zara Whyte of the particular Miss Zara Whyte of the Surveillance unit at the Ministry of Health.Surveillance unit at the Ministry of Health.Surveillance unit at the Ministry of Health.Surveillance unit at the Ministry of Health.

Reference:Reference:Reference:Reference:Brinker, Francis ND. Herb Contraindications and Drug Interactions, Eclectic Brinker, Francis ND. Herb Contraindications and Drug Interactions, Eclectic Medical Publications 1998Medical Publications 1998Medical Publications 1998 Medical Publications 1998

Buhner, Stephen and Duke, James A., Medicinal Plants and Herbs. Buhner, Stephen and Duke, James A., Medicinal Plants and Herbs. Peterson Field Guides 2000Peterson Field Guides 2000

Foster, Steven and Duke, James A., Medicinal Plants and Herbs. Peterson Foster, Steven and Duke, James A., Medicinal Plants and Herbs. Peterson Field Guides 2000.Field Guides 2000.

Meletis, Chris D. and Jacobs, Thad N.D. Interactions between Drugs and Meletis, Chris D. and Jacobs, Thad N.D. Interactions between Drugs and Natural Medicines, Eclectic Medical Publications 1999.Natural Medicines, Eclectic Medical Publications 1999.

Mills, Simon and Bone, Kerry. Principles and Practice of Phytotherapy. Mills, Simon and Bone, Kerry. Principles and Practice of Phytotherapy. , , y p y py, , y p y pyChurchill Livingstone , 2000.Churchill Livingstone , 2000.

Mowrey, Daniel B., PHD, The scientific Validation of Herbal Medicine, Keats Mowrey, Daniel B., PHD, The scientific Validation of Herbal Medicine, Keats Publishing 1986.Publishing 1986.ub s g 986ub s g 986

Reference:Reference:Reference:Reference:Tierra, Michael L.AC, OMD, The Way of Herbs by Michael Tierra Pocket Tierra, Michael L.AC, OMD, The Way of Herbs by Michael Tierra Pocket

Books: New York. 1998Books: New York. 1998..Arch Intern Med. 2004 Mar 22; 164(6):630Arch Intern Med. 2004 Mar 22; 164(6):630--66..

INTERNET SITESINTERNET SITES

www.herbalgram.orgwww.herbalgram.org ( American Botanical Council ) ( American Botanical Council ) www.acam.orgwww.acam.org (American College for Advancement in Medicine)(American College for Advancement in Medicine)www.uspharmacist.comwww.uspharmacist.comwww.medline.comwww.medline.comwww.herbnet.comwww.herbnet.com

Herbs-Safety in Use - Caribbean Poison Information Network

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