Chiefs Conference Herbal Supplements

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Chief’s Conference Herbal Supplements: A fo Z Katina Robertson, MD Emory University Family Medicine Program Thursday, January 7, 2010 

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Et Aloe Vera Se Joe vera, Aloe barbadensis > Common Names —aloe vera, burn plant, lily of the desert, elephant's gall » History: used in Ancient Egypt- “plant of immortality”. Presented as burial gifts to deceased pharaohs » Leaves contain clear gel often used topically > Oral preparation (juice or dried substance “Jatex”) from inner lining of green leaves 

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Aloe Vera Uses > Constipation- strong » Lichen Planus laxative properties: > Skin burns ‏واه‎ aloe-emodin and Dati ‏وستاقعط‎ ‎barbaloin ۱ - 5 : > Ulcerative Colitis— 2004 ‏۵عامتادی مطم‌دام ,۲2800۳26۵ -۲۱۵۲۵65 م6۵6۳‎ hydrophyllic cream trial. 44 patients, 100mL BID x امع اماك لفط 790 5ل 3096 .لمك prep eae ‏كلا 3796 مم‎ 796 34 > Psoriasis Vulgaris clinical improvement. » Seborrheic Dermatitis » Aphthous stomatitis “canker sores” DM type II v 

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Aloe Vera Adverse Events > Diarrhea, GI upset < Hypoglycemia in combination with oral diabetes meds » case report of aloe vera induced hepatitis in Des Moines, lowa VAMC (annals of Pharm, 2007) ® In 2002, FDA required that all OTC aloe laxative products be removed from the U.S. market or reformulated because the companies that manufactured them did not provide the necessary safety data 

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Black Cohosh actaea racemosa or Cimifuga racemosa ار الت 7 >» Common Names: black snakeroot, bugbane, bugwort, rattleroot, rattletop, rattleweed, and macrotys-- Insects avoid it » History: Native American medicine - malaise, Gyn d/o, kidney d/o, malaria, rheumatism and sore throat. 19" century home remedy, diuretic, and to cause menstruation » Member of buttercup family, perennial plant in N. America > Oral preparation are from the roots and rhizomes (underground stem)- Rem/fem/n most well studied prep 

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Black Cohosh ® Use: primarily hot flashes, post-menopausal sxs » ۶ Estrogenic properties » Evidence: None consistent o Kupperman Index-- measures of hot flashes, depression and insomnia (not vaginal dryness) German study: 60 women s/p hysterectomy. Compare 8 mg/d of a black cohosh extract version of Remifemin with three estrogen regimens: estriol (1 mg/day), conjugated estrogens (1.25 mg/day), and estrogen-progestin (2 mg estradiol / 1 mg norethisterone acetate) for 6mo. In all groups modified Kupperman. index was significantly lower at 4, 8, 12, and 24 wks post Tx. Black cohosh decreased symptoms similarly to the other treatments. NCCAM (wat! Center on Complimentary and Alternative Medicine)-currently funding 12-month, RPCT on whether black cohosh is effective in reducing the frequency /intensity of menopausal sxs , improve QOL 

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Black Cohosh » Not regulated by FDA, compositions vary greatly » Common adverse effects; headaches, gastric complaints, heaviness in legs, weight gain Case reports of acute hepatitis (one requiring liver transplant 3 wks after starting the herb) U.S. Pharmacopeia (the standards-setting organization for foods and drugs) advises black cohosh products be labeled with ; “Discontinue use and consult a healthcare practitioner if you have a jiver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice” Relative contraindication if liver dz, breast cancer, pregnant No published studies beyond 6 mos of use Oe ese) talons ate ‏ل‎ eee 

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Carnitine علمعكممء لااغمعاء قاع دبإعم لكا ‎carnitine, so even carnitine-poor‏ تفت ‎felt e-mal-‏ ‎body's total carnitine content‏ 0 ات ودره 0 43 Pd 3 9 0.2 6.1 سس 4 ,فعاوم ,دهع هوق ومع مناه ‎ee cae‏ ‎Gre‏ Canoe ay ‎Cc eure‏ رطعگفی ‎a Cu Cae CRY ounces ‎eer ee eee access Whole-wheat bread, 2 slices ‎Reet cc Rey ‎6 Comeonn otters include l-carnitine, acetyl-- carnitine, and propiony/-l-camnitine ‏ره‎ Man es) Main Role: transport long-chain FAs into mitochondria for oxidization. ‏و رو ‎diac muscle that utilize FAs for ‎7 ‎Healthy children and adults DO ۱۱۵۲ ۱۵۵۵ 1۵ ‏یعدم‎ ‎from food/ supplements, as the ‎5 produce sufficient amounts from the AAs lysine and ethionine to meet daily needs Animal products like meat, fish, poultry, and milk are the best 506 ‎Adult diet- 60-180mg/d ‎ ‎ ‎ ‎ ‎ ‎ ‎ 

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Carnitine » FDA approved to treat carnitine deficiencies only ‎ole eA‏ ره ‎Dye ect‏ ‎00 ‏اس ا ا‎ ad ‏عدمعى م1/ومتام1مدطة‎ ۳ ‎> Other ‏درز‎ ‎Athletic performance- no evidence it improves exercise/physical performance ۱ cI Clete cera aen ie [ood Miser iN oa ee PUSH ese casera ig reduce deterioration in older adults with mild cognitive impairment from Alzheimer's disease . Subjects took 1.5-3.0 grams/day of acetyl-L-carnitine for 3- eae ‏حلام قمة 6 كت » ‎De ence aaa ‏ا‎ een ieg either type 1 or type 2 diabetes found Tx with acetyl-L-carnitine (3 g/day orally) for one year provided significant relief of nerve pain and improved vibration perception in those with diabetic neuropathy. The treatment was most effective ۱ * Wale infertility ‎* ESRD and HD patients (studies small, not PCT or blinded) 

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Carnitine » At doses of 3g/day or more... adverse events 0 ‏انا‎ 3 Abdominal cramps 3 Diarrhea ‎“fishy” body odor‏ ل ‎Qa Muscle weakness in uremic pts ‎0 ? Lower seizure threshold 

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Dandelion Taraxacum officinale > Common Names— dandelion, lion's tooth, blowball >» Dandelion greens are great source of Vitamin A » Historically- used in Native American and traditional Arabic medicine to treat liver, spleen, kidney disease » Leaves are dried to make teas, capsule, extracts > Today, used as diuretic and for minor digestive problems » No evidence for use to treat any condition » Side Effects: generally safe, rare reports of GI upset, diarrhea 

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Echinacea Echinacea purpurea, Echinacea angustifolia > Common Names— echinacea, purple coneflower, coneflower, American coneflower » Believed to stimulate the immune system > Traditionally used to treat/prevent URI or viral syndromes. Less commonly for boils/acne » Plant and roots are dried to make teas, squeezed juice, extracts or preps for topical use » ۱۱۵ evidence for use to treat any condition » Side Effects: if taken orally- allergic rxns (rash, anaphylaxis), asthma flare. Worse in those with atopy and allergies to daisy family (ragweed, chrysanthemums, marigolds, etc) 

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laxseed/Flaxseed Oil 171771 +7 >» Common Names-— flaxseed, linseed > Uses: » Flaxseed itself contains lignans (phytoestrogens, or plant estrogens): laxative, hot flashes, breast pain * Flaxseed oil preparations lack lignans- arthritis * Both-- hyperlipidemia, cancer prevention. » Contains soluble fiber Whole or crushed flaxseed can be mixed with H2O or juice. Also in powder and capsule form. » Some studies suggest: alpha-linolenic acid (found in both) may benefit people w/ CAD. No consistent data. » Rare side effects: b/c fiber source, take w/ water to prevent constipation or intestinal blockage 5 

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Ginkgo Ginkgo biloba > Common Names— ginkgo, Ginkgo biloba, fossil tree, maidenhair 20 Tec oilecien oe] Corie on racers an) » ginkgo tree- one of oldest types of trees in the world » Ginkgo seeds- used in traditional Chinese medicine for thousands of years. Cooked seeds occasionally eaten. > Leaf extracts > tablets/capsules, teas, skin products > Uses: * Jraditionally- asthma, bronchitis, fatigue, tinnitus * Joday- improve memory (Alzheimer’s, dementia), intermittent claudication, sexual dyfunction, multiple sclerosis, tinnitus 

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Mee Ginkgo a Ginkgo biloba » Evidence * Ginkgo biloba for Prevention of Dementia study (JAMA 2008) ‎eR aN eae el aR‏ الا ا ی ی ‎Comune‏ ‎۱ Rar aelee=D) ۱۶ Melgar Wp RP Coda Ce ‏ل‎ era) Pascoe lade Mia ee eM Noe ee La) en eT biloba) * Ginkgo for Memory Enhancement- Six-week RPCT- DB. 203 pts age = 60 without cognitive impairment. Results- No improvement in performance on standard neuropsych tests of learning, memory, attention, concentration, naming or verbal fluency (JAMA 2002) Ie ‏وه ارف زرد کرت ی تیعبت ترا ارت‎ olny cognitive decline, sexual dysfunction 2/2 antidepressants, and ‏ور تخر رات رز‎ ‎Is IT OK TO TAKE... CAN’T HURT ....CAN IT? 

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Ginkgo Ginkgo biloba 2 » Side Effects " Headache, nausea, Gl! upset, diarrhea, dizziness, allergic reactions = some data suggest > increase bleeding risk. Use caution in people on anticoagulant drugs, w/ bleeding d/o, or who have scheduled surgical or dental procedures = Uncooked! ginkgo seeds contain al chemical| known as ginkgotoxin, which can cause seizures. Consuming large quantities of seeds over time can cause DEATH!! = Ginkgo leaf and ginkgo leaf extracts appear to contain little ginkgotoxin 

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Horse Chestnut Aesculus hippocastanum » Common Names— horse chestnut, buckeye, Spanish chestnut » native to Balkan Peninsula, but grows throughout N. Hemisphere Used for centuries for many diseases, NOW used to treat chronic venous insufficiency and hemorrhoids seed extract standardized to contain 16 to 20)% aescin (escin), the active ingredient, is the most commonly used form. Also topical forms. Small studies have found extract comparable to using compression stockings for venous insufficiency Risks " Homemade preparations of horse chestnut should NOT be used. Raw horse chestnut seeds, leaves, bark, and flowers contain esculin, Wien sirens * When properly processed, extract contains little or no esculin. Can cause itching, nausea, Gi upset 

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Kava eens u erable) >» Common Names— kava, kava Kava, awa, kava pepper » Native to islands of the S. Pacific -member of pepper family » Used as ceremonial beverage in S. Pacific for centuries. > In past for fatigue, asthma, UTI, topical anesthetic. NOW used to treat chronic anxiety, insomnia, and menopausal sxs. » root and rhizome (underground stem) -used to prepare beverages, extracts, capsules, tablets, and topical solutions » Little evidence that it is efficacious in any diseases: ? anxiety Tx AND... 

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Kava eens u erable) < ۲۱56 << ۸5 = Kava has been reported to cause liver damage, including hepatitis and liver failure associated with several cases of dystonia (abnormal muscle spasm) = interact with several drugs, including anti-Parkinson's meds = Long-term and/or heavy use of kava may result in scaly, yellowed skin * Avoid driving/operating heavy machinery - can cause drowsiness 

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Licorice Root Slycyrthiza glabra, Glycyrrhiza uralensis » Common Names=— licorice root, licorice, liquorice, sweet root, gan zao (Chinese licorice) » Grown mostly in Greece, Turkey, and Asia. Long h/o use in both Eastern and Western Medicine- stomach ulcers, bronchitis, sore throat, viral infxns — including Hep © » contains a compound called glycyrrhizin (or glycyrrhizic acid) » Peeled licorice root - available in dried and powdered forms. Also root in capsule, tablet and liquid extracts form » Licorice can be found with glycyrrhizin removed called DGL ("deglycyrrhizinated licorice”)- thought to have fewer side effects >» Some evidence glycyrrhizin may reduce complications from hepatitis 6 BUT... 

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Licorice Root ewlycyrrhiza glabra, Glycyrrhiza uralensis < ۱5: * In large amounts licorice containing glycyrrhizin can cause HIN, salt and water retention, and hypokalemia = safety of using licorice as a supplement for more than 4 - 6 weeks has not been thoroughly studied * Taking licorice together with diuretics or other meds that reduce potassium levels can cause severe hypokalemia = May interact with corticosteroids = May increase risk of preterm labor 

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Milk Thistle Silybum marianum Common oe milk thistle, Mary thistle, holy thistle, silymarin Native to Mediterranean- used for thousands of yrs to treat many ailments, especially liver problems Believed to have protective effects on liver & to improve liver tx, NOW used to treat liver cirrhosis, chronic hepatitis, GB dz Other claims: lower >cholesterol, insulin resistance in pts with DM II w/ cirrhosis, cancer cell growth (breast, cervix, prostate) Biological active part- si/marin> from seeds to make capsules, extracts, strong tea infusions Currently mixed data on effect on liver fx. Curent phase II trial by NCCAM and NIDDK on use for chronic Hep C and NASH (fatty ‏(معنااا‎ Side Effects- few... laxative effect, GI upset, bloating. Allergic Rxns to those allergic to daisy family (ragweed, chrysanthemum, marigold) 

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Noni Morinda citrifolia Common Names— noni, morinda, Indian mulberry, hog apple, canary wood) evergreen shrub native to tropics of Pacific Ocean, from SE Asia to Australia, especially in Polynesia. Traditional use- polynesian dye, topical prep for joint & skin conditions Today, people drink noni fruit juice as general health tonic and for chronic dz (cancer, CVD, DM) Lab research suggest> has antioxidant, immune-stimulating properties NCCAM and NCI -- ? efficacy in breast cancer prevention and Tx Side Effects: * High in K+, avoid if on K+ rich diet or CRD iste) ol Rovere tnele( * Makers of noni juice “warned” by FDA about making ۱۳5۱۷۵5۲۵۱۲۱۵۲6۵ ۱6۵۱۲۱ 5 

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Rs. Evening Primrose Oil th Oenothera biennis Common Names— primrose oil, EPO native to N. America and contains gamma-linolenic acid (GLA), an essential fatty acid Traditional use- eczema in 1930s Today, mastalgia, RA, PMS, menopausal sxs, DM and cancer Extracted from seeds-- usually put into capsules for use. No effect on menopausal or PMS sxs. Mixed data on RA, mastalgia (small studies, ?able study design) Side Effects: mild -- Gl upset, HA 

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Red Yeast Rice Monascus purpureus Common Names— Angkak, Beni-koji, Hong Qu, Red Koji, Red Leaven, Red Rice, Red yeast, Zhitai, Zue Zhi Kang Brand Name- Cholestin3 fermented product of the yeast species found on rice medicinal and non-medicinal purposes in China since 900 A.D contains several compounds collectively known as monacolins- monacolin K= powerful HMG-CoA reductase inhiabitor and is the same chemical as lovastatin 

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Red Yeast Rice Monascus purpureus > Evidence: كام امومع امغصا 6ه ماغأوغد مغ عناأودمععغ !اخ 5ق اهباء -دع01ن ند أمعععهم * ا ال ل ان 0 241006 8۱0 18009 6۷8 ۷۶ 6 مطم‌هام ‏ < » All patients were concomitantly enrolled in a 12-week therapeutic cere 0۲۵9۵ Saari meee ean > RYR--LDL§ 43 mg/dL @wk 12 & 35 mg/dL@ wk 24 (P 0.001) » Plac- LDL§ 11 mg/dL @wk 12 & 15 mg/dL@ wk 24 (P 0.011) » No difference in CPK, pain severity of liver enz » Risks: same as those for statins incl myopathy, rhabdomyolysis, hepatotoxicity » Monitoring organizations - large variation in the active compounds in RYR supplements- some supplements contaminated with citrinin, a nephrotoxic mycotoxin 

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WW Saw Palmetto ۱ renoa repens, Sabal serrulata ۱۷ Common Names— saw palmetto, American dwarf palm tree, cabbage palm Palm tree native to SE U.S. First use by Seminole Tribe in Florida Today, Urinary symptoms assoc w/ BPH. Also chronic pelvic pain, bladder d/o, decreased libido, and hair loss Fruit is ground, dried, or whole and prepped in form of liquid extract, tablet/capsule, tea infusion Mixed data-- 2006 DB, RPCT study of 225 men w/ mod- sev BPH showed no improvement w/ 320mg SP daily vs placebo. Primary outcome- max urinary flow rate and score on Amer Uro Assn Sx Index (AUASI) (WwE/m 2006) Side Effects: mild- Gl upset, ? decreased libido and breast tenderness in men 

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Turmeric Curcuma longa ياك >» Common Names— turmeric, turmeric root, Indian saffron » Shrub related to ginger, grown in Asia and Africa » Known for warm, bitter taste and golden color-- commonly used in fabric dyes & foods (curry, mustards, & cheeses) Today, heart burn, stomach ulcers, and gallstones, anti- inflammatory effects, cancer Tx finger-like underground stems (rhizomes) - dried and oral prep as powder,capsules, teas, or liquid extracts. Also topical paste Prelim animal data suggests anti-inflammatory and anti- cancer properties Side Effects: mild- high doses indigestion. May worsen gallbladder dz 

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Valerian Valeriana officinalis Common Names— setwall, Baldrianwurzel, and phu perennial plant native to Europe and Asia, distinctive odor that many find unpleasant Preps made from roots, rhizomes into teas, tinctures, extracts for capsules, tablets 2°¢ century uses- insomnia. 16 century- anxiety, HA, palpitations, tremor. WWII- relieve stress from air raids > Today, treatment of insomnia disorders » Systematic review of several trials-- inconclusive data on efficacy for insomnia. Limitations- sample size/power, differing dosing amounts and sources of valerian Side Effects: HA, dizziness, pruritis, Gl upset 

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Yohimbe Pausinystalia yohimbe Common Names— yohimbe, yohimbe bark Yohimbe tree -- tall evergreen native to W. Africa Bark traditionally used as an aphrodisiac Today, yohimbe bark as a dietary supplement-- in many 101105, 06 ‏اناوع"‎ 3660. dried bark — Used as tea orf bark extract put into capsules/tablets and is a dietary supplement (not FDA fegulated)) a regulated Rx form-- yohimbine HCI> indic for Erectile dysfx Tx but cannot use this as evidence that the dietary supplement is efficacious. No clinical trials conducted thus far on dietary supp version Side Effects: assoc with HTN, tachycardia, HA, anxiety, dizziness, sleeplessness. Caution if MAOI, BP meds, TCAs, phenothiazines, renal disease ۲ ۲ ۲ ۲ 

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References Becker DJ, Godon RY, Halbert SC, French B, Morris PB, Rader DJ. Red yeast rice for dyslipidemia in statin-intolerant patients: a randomized trial. Ann Intern Ieee etek nes nL Vase Repo genet anew ‏ترس دی‎ Daler etal erica tod arene hy elo y esto eiats mesa eer eeu Meee nae cea 0 UE te ee pete atest Langmead L, Feakins RM, Goldthorpe S, Holt H, Tsironi E, De Silva A, Jewell DP, Rampton DS. Randomized, double-blind, placebo-controlled trial of oral ۱۹ ‏ا‎ ‎119097۰ ‎Pern) oC oTatUC Utes eu Vale nnC-Ueae)‏ ی ‎randomized controlled trial. Journal of the American Medical Association.‏ .2002;288(7):835-840 ‎DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. Journal of the American Medical Association. 2008;300(19):2253-2262 ‎Ese CMON Ue QRS TT ant- CoN aml el-Ull al ices lire ‎Ny aati ‏ا ا‎ ier a 

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Questions