Chiefs Conference Herbal Supplements

Chiefs Conference Herbal Supplements

اسلاید 1: www.tabaye.ir

اسلاید 2: Chief’s Conference Herbal Supplements: A to Z Katina Robertson, MDEmory University Family Medicine ProgramThursday, January 7, 2010

اسلاید 3: Aloe Vera Aloe vera, Aloe barbadensisCommon Names —aloe vera, burn plant, lily of the desert, elephants gallHistory: used in Ancient Egypt– “plant of immortality”. Presented as burial gifts to deceased pharaohsLeaves contain clear gel often used topicallyOral preparation (juice or dried substance “latex”) from inner lining of green leaves

اسلاید 4: Aloe VeraUsesConstipation– strong laxative properties: aloin, aloe-emodin and barbaloinGenital Herpes– hydrophyllic cream prepPsoriasis VulgarisSeborrheic DermatitisAphthous stomatitis “canker sores”DM type IILichen PlanusSkin burnsWound healingUlcerative Colitis– 2004 randomized, placebo controlled trial. 44 patients, 100mL BID x 4wks. 30% vs 7% had clinical remission and 37% vs 7% had clinical improvement.

اسلاید 5: Aloe VeraAdverse EventsDiarrhea, GI upsetHypoglycemia in combination with oral diabetes medscase report of aloe vera induced hepatitis in Des Moines, Iowa 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

اسلاید 6: Black Cohosh actaea racemosa or Cimifuga racemosaCommon Names: black snakeroot, bugbane, bugwort, rattleroot, rattletop, rattleweed, and macrotys-- Insects avoid itHistory: Native American medicine – malaise, Gyn d/o, kidney d/o, malaria, rheumatism and sore throat. 19th century home remedy, diuretic, and to cause menstruationMember of buttercup family, perennial plant in N. AmericaOral preparation are from the roots and rhizomes (underground stem)– Remifemin most well studied prep

اسلاید 7: Black Cohosh Use: primarily hot flashes, post-menopausal sxs? Estrogenic propertiesEvidence: None consistentKupperman 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 (Natl 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

اسلاید 8: Black Cohosh Not regulated by FDA, compositions vary greatlyCommon adverse effects: headaches, gastric complaints, heaviness in legs, weight gainCase 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 liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice Relative contraindication if liver dz, breast cancer, pregnantNo published studies beyond 6 mos of useIf estrogenic-- long term effects on uterine tissue and CV risk?

اسلاید 9: Carnitine Generic term for compounds that include L-carnitine, acetyl-L-carnitine, and propionyl-L-carnitineFound in most cells in body… Main Role: transport long-chain FAs into mitochondria for oxidization.Concentrated in skeletal and cardiac muscle that utilize FAs for energyHealthy children and adults DO NOT need to consume carnitine from food/ supplements, as the liver and kidneys produce sufficient amounts from the AAs lysine and methionine to meet daily needsAnimal products like meat, fish, poultry, and milk are the best sources. Adult diet– 60-180mg/dFoodMilligrams (mg)Beef steak, cooked, 4 ounces 56-162Ground beef, cooked, 4 ounces 87-99Milk, whole, 1 cup 8Codfish, cooked, 4 ounces 4-7Chicken breast, cooked, 4 ounces 3-5Ice cream, ½ cup 3Cheese, cheddar, 2 ounces 2Whole-wheat bread, 2 slices 0.2Asparagus, cooked, ½ cup 0.1Kidneys efficiently conserve carnitine, so even carnitine-poor diets have little impact on the bodys total carnitine content

اسلاید 10: Carnitine FDA approved to treat carnitine deficiencies onlyPrimary-- genetic d/o manifests w/ cardiomyopathy, Skeletal muscle weakness, hypoglycemiaSecondary– renal dz or drugs (chemotx, antiseizure, pivampicillin) that reduce absorption/increase excretionOther UsesAthletic performance– no evidence it improves exercise/physical performanceAging– decline in mitochondrial function thought to contribute to aging, carnitine decreases with age. Meta-analysis of PCT- DB suggests acetyl-L-carnitine may reduce deterioration in older adults with mild cognitive impairment from Alzheimers disease . Subjects took 1.5-3.0 grams/day of acetyl-L-carnitine for 3-12 months.CV D and PVDDM type II-- recent analysis of two multicenter clinical trials of subjects with 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 in subjects with type 2 diabetes of short duration. Diabetes Care 2005;28:96-101Male infertilityESRD and HD patients (studies small, not PCT or blinded)

اسلاید 11: Carnitine At doses of 3g/day or more… adverse eventsNausea/vomitingAbdominal crampsDiarrhea“fishy” body odorMuscle weakness in uremic pts? Lower seizure threshold

اسلاید 12: Dandelion Taraxacum officinale Common Names— dandelion, lions tooth, blowballDandelion greens are great source of Vitamin AHistorically– used in Native American and traditional Arabic medicine to treat liver, spleen, kidney diseaseLeaves are dried to make teas, capsule, extractsToday, used as diuretic and for minor digestive problemsNo evidence for use to treat any conditionSide Effects: generally safe, rare reports of GI upset, diarrhea

اسلاید 13: Echinacea Echinacea purpurea, Echinacea angustifolia Common Names— echinacea, purple coneflower, coneflower, American coneflowerBelieved to stimulate the immune systemTraditionally used to treat/prevent URI or viral syndromes. Less commonly for boils/acnePlant and roots are dried to make teas, squeezed juice, extracts or preps for topical useNo evidence for use to treat any conditionSide Effects: if taken orally– allergic rxns (rash, anaphylaxis), asthma flare. Worse in those with atopy and allergies to daisy family (ragweed, chrysanthemums, marigolds, etc)

اسلاید 14: Flaxseed/Flaxseed Oil Linum usitatissimum Common Names— flaxseed, linseedUses: Flaxseed itself contains lignans (phytoestrogens, or plant estrogens): laxative, hot flashes, breast painFlaxseed oil preparations lack lignans- arthritisBoth-- hyperlipidemia, cancer prevention.Contains soluble fiberWhole 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

اسلاید 15: Ginkgo Ginkgo biloba Common Names— ginkgo, Ginkgo biloba, fossil tree, maidenhair tree, Japanese silver apricot, baiguo, bai guo ye, kew tree, yinhsingginkgo 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 productsUses: Traditionally- asthma, bronchitis, fatigue, tinnitusToday- improve memory (Alzheimer’s, dementia), intermittent claudication, sexual dyfunction, multiple sclerosis, tinnitus

اسلاید 16: Ginkgo Ginkgo biloba EvidenceGinkgo biloba for Prevention of Dementia study (JAMA 2008)RPCT-DB5 academic ctrs betw 2000-2008, 3,069 elderly pts age ≥ 75 with normal cognition or mild cognitive impairment (MCI)placebo vs 120mg G biloba extract BIDQ6 month eval x median 6.1 yrs . Primary outcome incident dementia or ADIneffective in slowing cognitive decline. 246 (placebo) vs 277 (receiving G 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)NCCAM future studies- asthma, MS, intermittent claudication, cognitive decline, sexual dysfunction 2/2 antidepressants, and insulin resistanceIS IT OK TO TAKE… CAN’T HURT …. CAN IT?

اسلاید 17: Ginkgo Ginkgo biloba Side EffectsHeadache, nausea, GI upset, diarrhea, dizziness, allergic reactionssome data suggest  increase bleeding risk. Use caution in people on anticoagulant drugs, w/ bleeding d/o, or who have scheduled surgical or dental proceduresUncooked ginkgo seeds contain a 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

اسلاید 18: Horse Chestnut Aesculus hippocastanum Common Names— horse chestnut, buckeye, Spanish chestnutnative to Balkan Peninsula, but grows throughout N. Hemisphere Used for centuries for many diseases, NOW used to treat chronic venous insufficiency and hemorrhoidsseed 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 insufficiencyRisksHomemade preparations of horse chestnut should NOT be used. Raw horse chestnut seeds, leaves, bark, and flowers contain esculin, which is poisonousWhen properly processed, extract contains little or no esculin. Can cause itching, nausea, GI upset

اسلاید 19: Kava Piper methysticum Common Names— kava, kava kava, awa, kava pepperNative 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…

اسلاید 20: Kava Piper methysticum Risks >> BenefitsKava has been reported to cause liver damage, including hepatitis and liver failureassociated with several cases of dystonia (abnormal muscle spasm) interact with several drugs, including anti-Parkinsons medsLong-term and/or heavy use of kava may result in scaly, yellowed skinAvoid driving/operating heavy machinery – can cause drowsiness

اسلاید 21: Licorice Root Glycyrrhiza 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 Ccontains a compound called glycyrrhizin (or glycyrrhizic acid)Peeled licorice root - available in dried and powdered forms. Also root in capsule, tablet and liquid extracts formLicorice can be found with glycyrrhizin removed called DGL (deglycyrrhizinated licorice“)- thought to have fewer side effectsSome evidence glycyrrhizin may reduce complications from hepatitis CBUT…

اسلاید 22: Licorice Root Glycyrrhiza glabra, Glycyrrhiza uralensis Risks:In large amounts licorice containing glycyrrhizin can cause HTN, salt and water retention, and hypokalemiasafety of using licorice as a supplement for more than 4 - 6 weeks has not been thoroughly studiedTaking licorice together with diuretics or other meds that reduce potassium levels can cause severe hypokalemiaMay interact with corticosteroidsMay increase risk of preterm labor

اسلاید 23: Milk Thistle Silybum marianum Common Names— milk thistle, Mary thistle, holy thistle, silymarinNative to Mediterranean- used for thousands of yrs to treat many ailments, especially liver problemsBelieved to have protective effects on liver & to improve liver fx, NOW used to treat liver cirrhosis, chronic hepatitis, GB dzOther claims: lower cholesterol, insulin resistance in pts with DM II w/ cirrhosis, cancer cell growth (breast, cervix, prostate)Biological active part– silmarin from seeds to make capsules, extracts, strong tea infusionsCurrently mixed data on effect on liver fx. Curent phase II trial by NCCAM and NIDDK on use for chronic Hep C and NASH (fatty liver)Side Effects– few… laxative effect, GI upset, bloating. Allergic Rxns to those allergic to daisy family (ragweed, chrysanthemum, marigold)

اسلاید 24: Noni Morinda citrifolia Common Names— noni, morinda, Indian mulberry, hog apple, canary woodevergreen shrub native to tropics of Pacific Ocean, from SE Asia to Australia, especially in Polynesia.Traditional use- polynesian dye, topical prep for joint & skin conditionsToday, people drink noni fruit juice as general health tonic and for chronic dz (cancer, CVD, DM)Lab research suggest has antioxidant, immune-stimulating propertiesNCCAM and NCI -- ? efficacy in breast cancer prevention and TxSide Effects: High in K+, avoid if on K+ rich diet or CRDReports of liver damageMakers of noni juice “warned” by FDA about making unsubstantiated health claims

اسلاید 25: Evening Primrose Oil Oenothera biennis Common Names— primrose oil, EPOnative to N. America and contains gamma-linolenic acid (GLA), an essential fatty acidTraditional use- eczema in 1930sToday, mastalgia, RA, PMS, menopausal sxs, DM and cancerExtracted 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 -- GI upset, HA

اسلاید 26: Red Yeast Rice Monascus purpureus Common Names— Angkak, Beni-koji, Hong Qu, Red Koji, Red Leaven, Red Rice, Red yeast, Zhitai, Zue Zhi KangBrand Name– Cholestin3fermented product of the yeast species found on ricemedicinal and non-medicinal purposes in China since 900 A.Dcontains several compounds collectively known as monacolins- monacolin K= powerful HMG-CoA reductase inhiabitor and is the same chemical as lovastatin

اسلاید 27: Red Yeast Rice Monascus purpureus Evidence:Recent studies- eval as alternative to statin for intolerant ptsSmall RPCT- 62 pts in community cards practice (Annals 06/09)½ placebo & ½ RYR 1800mg  BID x 24wkAll patients were concomitantly enrolled in a 12-week therapeutic lifestyle change programPrimary outcome: LDLRYR --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 enzRisks: same as those for statins incl myopathy, rhabdomyolysis, hepatotoxicityMonitoring organizations - large variation in the active compounds in RYR supplements- some supplements contaminated with citrinin, a nephrotoxic mycotoxin

اسلاید 28: Saw Palmetto Serenoa repens, Sabal serrulata Common Names— saw palmetto, American dwarf palm tree, cabbage palmPalm tree native to SE U.S. First use by Seminole Tribe in FloridaToday, urinary symptoms assoc w/ BPH. Also chronic pelvic pain, bladder d/o, decreased libido, and hair lossFruit is ground, dried, or whole and prepped in form of liquid extract, tablet/capsule, tea infusionMixed 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) (NEJM 2006)Side Effects: mild- GI upset, ? decreased libido and breast tenderness in men

اسلاید 29: Turmeric Curcuma longa Common Names— turmeric, turmeric root, Indian saffronShrub related to ginger, grown in Asia and AfricaKnown 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 Txfinger-like underground stems (rhizomes) - dried and oral prep as powder,capsules, teas, or liquid extracts. Also topical pastePrelim animal data suggests anti-inflammatory and anti-cancer propertiesSide Effects: mild- high doses indigestion. May worsen gallbladder dz

اسلاید 30: Valerian Valeriana officinalis Common Names— setwall, Baldrianwurzel, and phuperennial plant native to Europe and Asia, distinctive odor that many find unpleasantPreps made from roots, rhizomes into teas, tinctures, extracts for capsules, tablets2nd century uses- insomnia. 16th century- anxiety, HA, palpitations, tremor. WWII- relieve stress from air raidsToday, treatment of insomnia disordersSystematic review of several trials-- inconclusive data on efficacy for insomnia. Limitations- sample size/power, differing dosing amounts and sources of valerianSide Effects: HA, dizziness, pruritis, GI upset

اسلاید 31: Yohimbe Pausinystalia yohimbe Common Names— yohimbe, yohimbe barkYohimbe tree -- tall evergreen native to W. AfricaBark traditionally used as an aphrodisiacToday, yohimbe bark as a dietary supplement-- in many forms, not regulated. dried bark – used as tea or bark extract put into capsules/tablets and is a dietary supplement (not FDA regulated)a regulated Rx form-- yohimbine HCl 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 versionSide Effects: assoc with HTN, tachycardia, HA, anxiety, dizziness, sleeplessness. Caution if MAOI, BP meds, TCAs, phenothiazines, renal disease

اسلاید 32: ReferencesBecker 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 Med. 2009;150:830-839, W147-149.Tisha R. Joy and Robert A. Hegele. Narrative Review: Statin-Related Myopathy. Ann Intern Med. June 16, 2009 150:858-868.http://dietary-supplements.info.nih.gov/Health_Information/Information_About_Individual_Dietary_Supplements.aspxLangmead L, Feakins RM, Goldthorpe S, Holt H, Tsironi E, De Silva A, Jewell DP, Rampton DS. Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis. Aliment Pharmacol Ther. 2004 Apr 1;19(7):739-47.Solomon PR, Adams F, Silver A, et al. Ginkgo for memory enhancement: a 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.Bent S, Kane C, Shinohara K, et al. Saw palmetto for benign prostatic hypertrophy. New England Journal of Medicine. 2006;354(6):557–566.

اسلاید 33: Questio