Integrating Herbs with Conventional Medicine

Linda Diane Feldt RPP, NCTMB Holistic Health Practitioner and Herbalist

Objectives

       Identify the difference between nourishing and medicinal herbs Identify how nourishing herbs are provided Identify how medicinal herbs are provided Know reasons to use nourishing or medicinal herbs Learn about 9 popular herbs Learn some of the problems with herbal marketing and preparations Time for questions and individual concerns

Nourishing herbs

         Nutrient rich Bio-available Generally considered safe, side effects uncommon Dosage and strength less important Tend to be local, whole, and common Large amounts used, in contrast to medicinal plants Includes tonics Supportive to body systems Long term use is usually beneficial

Nourishing Herbs con’t.

  Internal use   Infusions   Water based Vinegar based Whole plant   Cooked Raw (salad) External use  Compress   Poultice Salve

Medicinal Herbs

       Dosage and strength important or critical Tend to utilize more toxic parts of plant Stimulate or sedate More likely to have side effects Are often plants that are less common, or rare Long term use is generally discouraged More extensive knowledge is needed to use safely and effectively

Medicinal Herbs con’t.

 Tinctures  Alcohol based  Glycerin  Extracts  Capsules

Case Study: Prophylactic Use of Echinacea angustifolia and purpurea Tincture for Management of a Recurrent Staphylococcus Infection

Case Study con’t.

 46 yo female CHF  Heart cath age 53, followed by staph infection  Broad spec. antibiotics no effect  Echinacea ang. 30-40 drops every 3 hours  Symptom improvement within 2 hours  Two days both, stopped Ech. Symptoms returned within 4 hours  Ech and Antibiotic together, no symptoms

Case Study con’t.

 MD stopped antibiotics, pt. stopped Ech. Symptoms returned  Ech. as before - symptoms gone  One day without Ech, some symptoms  Ech 10 drops day no symptoms  For next 7 years, until death, two skipped days symptoms return -proven at least five times

Significant points

 Echinacea fought an antibiotic resistant infection  Low dose (nourishing) as effective as high dose (stimulating)  Low dose safe to use long term  Long term use was necessary  Mechanism of action for effect of low dose unknown

Popular Herbs

Ginkgo biloba St. John’s wort Garlic Echinacea Goldenseal

The Herbs

Saw palmetto Milk thistle Black cohosh Ginger

Ginkgo biloba

  Powdered leaves Tincture or infusion   Most ancient tree known Uses: cerebral insufficiency, Alzheimer’s Ds, intermittent claudication, tinnitis

Ginkgo

 Increases vascular flow  diabetic peripheral vascular disease  Raynauds syndrome  Other circulatory benefits fro varicose veins, hemorrhoids, eye disorders  Affinity for cerebral circulation  Inhibits platelet activity factor

Ginkgo

 Used to relieve tension, anxiety, elevate mood  Contains flavanoids, terpene lactones, ginkgolides A, B, and C, bilobalide, quercetin, and kaempferol.  ginkgolides control allergic inflammation, anaphylactic shock and asthma  antioxidant

What to watch for

 Can increase blood flow  Discontinue before surgery  Do not use with menstrual flooding  Do not use with other bleeding problems (ulcer, bruising, etc.)  Not suggested with blood thinners, aspirin, etc.

Gingko biloba & Dementia

  52 week RCT, double blind, multi-center Outcomes in 309 pts (ITT):  Pt cognition: tx no change, placebo worse (p=0.04)  Caregiver assess: tx slight improve, placebo worse (p=.004)  Dose: 120 mg/d of EGb 761  Safety: side effects equal  Problems: high dropout rate (50% tx, 62% placebo)

Ginkgo & Claudication

 Meta-analysis of Egb 761   5 placebo controlled trials Moderate to large effect (0.75 Cohen’s

d

) on pain-free treadmill walking distance Schneider B.

Arzneimforsch

1992;42(4):428-436

Ginkgo - Toxicology

 Adverse events  GI complaints  bruising & spontaneous bleeding  Avoid if taking warfarin, heparin, or NSAIDs  Can increase insulin levels  May increase sedation with trazodone

St. John’s Wort

Hypericum Perforatum

Used as tincture, extract in pill form, topically as oil or salve Popular as anti-depressant.

Also used for muscle aches, nerve pain, nerve regeneration, for herpes outbreaks, bruising

St. John’s Wort

 P450 Cytochrome system  Can interfere with effectiveness of other medications  Possible rash from exposure to sun (sheep and cows)  Use with other mood altering drugs of concern  Use by people with manic depressive and other psychological conditions of concern

St. John’s Wort & Depression

 Meta-analysis: 23 studies, 1757 pts  Mild-mod depression    Superior to placebo, rrr =2.67 (1.78-4.01) As effective as TCA’s , rrr=1.10 (0.93-1.31) Fewer side effects than TCA’s  Dose: 0.4-2.7 mg Hypericin (standardized extract)  Multi-center trial vs. SSRI’s at Duke Linde K, et al. BMJ 1996;313:253-8

St. John’s Wort and Zoloft

  Randomized controlled trial St. John’s wort vs. Zoloft vs. placebo  effects  Side effects  Placebo < SJW < Zoloft (p= 0.000

St. John’s Wort - Toxicology

 Side effects  Theoretical risk - sunburn  Herb-drug interactions  Studies - digoxin, protease inhibitors, TCAs  Case reports - cyclosporine, warfarin, oral contraceptives, theophylline, SSRIs  Theoretical - iron Facts & Comparisons Review of Natural Products, Dec 2000.

Garlic (

Allium sativum

)

 Uses  Lower cholesterol  anti-thrombotic  lower blood pressure  anti-microbial agent  Strengthen heart muscle  Reduce platelet clumping and clotting  Stabilize blood sugar levels

Garlic

 Some concern about use if bleeding is of concern  Odor  Large amounts can great gas  Potential decreased platelet aggregation

Garlic

  Contains alliin in intact garlic bulb Alliin  allicin (crushed)  600 – 900 mg of dried powder (1.3% allicin)

Garlic - Evidence

 German Commission E  elevated blood lipids  prevention of age-related vascular changes  25 studies between 1979-1998 with 2,920 people  Mixed results highly dependent on type of garlic preparation

Garlic - Evidence

 2 Meta-analyses  garlic lowered total cholesterol between 9-12%  Meta-analysis  Anti-hypertensive - 10% reduction  Double blind RCT - 152 subjects for 4 years  garlic reduced development of atherosclerosis

Echinacea spp.

     E. pallida purpurea angustifolia Use: prevention and treatment of colds, flu One of most popular herbs in US German Commission E  supportive for colds, chronic URI, UTI UK - GSL

Echinacea

 Stimulating dose not advised with autoimmune and some systemic diseases  Can interfere with immune suppression during chemotherapy treatment  Stimulating dose should be short term (3-4 days) only  No known side effects  Concern with steroid treatment - depends on use

Echinacea - Human Evidence

   26 controlled trials (many open label) 3 blinded RCT’s on URI   1 showed dose dependent decrease in symptoms and duration of “flu” 2 showed 13-20% relative risk reduction of acquiring URI Dose: 30-60 gtts 1:5 (g/ml) tincture TID

Echinacea Systematic Review

 16 randomized or quasi randomized trials  Echinacea preparation vs. no treatment or placebo  8 trials on prevention, 8 trials on treatment  3396 patients involved  Majority with positive results  Cannot say which preparation is best Melchart, D. et al. Cochrane Database Syst Rev 2000;2.

Goldenseal

( Hydrastis canadensis)

 Used in Native American medicine  Taken up by European immigrants  Deep forest dweller, endangered species  Part used is the root  Colds, flu, bacterial diarrhea, intestinal parasites, and ocular trachoma infections

Goldenseal

 Endangered herb  Internal use has antibiotic effect  concern for contributing to antibiotic resistant bacteria  Dose, duration, and strength important  Can be difficult to self-administer  Overused and misused by general public  Present in tooth paste, lip balm, herbal mixtures

Goldenseal - Evidence

 Antimicrobial activity vs. bacteria, viruses, fungi, protozoans, helminths, and chlamydia  Active components:  berberine (anticholinergic, antisecretory, and antimicrobial)  beta-hydrastine (astringent)  In rats, Goldenseal increases IgM antibodies

Saw Palmetto (Serenoa repens)

 Hexane extract of dried berries  Spasmolytic activity  Inhibition of androgen   Anti-inflammatory Not an inhibitor of 5  reductase  Used for benign prostatic hypertrophy

Saw Palmetto - Evidence

 18 RCT’s, 16/18 double-blinded  2939 men, duration 4-48 weeks  Decreased nocturia, improved symptom scores vs. placebo  Improved symptom score, improved peak urine flow vs. finasteride  Dose: 400 mg dry extract BID Wilt TJ, et al. JAMA 1998; 280:1604-1609.

Saw Palmetto - Toxicology

 Rats: 80x human dose for 6 months  No negative influences  Human trials, German Commission E  GI disturbances, headache  No significant adverse effects  Drug interactions  Theoretical - Estrogens, oral contraceptives, iron  German Commission E reports none

Black Cohosh (Cimicifuga

racemosa)

    Fresh root tincture or dried root infusion Remifemin, used in Germany since 1950’s Used for hot flashes and night sweats German Commission E:    Premenstrual discomfort Dysmenorrhea Menopausal neurovegetative symptoms

Black Cohosh - Mode of action

   Steroidal terpenes? isoflavones? others?

Methanol extracts bind estrogen receptors Inhibits estrogen dependent breast tumor cell lines   Lowers LH in rats and women, no effect on FSH a Stimulatory effect on endometrium b,c  Actein may be beneficial in hypercholesterolemia and peripheral arterial disease a. Duker 1991; b. Stoll 1987; c. Warnecke 1985

Black Cohosh - Clinical Trials

 5 RCTs in literature  Randomized, head to head trial  60 pts, < 40 yr. old with hysterectomies   Estriol vs. conjugated estrogens vs. estrogen-gestegen sequential vs. black cohosh extract Outcome: Kupperman’s Menopausal Index  Black cohosh equal to other treatments Lehmann-Willenbrock, et al.

Zentralblatt fur Gynakologie

1998;110:611-8 similar findings: Warnecke, 1985

Black Cohosh Update

 Recent RCT  85 breast cancer survivors  59 were on tamoxifen  40 mg/d Remifemin vs. placebo x 2 months  No benefit for hot flashes  Jacobson JS, et al. J. Clin. Oncol 2001;19:2739-45.

On-going trial at Columbia Univ  RCT, 1 year duration  hot flashes, endometrial thickness, bone metab, cognitive effects

Black Cohosh - Toxicology

  Overdose: nausea, dizziness, nervous system disturbance Mice  spread of breast CA  Large doses may cause miscarriage. Contraindicated in pregnancy  Long term safety unknown

Ginger Zingiber officinale

 Used for nausea  Helpful for colds and flu  Warming herb  Many other folkloric uses

Ginger for Nausea & Vomiting of Pregnancy

 2 trials show efficacy compared to placebo  excess Yang (excess Qi)   N not in AM, N worse p eating, N improves p vomiting ginger is too “hot”, use peppermint  excess Yin (deficient Qi)  N in AM, N better p eating, N worse p vomiting  ginger will be helpful Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196

How to take ginger

 Dose 3-9 grams fresh (or dried) peeled ginger root  Tea made from grated fresh root  Commercially available capsules  NOT ginger biscuits or ginger beer Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196

Ginger Root Safety?

 Contraindicated in German Commission E      6-gingerol is mutagenic in vitro at high doses Other compounds in ginger are anti-mutagenic Widely used in Traditional Chinese Medicine No contraindication in Pharmacopoeia of the People’s Republic of China (1995) May increase miscarriage

Milk Thistle

Silybum marianum

 Protects liver  Promotes hepatic cell growth  Supports normal liver function  Antioxidant

Milk thistle

 Hepatoprotective  antioxidant activity 1      toxin blockade at the membrane level 1 enhanced protein synthesis 1 antifibriotic activity 1 possible anti-inflammatory or immunomodulating effects 1 Stimulates action of nucleolar polymerase A causing in ribosomal protein synthesis, stimulating regenerative ability and formation of hepatocytes 2 1 Milk Thistle: Effects on Liver Disease and Cirrhosis and Clinical Adverse Effects Summary, Evidence Report/Technology Assessment: Number 21 Sept. 2000. Agency for Healthcare Research and Quality, Rockville MD 2 German commission E monographs

Milk thistle

 German Commission E Monographs report  No contraindications  No known side effects  No known interactions with other drugs

Issues around herbal preparations

    Preparations  Capsules and pills    Tinctures and extracts Infusions Teas Effectiveness Herbs in combination formulas Locally grown and wild crafting

Slide credit # 14-48 based on material prepared with Sara L. Warber, MD Suzanne Zick, ND, MPH Leslie Shimp, PharmD

Contact Information Linda Diane Feldt P.O. Box 3218 Ann Arbor MI 48106-3218 734-662-4902 [email protected]

www.holisticwisdom.org

www.moonfieldpress.com

Free Herb Class 2nd Monday of each month, sponsored by the People’s Food Co-op, at Crazy Wisdom Bookstore, Ann Arbor Other classes and workshops listed on the web site.