Herbal Remedies:

1
Herbal Remedies

• Facts For Advanced Practice Nurses

2
Objectives

• Explain the dramatic rise in the use of herbal
  products
• Discuss the current laws dealing with herbal
  products
• Discuss some of the most popular herbs used in
  the U.S.
• Explain how an Advanced Practice Nurse should
  deal with patients considering the use of herbs

3
Reasons For Increased Use of Herbal Products

• Disillusionment with modern medicine
• Superior because theyre natural
• Emphasis on disease prevention
• Multimillion-dollar ad campaigns
• Health conscious American public

4
The Dietary Supplement Health and Education Act
(DSHE)

• Went into effect on October 25, 1994
• Includes vitamins, minerals, amino acids and
  herbs
• FDA does not regulate quality control
• Category II or III OTC drugs
• Must prove substantial and reasonable risk to
  ban the sale of a product

5
Advertisement of Herbal Products

• Regulated by DSHE
• Effect on physiological structure and function
• Cant be labeled for treatment of a disease
• Must include disclaimer
• Names of products not regulated by FDA

6
Advanced Practice Nurses and Herbal Products

• Economic opportunities
• Lack of good scientific data
• Little emphasis in colleges of pharmacy
• Numerous CE courses available
• Research manufacturers
• Assume that patients may be taking herbal products

7
Aloe Vera

• Tropical
• Light Green Leaves that contain gel

8
Aloe Vera

• History
• 1500 BC
• Ramses the 2nd and Jesus Christ

9
Aloe Vera

• Various uses
• External use - Skin application
• Internal use - Aloe vera drinks

10
Aloe Vera

• 96 water
• The remaining constituents - Known as aloin
  made up of complex carbs, enzymes, vitamins, and
  minerals.

11
Aloe Vera

• Sold OTC
• Is available in many different preparations.

12
Aloe Vera

• Conflicting reports and data
• External vs. Internal use
• Advanced Practice Nurse involvement

13
Arnica

• Latin name is Arnica Montana
• AKA Leopards Bane
• Used for pain and inflammation

14
Arnica

• Sesquiterpene lactones
• Used externally
• Toxic internally
• Sold in lotions and creams

15
Bilberry

• Vaccinium myrtillus aka Huckleberry
• Low growing shrub
• Fruit and leaves used since 16th century

16
Bilberry

• Uses
• Vascular and blood disorders
• Visual uses
• Gastro-intestinal

17
Bilberry

• Diabetes 7-methyl delphinidin or
  other active substance.

18
Bilberry

• Many uses
• Need more proof
• Bilberry is available now in various products

19
Cats Claw (Uncaria tomentosa)

• Many different species
• Tropical vine

20
Cats Claw

• History
• South America
• Ashanica Indians

21
Cats Claw

• Immune system booster
• Antihypertensive
• Stroke and heart attack
• Cholesterol

• Crohns disease
• Gastric ulcers
• Diabetes
• Contraceptive

22
Cats Claw

• No supporting clinical studies
• Diarrhea reported

23
Dong quai (Angelica sinensis)

• Extract from Angelica sinensis
• All-purpose womens tonic herb
• No supporting clinical studies
• Discourage use

24
Dong quai

• Claims
• Menstrual cramps
• Menopausal symptoms
• Strengthens heart, liver, spleen, kidneys

25
Echinacea (Echinacea purpurea)

• Most studied and used
• Parthenium integrifolium L.
• Traditional medicine by Native Americans

26
Echinacea

• Claims
• Immunostimulant
• Wound healing

27
Echinacea

• Pharmacological effects
• Phagocytosis stimulation
• Increased cellular respiratory activity
• Increased WBC motility

28
Echinacea

• Contraindications
• Autoimmune disorders
• Immunosuppressive therapy

29
Echinacea
New evidence
30
Evening Primrose OilCommon uses

• Atopic eczema
• Mastalgia
• Diabetic neuropathy
• Rheumatiod arthritis
• Menopausal flushing

31
Evening Primrose OilPharmacologic Properties

• Linoleic acid
• Gamma-linoleic acid
• essential fatty acids
• precursors to prostaglandin
• heart protective effect

32
FeverFewCommon uses

• Headache
• Menstrual irregularities
• Stomachache
• Arthritis
• Insect bites
• Migraine headaches

33
FeverFewPharmacologic Properties

• Sesquiterpene lactones
• Inhibit prostaglandin synthesis
• Decrease platelet aggregation
• Inhibit histamine release
• Seratonin antagonist
• Parthenolide

34
GarlicCommon uses

• Antibiotic
• Antiviral
• Atherosclerosis
• Reducing Blood Pressure
• Reducing Cholesterol
• Regulating circulatory system

35
GarlicPharmacologic properties

• Allicin
• antibiotic
• antiplatelet
• antihyperlipidemic
• Ajoenes
• antithrombotic

36
Ginger rootCommon uses

• Ease congestion
• Promote perspiration
• Stimulates the circulatory system
• Blocks muscle intestinal spasms
• Provides stress relief
• Indigestion, upset stomach
• Motion morning sickness

37
GingerPharmacologic properties

• Ginerols
• Shogoals
• Inhibit enzymes that produce
• Prostaglandins
• Leukotrienes
• Clinical trials
• /-

38
Ginkgo biloba
39
Ginkgo biloba

• Background
• Ginkgo tree
• 2 lobed fan-shaped leaves
• Seeds originally used

40
Ginkgo biloba

• Active Constituents
• Ginkgolides A, B, C, J, and M
• Inhibit platelet activating factor (PAF)
• PAF causes
• Platelet aggregation
• Bronchoconstriction
• Peripheral vasodilation
• Release of inflammatory mediators

41
Ginkgo biloba

• Proposed Uses
• Alzheimers dementia
• Peripheral vascular disease
• improves perfusion
• Vertigo
• Tinnitus
• Short-term memory enhancement

42
Ginkgo biloba

• Side Effects
• Rare
• Headache
• Dizziness
• GI upset
• Standardization
• 24 flavonoids
• 6 terpenoids

43
Ginseng

• Korean ginseng
• (Panax ginseng)

44
Ginseng

• Background
• Human-shaped root
• Different types of ginseng
• Korean ginseng
• American ginseng
• Siberian ginseng

45
Ginseng

• Active Constituents
• triterpene saponins
• structure related to steroids
• no steroid effect

46
Ginseng

• Proposed Uses
• Adaptogen
• Aphrodisiac
• Improve athletic performance

47
Ginseng

• Side Effects
• Nervousness and excitation
• Decrease with continued use or decreased dose
• Hypoglycemia
• Inverse relationship between dietary intake and
  stomach cancer

48
Ginseng

• Standardization
• Wide range in quantity of ginseng between ginseng
  products

49
Hawthorne

• Derived from bright red berries grown on small
  bush
• Very common in European medicine
• Three dozen preparations marketed in
• Germany

50
HawthorneUses

• Increases blood flow to heart tissue
• relieves angina
• prevents arrhythmias
• improves heart tone
• Peripheral vasodilator
• lowers blood pressure

51
HawthorneLimitations

• Side effects at high doses
• sedation
• hypotension
• arrhythmias
• Safety and efficacy yet to be evaluated

52
Hawthorne

• Appropriate Use
• in healthy patients seeking a lifestyle
  supplemented with herbal therapies

• Inappropriate Use
• in patients with severe cardiovascular disease

53
Horse Chestnut

• Aesculus hippocastanum
• Derived from the dried seed extract
• Related to American horse-chestnut and Ohio
  buckeye

54
Horse ChestnutUses

• Increases overall venous tone
• in turn improves return blood flow to heart
• reduces edema caused by venous insufficiency
• studies compared to compression stockings
• Anti-inflammatory properties
• treat phlebitis, varicosity, and hemorrhoids

55
Horse ChestnutLimitations

• Relatively safe in recommended doses
• Isolated cases of renal and hepatotoxicity

56
Horse Chestnut

• Appropriate Use
• in healthy patients
• mild edema

• Inappropriate Use
• in patients with severe edema

57
Kava-kava

• Member of the pepper family
• Grows as a bush in the South Pacific
• Derived from the extracts of the rhizomes

58
Kava-kavaUses

• Anxiolytic
• clinical studies showed reduction from 25.3 to
  12.6 on the Hamilton Anxiety Scale
• Anesthetic
• Anti-inflammatory
• Antispasmodic

59
Kava-kavaLimitations

• Mildly narcotic
• euphoric changes such as elevated mood
• Side effects at high doses
• muscle weakness, visual impairment, dizziness,
  dry skin
• Long term use
• hypertension, reduced protein levels, liver
  damage, blood cell abnormalities

60
Kava-kava

• Appropriate Use
• in healthy patients
• mild anxiety

• Inappropriate Use
• contraindicated for endogenous depression
• sever anxiety
• alcohol consumption

61
Milk Thistle (Silybum marianum)

• Tonic for liver function
• regenerates liver tissue
• protects liver cells

62
Milk Thistle

• Silybin
• Hepatoprotectant
• Classified as flavonolignans

63
Milk Thistle

• Treatment of cirrhosis and hepatitis
• Increased survival of cirrhosis
• APAP and mushroom poisoning

64
Milk Thistle

• Adverse reactions
• Laxative effect

65
St. Johns Wort (Hypericum perforatum)

• Versus SSRIs and placebo
• Components
• Hypericin-MAO inhibitor
• Other components

66
St. Johns Wort

• Uses
• Depression
• Anxiety
• Inflammation
• AIDS

67
St. Johns Wort

• RPh shouldnt recommend dietary supplements for
  treatment of depression or AIDS

68
St. Johns Wort

• Drug Interactions
• Potentiate MAO inhibitors
• MAO inhibitor-like reactions
• tyramine-containing foods
• dextromethorphan
• SSRIs
• sympathomimetics
• TCAs

69
St. Johns Wort

• Adverse Reactions
• Phototoxicity

70
Saw palmetto (Serenoa repens, Serenoa serrulata)

• American dwarf palm
• Native to southern U.S. Atlantic coast
• Officially used for many ailments before WWII
• French extract Permixon used

71
Saw palmettoUses

• Anti-androgenic, anti-inflammatory, and
  anti-estrogenic activity
• Benefits shown in the treatment of BPH
• Has yet to undergo FDA safety and efficacy testing

72
Saw palmettoStudies

• Proposed mechanisms of action
• inhibition of 5-alpha-reductase
• inhibition of androgen-receptor binding
• Results of study versus finasteride
• greater reduction in IPS score
• greater increase in urinary peak flow

73
Saw palmettoLimitations

• Studies criticized for lack of placebo
• Little or no bioequivalence data among products
  available
• Limited toxicity data
• SEs headache, nausea, and abdominal pain

74
Saw palmettoOverview

• Inexpensive
• Decreased side effects compared to other drugs
• No effect on PSA level
• Look for fatty acid or lipophilic extract
• Maintain regular physician visits

75
Valerian (Valeriana officinalis)

• Commonly used sedative in Europe
• Alternative to anxiolytic medications
• Previously used to relieve menstrual and stomach
  cramps

76
Valerian

• Popular herb all over the world
• Major ingredient valerian acid
• Available as tea, tincture, or capsule
• Effects seen within one hour of administration
• Hangover not associated with use

77
ValerianStudies

• Used in patients suffering from sleep dysfunction
• Results of study using extract
• improved sleep quality
• decreased sleep latency
• Most benefit seen in smokers and poor sleepers

78
ValerianLimitations

• Evidence subjective
• SEs headache, excitability, and insomnia
• Tea and tincture have foul odor
• Depression possible after prolonged use

79
ValerianOverview

• FDA generally regards as safe
• Kava-kava and St. Johns Wort effective
  alternatives without the odor
• May be most beneficial in smokers and poor
  sleepers

80
Requirements for Dietary Supplement Labels

• Statement of identity (ex. Ginko biloba)
• Net quantity of contents (ex. 50 capsules)
• Directions for use (ex. 1 cap tid)
• Constituent panel (ex. serving size, amt.,
  active ingredient)
• Other ingredients (in descending order)
• Name, place, address of manufacturer
• Structure-function claim and statement

81
Advice for the Patients on the Use of Herbal
Products

• Fraudulent Products/Claims
• Quality Products
• Caution With Use
• RPhs Role in Patient Care

82
Fraudulent Products

• Avoid break through, miracle cure, etc
• Careful with detoxify, purify, energize
• Claims for wide ranges of diseases
• Backed by scientific studies
• Benefits WITHOUT side effects
• Notions about the medical community hiding
  information

83
Quality Products

• Consider the manufacturer
• Single agent products
• Part of the plant used (ex. Saw Palmetto berries
  vs. the roots)
• Stick with the same product

84
Caution ! ! !

• Do Not Use if
• Pregnant or Breast Feeding
• Chronically Ill
• Elderly
• Under 18 y.o.
• Taking Rx and OTC Medications
• Discontinue STAT if Adverse Reaction!

85
Advanced Practice Nurses Role

• Recognize a potential benefit
• Do not criticize
• Encourage to inform health care providers about
  product use
• Inquire about successful outcomes
• FDA Med-Watch Reporting

86
Conclusions

• Herbals Drugs ????
• Regulation and GMP
• RPh Recommendations
• Be There For The Patient