he Permanente Journal Fall 2002 Volume 6 No 4 - PDF document

1 he Permanente Journal/ Fall 2002/ Volume
he Permanente Journal/ Fall 2002/ Volume 6 No. 4 he Herbal Medicine Pharmacy UpdateBy Philip J Tuso, MD, FACP Introductioncine in the United States and amongof Kaiser Permanente(KP) makes an updated review ofthis topic timely and important.Many pharmacies at KP facilities inSouthern California now carry tra-Òdietary supplementsÓ are Philip J Tuso, MD, FACP, has been with the Southern California Medical Group since 1993.In 2001, he was appointed Physician Director for the Kaiser Permanente Fresenius MedicalCare Unit in Lancaster, California. E-mail: philip.j.tuso@kp.org. percent ofcaregiversalternativeimprove thepatientÕs e Permanente Journal/ Fall 2002/ Volume 6 No. 4 he Herbal Medicine Pharmacy Updateare to provide treatment that makespatients from treatment that maycause harm. Inaddition, we do notUnited States are not approved by the(FDA) as drugs used to help treat dis-eases, these products do not undergopremarketing safety and efficacy stud-ies and are not manufactured in a stan-dard way. Herbal medicines are de-Education Act of 1994 as dietaryand they are presumedsafe until new information shows oth-herbal medicine can make structureand function claims without supportof scientific research, although theclaims must be truthful and not mis-ented, no incentive exists for pharma-prove that an herb was harmful be-fore taking it off the market; however,the FDA has no authority to test herbs.a quality control perspective,e concerned about reportedtions are contaminated with pesti-microorgan-This is just one of the reasons thatefficacy of any therapy is the ran-domized clinical trial (RCT). SinceThe Permanente Journallished a review of herbal medicine,more RCTs and meta-analyses ofRCTs on herbal medicine have beenpublished. We used these data tohelp determine whetheror not selected catego-ries of herbal medicinethe results of RCTs,meta-analyses of RCTs,riety of herbal medi-Ernst and Pittler articletitled cine that passes the evi-RCTs show that someherbs may be efficacious for treatingsymptoms of certain diseases, suchas ginkgo for dementiaand inter-extract for chronic venous insuffi-ever, before starting these forms oftheir physicians should review theconsumer report on the herb postedon the Internet at consumerlab.comand other resources for information.Journal of the Ameri-can Medical Associationefficacy for treatment of moderatelyable 2 lists herbal medicine formsthat are not supported by RCTs, sys-RCTs as efficacious treatment forcertain diseases. These medicationsshould not be part of our treatmentable 3 lists types of herbal medi-cine that may be harmful as de-scribed in RCTs, meta-analyses ofRCTs, and case reports. These herbsshould not be used or should beused only with extreme caution. Forinstance, licorice has mineralocor-ticoid properties and has been re-some patients.should not be used by patientswith liver disease or who areOther herbal med

2 icine forms,such as ginger, ginseng, fev
icine forms,such as ginger, ginseng, fever-few, devilÕs claw, and donqquai, can interact with warfarinsodium and may affect plate-mes. This type of herbal medica-tion should not be taken by patientscation such as aspirin, warfarin so-dium, or nonsteroidal anti-inflam-to receive any procedure that maycause bleeding should be asked ifshould be instructed to stop taking Table 1. Herbal medicine forms that have studies supporting HerbCondition treatedReference (Ginkgo biloba)Dementia20 Intermittent claudication21 Horse chestnut seed extractChronic venous insufficiency22 nxiety23 St JohnÕs wortHypericum perforatumDepression24 HerbCondition treatedReference Asian ginseng (Panax ginsengperformance27 Evening primrose(Oenothera biennis)Premenstrual syndrome Prevent migraine29 Garlic (Allium sativumlevels31 Tinnitus32 Insomnia33 these productspremarketingefficacy studiesand are notmanufactured ina standard way. he Permanente Journal/ Fall 2002/ Volume 6 No. 4 clinical contributions he Herbal Medicine Pharmacy Updateties for two weeks beforeOther recent reports indi-result in lower cyclosporin levels,findings are explained in more de-For a more complete list of herbsthat may have serious adverse effects,please refer to the complete Germanglish translation) published in 1998.Chinese Herbs Nephropathyfibrosing interstitial nephritis withoutprogresses rapidly to end-stage re-tient requires dialysis and a renalSt JohnÕs Wort and AcuteOrgan Transplant Rejectionperforatum),an herb extract, is anover-the-counter remedy for treatingplant recipient who self-prescribedwhich resulted in marked re-has been described in heart,recipients. Transplant rejectionepisodes did not recur whenResourcesConsumerLab.com, LLCprovides independent test re-to help consumers andhealth care providers trition products.as well as by consumers, althoughthe Web site may not be free andmay require subscription for someusers. For example, a search of theConsumerLab.com Web site in prepa-ration for this article yielded a reportwhich showed that ofamounts of ginsenocide (active ingre-Physicians need to be aware ofmedicine and are encouraged toreview the information on herbalproducts before recommendingany herbal medTo keep the FDA apprised of thereal risks of using herbs, physicianscan report adverse effects of any herbalmedicine to FDA MedWatch on theInternet at www.fda.gov/medwatch.forms of herbal medication that havetreat certain disease conditions,of benefit, and some herbs that areknown to cause harm. Most of theseconditions can also be treated withAs a result of the Dietary Supple-ment Health and Education Act ofmanufacturing of herbal ex-tracts is not submitted to the typeof quality control used for manu-nor is premarketing safety and effi-cacy research required. Not allherbal preparations are safe, not allparticular levels of the active ingre-tain contaminants such as pesticideseffects from

3 herbal medication andof drug-herb inter
herbal medication andof drug-herb interaction, physiciansthe use of over-the-counter medica-tion in all patients. Herbs should notbe used by pregnant women and maybe harmful to high-risk groups, par-ticularly the elderly. Herbal medica-e severe adverse effects, Table 3. Herbal medicine forms that may harm patients Adverse effectHerb Renal failureChinese herbs ( Transplant rejectionSt JohnÕs wort (Hypericum perforatum) Heart failureAconite ( HypertensionEphedra sp Hypertension andhypokalemiaLicorice (Glycyrrhiza glabra) HyperthyroidismKelp ( HepatitisComfrey (Symphytum officinale),Chaparral (Larrea tridentata),Celandine (Chelidonium majus) Tanacetum parthenium), Harpagophytum procumbens), SeizuresEvening primrose oil ( (www.consumerlab.com)provides independenttest results to helpcare providers evaluatenutrition products. e Permanente Journal/ Fall 2002/ Volume 6 No. 4 he Herbal Medicine Pharmacy Updatetion. The use of most herbal medi-cine is not evidence-based, and theand one good informationresource is on the Internet atAs healthcare providers, we should be lead-are encouraged to report adverseFDA MedWatch on the Internet atconsidered in order to require thatsame stringent premarketing scrutinyPharmacist should be aware of herb-drug interaction, and our pharmacyand clinical information systemsinformation about herbal medicineand interaction profile screening. References1.Eddy D. Embedding PermanenteClinical Content Network, Evidence-based Medicine, March 2001.national/ikmr/nccn/powerpoint/2.Eddy DM. Clinical policies and thequality of clinical practice. N Engl JMed 1982 Aug 5;307(6):343-7.3.Eddy DM. Clinical decision making:from theory to practice. Anatomy ofa decision. JAMA 1990 Jan4.Eddy DM. Clinical decision making:from theory to practice: a collectionof essays from JAMA. Boston: Jones5.Eisenberg DM, David RB, Ettner SL,et al. Trends in alternative medicineresults of a follow-up nationalsurvey. JAMA 1998 Nov6.Eisenberg DM. Advising patientsho seek alternative medicaltherapies. Ann Intern Med 1997 Jul7.Delbanco T. A piece of my mind.Leeches, spiders, and astrology:predilections and predictions. JAMA1998 Nov 11;280(18):1560-2.8.Brevoort P. The booming USbotanical market: a new overview.HerbalGram 1998;48:33-40.9.Foster DF, Phillips RS, Hamel MB,Eisenberg DM. Alternative medicineuse in older Americans. J Am GeriatrColeman LM, Fowler LL, WilliamsME. Use of unproven therapies bypeople with AlzheimerÕs disease.J Am Geriatr Soc 199511.Kaboli PJ, Doebbeling BN, Saag KG,tary and alternative medicine bypopulation-based study. ArthritisRheum 2001 Aug;45(4):398-403.12.Ernst E. Harmless herbs? A review ofthe recent literature. Am J Med 199813.Gurwitz JH, Avorn J. The ambiguousrelation between aging and adversedrug reactions. Ann Intern Med 199114.United States. Food and DrugAdministration. Dietary SupplementHealth and Education Act of 1994,Public Law No. 1

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