aigul baigazieva common herbs and supplements

8/13/2019 Aigul Baigazieva Common Herbs and Supplements

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COMMON HERBS AND

SUPPLEMENTS:A REVIEW OF SAFETY AND EFFICACY

Marina Shkayeva, PharmD

Natural Standard, PGY-1 Pharmacy Resident


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Natural Standard: Webinar Disclaimer

This webinar is intended for informational purposes only, and should not beinterpreted as specific medical advice. A qualified healthcare providershould be consulted before making decisions about therapies and/or healthconditions.

While some complementary and alternative techniques have been studiedscientifically, high quality data regarding safety, effectiveness, andmechanism of action are limited or controversial for most therapies.

Whenever possible, it is recommended that practitioners be licensed byrecognized professional organizations that adhere to clearly publishedstandards. In addition, before starting a new technique or engaging a

practitioner, it is recommended that patients speak with their primaryhealthcare providers.

Potential benefits, risks (including financial costs), and alternatives should becarefully considered. The following webinar is designed to providehistorical background and an overview of clinically oriented research, andneither advocates for or against the use of a particular therapy.


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Natural Standard evidence-based validated grading rationale


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Aa

An antioxidant berry from tropical Central and

South America

Reddish-purple fruit, tastes like a blend of berry

and chocolate

Variety of aa products are available: Juices, powders, tablets, and capsules


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Natural Standard: Dosing Disclaimer

The following doses are based on scientific research,publications, traditional use, or expert opinion.Many herbs and supplements have not been

thoroughly tested, and safety and effectiveness maynot be proven. Brands may be made differently,with variable ingredients, even within the same

brand. The below doses may not apply to allproducts. You should read product labels, anddiscuss doses with a qualified healthcare provider

before starting therapy.


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Aa

Evidence grade B:

Antioxidant

Evidence grade C:

Metabolic syndrome

Suggested:

1 oz. of powder mixedwith 10-12 oz. of

water once or twice

daily

Freeze-dried aa incapsules or tablets at

1-2g daily

INDICATIONS DOSE


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Natural Standard: Safety Disclaimer

The U.S. Food and Drug Administration does notstrictly regulate herbs and supplements. There is noguarantee of strength, purity or safety of products,

and effects may vary. You should always readproduct labels. If you have a medical condition, orare taking other drugs, herbs, or supplements, youshould speak with a qualified healthcare provider

before starting a new therapy. Consult a healthcareprovider immediately if you experience sideeffects.


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Natural Standard: Interactions Disclaimer

Most herbs and supplements have not beenthoroughly tested for interactions with other herbs,supplements, drugs, or foods. The interactionslisted below are based on reports in scientific

publications, laboratory experiments, or traditionaluse. You should always read product labels. If youhave a medical condition, or are taking other drugs,herbs, or supplements, you should speak with aqualified healthcare provider before starting a newtherapy.


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Aa

Likely safe in food

amounts

May reduce blood sugarlevels, caution with

diabetic agents

May block the effects ofimmunosuppressantagents

May increase potassiumlevels

ADVERSE EFFECTS INTERACTIONS


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Coenzyme Q10

CoQ10, ubiquinone Endogenously produced, fat-soluble

A co-factor in oxidative respiration for the Krebs cycle andthe electron transport chain

Levels decrease with age & in patients with: Cardiovascular disease, muscular dystrophy, Parkinson's

disease, cancer, diabetes, human immunodeficiency virus(HIV)

Standard therapy for congestive heart failure in Europe,Russia and Japan


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Coenzyme Q10

Evidence grade A CoQ10 deficiency

Evidence grade B Hypertension

Evidence grade C Alzheimer's disease

Cancer

Chronic fatigue syndrome

Migraine

50-1,200mg of CoQ10

daily

INDICATIONS DOSE


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Coenzyme Q10

Mild, brief, and self-resolving:

Nausea/vomiting/diarrhea(N/V/D), stomach upset,heartburn, appetite loss

Pruritis, rash

Insomnia, headache,dizziness, irritability,fatigue

Flu-like symptoms

May reduce warfarinseffectiveness

May deplete CoQ10 levels: Diabetes drugs

Tricyclic antidepressants

Antipsychotics

Statins

Alzheimer's drugs Anticancer drugs

Immune system-alteringdrugs

Diuretics, beta-blockers



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Omega-3 Fatty Acids (Fish Oil)

Inuit people of Greenland have low occurrence of heartdisease Diet high in fat and rich in omega-3 fatty acids

Essential fatty acids in diet are omega-3 and omega-6 fattyacids Omega-3 and Omega-6 compete for same receptors

Omega-3: decreases inflammation

Omega-6: promotes inflammation

Optimal ratio of omega-6:omega-3 fatty acids is 4:1 American diet 20:1 up to 30:1


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Alpha-linolenic acid (ALA) Green vegetables, canola oil,

nuts, soybeans


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Evidence grade A

Coronary heart diseaseHyperlipidemia

Hypertension

Rheumatoid arthritis

Secondarycardiovascular disease

prevention

Americans consume 1.6g ofomega-3 fatty acids daily

~90% from ALA, and ~10% from EPA and DHA

Clinical trials:

1g capsules of omega-3 fattyacids

GRAS: 3g of omega-3 fatty acids

from fish daily

INDICATIONS DOSAGE


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N/V/D, decreasedappetite, constipation,

steatorrhea, fish burp Rare:

Mild elevations in liverfunction tests

Mania in patients with

bipolar disorder or majordepression.

Restlessness andformication

May increase bleeding

with:Aspirin

Anticoagulants

Anti-platelet drugs

Non-steroidal anti-inflammatory drugs(NSAIDs)



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Red Yeast Rice

Red yeast rice (RYR) is the product of yeast (Monascus

purpureus) grown on rice, popular in Asian countries

Sold over the counter as Cholestin (Pharmanex, Inc.)

Contains monacolins, which inhibit cholesterolsynthesis

Monacolin K, has the same chemical structure as the drugs

lovastatin and mevinolin

RYR may lead to a 10-33% reduction in low-density

lipoprotein (LDL) levels


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RYR: A Federal Case

1998: Cholestin (Pharmanex, Inc.)taken off the

market due to monacolin K or lovastatin content,

an active ingredient of Mevacor (Merck & Co.)

Now: Cholestin can be purchased in the United

States from Pharmanex or specific dealers

Pharmanex claim:Cholestin contains 12 natural

substances acting together to "support healthycholesterol levels."


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Red Yeast Rice

Evidence grade A:

Hyperlipidemia

Evidence grade C:

Coronary heart disease

Diabetes

1,200mg of RYR

capsules two timesdaily

INDICATIONS DOSAGE


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Red Yeast Rice

Limited evidence on theside effects of red yeast

Like lovastatin: Heartburn, gas, bloating

Muscle pain or damage

Dizziness, asthma, andkidney problems

Avoid in people with liverdisease

Additive effects with

drugs that increasebleeding

Like lovastatin:Alcohol and other drugs

toxic to the liver should

be avoided



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Garlic

A culinary herb used for cardiovascular disease and

cancer

Use of garlic might date back to ancient Greek

medicine and traditional Chinese healers

Has a sulfur compound alliin, which makes allicinwhen the bulb is crushed or ground


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Garlic

Evidence grade A

HyperlipidemiaHypertension

Evidence grade BCardiovascular disease

risk

World Health

Organization (WHO)recommends daily:

2-5g fresh garlic (2-5mg of allicin)

2-5mg oil 300-1,000 mg of

extract

INDICATIONS DOSAGE


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Garlic

Allergies:Liliaceae family Hyacinth, tulip, onion, leek,

and chives

Common:Bad breath, bodyodor

Rare: Dizziness, anorexia,

N/V/D, belching, heartburn,constipation, flushing,tachycardia, insomnia,headache, fever, chills

Serious:Bleeding

Increased bleeding risk

with:Aspirin

Anticoagulants

Anti-platelet drugs

NSAIDs



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Ginseng

Species of the genusPanax of the Araliaceae family

Most common are American and Asian ginseng

Ginsenosides are the active components of ginseng Quantity depends on species and growth conditions

In traditional Chinese medicine used for:

Increasing appetite, blood volume, strength Enhancing physical performance and memory

Reducing fatigue and stress


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Ginseng

Evidence grade B

Hyperglycemia Immune system

enhancement

Mental performance

100-200mg daily

German pharmacopeia(DAB 10):

1-2g of dried ginseng

root or 20-30mg

ginsenosides

INDICATIONS DOSAGE


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Ginkgo

Ginkgo bilobahas been used for thousands of yearsand is a top selling herb in the United States

Traditional Chinese Medicine (TCM): Pulmonary diseases, circulatory disorders, memory

loss, and skin lesions

Europe and the United States:Dementia, memory enhancement, and claudication

Not GRAS


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Ginkgo

Evidence grade A

Claudication(peripheral vascular

disease)

Dementia

80-240mg of a 50:1standardized leaf extract

daily

30-40mg of extractprepared as a tea

Effects may take 4-6weeks to appear

INDICATIONS DOSE


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Ginkgo

Cross-sensitivity withurushiols

Mango rind, poison sumac,poison ivy, poison oak,cashews

Well tolerated at suggesteddoses up to six months

Headache, nausea, intestinal

complaints, bleeding May be unsafe in children

May increase the risk ofstroke

May increase bleedingrisk with:

Aspirin

Anticoagulants

Anti-platelet drugs

NSAIDs

May affect insulin andblood sugar levels



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Echinacea

Echinaceaspecies are of the Asteraceae family andoriginated from North America

In Europe and the United States for upperrespiratory tract infections (URIs)

~10% of the dietary supplement market

Many positive trials published before 2001

Limited quality or combination products


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Echinacea

Evidence grade B URI treatment (adults)

Evidence grade C Cancer

Genital herpes

Immune systemstimulation

URI prevention

URI treatment (children)

URI or common cold: 500-1,000mg three times

daily

Tea: two teaspoons (4g)of herb in one cup of

water daily

Taken for up to a week

INDICATIONS DOSAGE


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Echinacea

Cross-sensitivity to theAsteraceae family

Including ragweed,chrysanthemum,marigold, and daisy

Well tolerated and fewadverse effects

GI effects and rashes

Mildly interact with

cytochrome P450enzymes



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Question

Which of the following herbs increase the risk of

bleeding?

A. Coenzyme Q10

B. Red yeast rice C. Garlic

D. Ginseng

E. Ginkgo

F. Echinacea


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Question

Which of the following herbs increase the risk of

bleeding?

A. Coenzyme Q10

B. Red yeast rice

C. Garlic

D. Ginseng

E. Ginkgo F. Echinacea


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Summary

SUPPLEMENT INDICATION ADVERSE

REACTION

Acai Anti-oxidant Generally safe

Coenzyme Q10 Deficiency, HTN Mild GI

Omega-3 fatty acids Elevated triglycerides Mild GI, fish burp

Red yeast rice Hyperlipidemia GI, muscle pain

Garlic Hyperlipidemia, HTN Bad odor, bleeding

Ginseng Mental performance,immune stimulation Insomnia, bleeding

Ginkgo Dementia Bleeding,

hypoglycemia

Echinacea Immune stimulation Allergic reactions


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Black Cohosh

Alternative to hormonal therapy for menopause:

Hot flashes, mood disturbances, sweating, palpitations,vaginal dryness

Controlled trials and case series:

Improved menopausal symptoms for up to six months

Lacking safety and efficacy data after six months

Controversy:is there an effect on estrogenreceptors?


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Black Cohosh

Evidence grade C:

Arthritis painBreast cancer

Infertility

Menopausal symptoms

Migraine (menstrual)

Traditional doses

1-2g three times a day

Studies, menopausalsymptoms

20-40mg Remifemintablets twice a day for12 weeks

INDICATIONS DOSAGE


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Black Cohosh

Not GRAS

High doses:

Frontal headache, dizziness,visual disturbances

Rare:

GI effects, bone mass loss,irregular heartbeat, low blood

pressure, muscle damage

Unclear if safe in hormone-sensitive conditions

Estrogen-like effect isdebated

May interact with Tamoxifen

Raloxifine

Caution with otherhypotensive agents, foradditive effects



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Blue Cohosh (Do Not Confuse)

Traditionally: To stimulate and ease labor

Theory: Pelvic inflammatory

disease, endometriosis,erratic menstruation

I n vitroand in vivo: Increased uterine

contractions

Sufficient data is lacking

Overdose: Nausea, vomiting,

headache, thirst, dilatedpupils, muscle weakness,tachycardia, cardiovascularcollapse, and convulsions

Cases of neonatal

myocardial toxicity andnewborn myocardialinfarction

Sufficient data is lacking

INDICATIONS SAFETY


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DHEA (Dehydroepiandrosterone)

An endogenous hormone from the adrenal gland

Precursor to androgens and estrogens

DHEA levels in the body begin to decrease afterage 30, and reported to be low in people with:

Anorexia, end-stage kidney disease, type 2 diabetes,AIDS, adrenal insufficiency, and in the critically ill

DHEA levels may be depleted by drugs


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DHEA

Evidence grade B: Adrenal insufficiency

Depression Obesity

Systemic lupuserythematosus

Evidence grade D: Memory

Muscle strength

Common

25-200mg daily up toone year

Depression in

HIV/AIDS

200-500mg daily

INDICATIONS DOSAGE


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Kava

Kava beverages, from roots of the shrubPipermethysticum

Traditionally used in the South Pacific

Pleasant mild psychoactive effects, similar to alcoholicbeverages

Preliminary evidence:

Efficacy may be equivalent to benzodiazepines

Was used as an anxiolytic in Europe and USA


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Kava

Evidence grade A:

Anxiety

Evidence grade C:

Insomnia Parkinson's disease

Start low and increaseover time

50-280mg kava lactonesat bedtime

60-120mg ofkavapyrones daily

High dose in studies 800mg daily of kava

extract (short term)

INDICATIONS DOSAGE


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Kava

Not GRAS anymore Cases of liver toxicity

and liver failure May cause kidney

damage

Natural medicineexperts: Kava is safe at

recommended doses

No clear conclusion

Acetaminophen

Additive sedation with

alcohol Worsen side effects of drugs

blocking dopamine (e.g.Haldol)

Additive with monoamineoxidase inhibitors

Prolong effects of anesthesia

Stop kava 2-3 weeks beforesurgery

ADVERSE EFFECTS INTERACTIONS (Theoretical)


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Valerian

Valeriana officinalis: Valium of the 19th Century" Restlessness, insomnia, hypnotic, sedative, antispasmodic

MOA:increase synaptasomal gamma-aminobutyric

acid (GABA) concentrations

May contain up to 150 compounds, not all of whichhave been investigated

Known compounds: valepotriates, volatile oils, kessanes,valerenal, valeranone, and valerenic acid

Bad smell: isovaleric acid

Cat attractant: actinidine


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Valerian

Evidence grade C:

AnxietyDepression

Insomnia

Menopausal symptoms

Sedation

Studies:

400-900mg of extractat bedtime

300-1,800mg capsule

Historically as tea

1.5-3g root

INDICATIONS DOSAGE


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Saw Palmetto

Traditionally used by Native Americans

Serenoa repensused in Europe and USA for benignprostatic hypertrophy (BPH)

Many studies:superior to placebo for BPH symptoms

However: Trials were short(1-6 months) and had small sample sizes

Did not use standardized outcomes measurements


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Saw Palmetto

Evidence grade A: Benign prostatic

hypertrophy

Evidence grade C Androgenetic alopecia

Hypotonic neurogenic

bladder Prostate cancer

Prostatitis

BPH studies:

320mg daily

Reports:

160mg daily may be

as effective as 160mg

twice a day

INDICATIONS DOSAGE


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Saw Palmetto

Common:

Gastrointestinaleffects, bad breath,

constipation

Increases bleeding risk with:

Aspirin

Anticoagulants Anti-platelet drugs

NSAIDs

Should not be taken withdrugs that affect androgenlevels:

Finasteride (Proscar)

Flutamide (Eulexin)



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Peppermint

Mentha x piperitais a hybrid of spearmint and watermint

Products: peppermint oil, menthol

GRAS in food amounts

MOA: reduces gastrointestinal smooth muscle motility,perhaps by calcium channel antagonism

Food and pharmaceutical industries use for coolingproperty, scent, and flavor


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Peppermint

Evidence grade A Irritable bowel

syndrome (IBS)

Evidence grade B Antispasmodic

Breast tenderness Dyspepsia

Headache (topical)

Recommend not usingpeppermint oil topically morethan 3-4 times daily

Intestinal/digestion disorders:

0.2-0.4mL of peppermint oilin enteric-coated capsules orliquid preparations TID

For sore throat

2-10mg of peppermint oil in alozenge

INDICATIONS DOSAGE


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Peppermint

Topically: allergic reactions,mouth ulcers, chemical burn

Orally: dizziness, heartburn,slow heart rate, dental caries,gingivitis, or muscle tremor

Use cautiously in hiatalhernia, achlorhydria,gastroesophageal refluxdisease

May moderately inhibit CYP1A2, 2E, and 3A4

May cause synergistic effectswith anti-hypertensives andanti-hyperglycemics

Menthol may enhanceabsorption of steroids,salicylates



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St. Johns Wort

Extracts ofHypericum perforatumis not on GRASlist

Treatment of mild-moderate major depression:More effective than placebo and equally effective as

tricyclic antidepressant drugs for 1-3 months

Controversy about the trials, problems in design

Serious interactions with prescription drugs, herbs,and supplements


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St. Johns Wort

Evidence grade A Depression

Evidence grade B Somatoform disorders

Evidence grade D Depressive disorder

Human immunodeficiencyvirus (HIV)

Trials:

0.17-2.7mg ofhypericin daily

150-1,800mg of St.

John's wort extractdaily

INDICATIONS DOSAGE


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St. Johns Wort

Well tolerated atrecommended doses for up to1-3 months

Common (1-3%):

GI upset, fatigue, sedation,anxiety, sexual dysfunction,dizziness, headache, dry

mouth

May cause suicidal andhomicidal thoughts

CYP 450 inducer

Studies had smallpopulations, bias, variableduration and dose

Carbamazepine,cyclosporine, midazolam,simvastatin, warfarin

FDA: patients on medicationsfor HIV should not take St.John's wort

Antidepressants: serotoninsyndrome and mania



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Summary

SUPPLEMENT INDICATION ADVERSE EFFECTS

Black cohosh Menopausal symptoms GI effects, bradycardia,

hypotension

**Blue cohosh Stimulate labor Toxic to mother &

fetusDHEA Adrenal insufficiency Fatigue, tachycardia

Kava Anxiety Liver toxicity

Valerian Anxiety, insomnia Sedation

Saw palmetto BPH BleedingPeppermint Irritable bowel

syndrome

Dyspepsia, topical

irritation

St. Johns Wort Depression GI effects, anxiety


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Conclusions

Many herbs and supplements lack quality studies

Supplements/herbs are generally well tolerated in

recommended doses with no contraindications

Be aware of interactions and safety information

that is available

f


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References

Information is based on a systematic review of scientific literatureedited and peer-reviewed by contributors to the Natural StandardResearch Collaboration (www.naturalstandard.com)

Dietary Supplements. Food and Drug Administration. October 14,

2012.

Kimpel , Paul. The Cholestin Case: Drug vs. Supplements. InteractiveMedia Lab at University of Florida. October 12, 2012.

aigul baigazieva common herbs and supplements

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