Herbal Remedy

Aka: Herbal Remedy, Alternative Medicine, Natural Product, Chinese Herbal Medicine, Herbal Interaction, Herbal Medicine, Herbals

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II. Epidemiology: United States

  1. Adults on Herbals and prescribed medication: 15 Million
    1. Adults alerting doctor of concurrent herbal use: 50%
  2. Americans spent $4 billion on Herbals in 1998
  3. Worldwide use: 4 billion people
  4. Most commonly used herbal products in the United States
    1. Echinacea
    2. St. John's Wort
    3. Ginkgo Biloba
    4. Garlic
    5. Saw Palmetto
    6. Ginseng
    7. Goldenseal
    8. Aloe
    9. Siberian Ginseng
    10. Valerian

III. Background

  1. Traditional medicine is basis for 80% world healthcare
  2. Most medications are synthesized from plant sources
    1. Plant Derivatives: 75% of modern medications
    2. Direct Extracts: 25% of modern medications
  3. Little efficacy data exists for Herbals
    1. Only 30-40 of 1200 herbs have evidence of benefit
    2. Prescribed medications by contrast must show benefit
  4. Modern drugs directly derived from plant sources
    1. Acetylsalicylic Acid (Aspirin) from willow bark
    2. Atropine from deadly nightshade plant
    3. Cantharidin from Blister beetle (for Wart Treatment)
    4. Colchicine from meadow saffron plant
    5. Cortisone from Mexican Discorea species
    6. Digitalis (Digoxin) from the foxglove plant
    7. Metformin from French Lilac
    8. Morphine and other Narcotics from the opium poppy
    9. Pilocarpine from the South American Jaborandi Tree
    10. Podophyllin or Podophyllum from mayapple plant
    11. Pyrethrins from chrysanthemums (for lice treatment)
    12. Quinine from yellow cinchona
    13. Reserpine from the snakeroot plant
    14. Scopolamine from Colombian Datura arborea tree
    15. Senna Laxatives from the senna plant
    16. Taxol from the yew tree
    17. Vincristine, Vinblastine from rosy periwinkle plant
    18. Yohimbine from black currant trees (Rubiaceae)

IV. Disadvantages: Related to herbal medication use

  1. No enforced labeling of efficacy
  2. No quality control regulation
    1. USP Verified Mark may be found on some products
  3. Adverse effects are not routinely labeled
    1. See below as well as specific herbal medications
    2. Some touted products (e.g. colloidal silver) have no significant benefit and carry great risk (see agyria)
    3. Serious Drug Interactions may exist
      1. St. John's Wort reduces Oral Contraceptive effectiveness
      2. American Ginseng decreases INR for patients on Warfarin
  4. No standardization of concentration and potency
    1. Many herbal preparations are mislabeled
    2. Some contain little if any active ingredient
  5. Toxin concentrations vary by part of the plant
    1. Toxins may concentrate in roots, stems, nuts and seeds
    2. Leaves tend to have lower toxin concentrations
  6. Preparations may contain contaminants
    1. Serious, permanent injury has occurred in epidemic outbreaks from contaminated products (e.g. L-Tryptophan)
    2. Pesticides
    3. Heavy Metals (often found in folk remedies)
      1. Arsenic
      2. Mercury
      3. Lead (see Lead-Containing Herbal Remedies)
      4. Cadmium
      5. Cyanide (home cooked Elderberry syrup)
    4. Prescription drugs illicitly placed in product
      1. Phenylbutazone
      2. Aminopyrine
      3. Prednisone
      4. Testosterone
      5. Diazepam
      6. Indomethacin
  7. Serious Drug Interactions may occur
    1. See Herbal Toxicity
    2. Goldenseal (high risk of interactions with multiple agents)
    3. St John's Wort (high risk of interactions with multiple agents)
    4. Ginkgo Biloba (increased bleeding risk with Warfarin)
    5. Milk Thistle (multiple interactions)
    6. Asian Ginseng (multiple interactions)
    7. Curcumin (decreases levels of many psychiatric medications)
  8. Many plants are highly poisonous (fatal at low dose)
    1. See Poisoning Causes in Children
    2. Deadly nightshade
    3. Hemlock
    4. Mistletoe
    5. Oleander (see Cardiac Glycoside Overdose)
    6. Daphne Berry
    7. Rosary Pea
    8. Jasmine
    9. Red sage
    10. Yew

V. History

  1. Do you use Alternative Medicines?
    1. Herbal Product?
    2. Herbal Supplement?
    3. Natural Remedy?
  2. What other prescribed or OTC Medications do you use?
  3. For how long have you used this herbal product?
  4. Do you have any allergies to plant products?
  5. Are you currently pregnant or Breast Feeding?

VI. Precautions: Pointers for patients purchasing herbal products

  1. Purchased products should be labeled appropriately
    1. Botanical name of herb
    2. Strength or concentration of active ingredient
    3. Batch or lot number
    4. Expiration date
    5. Name of manufacturer and contact information
  2. Avoid herbal products in pregnancy and Lactation
    1. Be particularly cautious in first trimester
    2. See adverse effects above or see specific herb
  3. Use herbal therapies with caution if Immunocompromised
    1. Herbal therapies may be contaminated with Microbes
  4. Use the lowest effective dose of a product
  5. Avoid prolonged use of any product
  6. Stop herbal therapies 2 weeks before elective surgery
  7. Avoid mixing herbal products
  8. Discuss herbal use with your physician
    1. Discuss potential Drug Interactions with physician
    2. Discuss adverse effects (see above)
    3. Reevaluate efficacy and safety on regular basis
  9. Avoid potentially sedating agents prior to driving or other activity requiring full concentration
    1. Relaxation drinks (e.g. Neuro Bliss, Just Chill, Marley's Mellow Mood)
      1. Contain Valerian Root, Kava xtract, GABA and Melatonin
      2. (2014) Presc Lett 21(1): 5
  10. Check manufacturer quality
    1. ConsumerLab.com
      1. http://www.consumerlab.com

VII. References

  1. (2015) Presc Lett 22(12): 70
  2. Asher (2017) Am Fam Physician 96(2): 101-7 [PubMed]
  3. Borins (1998) Postgrad Med 104(1):91-100 [PubMed]
  4. Cupp (1999) Am Fam Physician 59(5):1239-44 [PubMed]
  5. Dipaola (1998) N Engl J Med 339(12):785-91 [PubMed]
  6. Eliason (1997) J Am Board Fam Prac 10:265-71 [PubMed]
  7. Ernst (1998) Am J Med 104:170 [PubMed]
  8. Ko (1998) N Engl J Med 339(12):847 [PubMed]
  9. Laliberte (1996) Can Med Assoc J 154(11):1689-92 [PubMed]
  10. Litovitz (1994) Am J Emerg Med 12:46-85 [PubMed]
  11. Mar (1999) West J Med 171:168-71 [PubMed]
  12. Rand (November, 1998) Modern Medicine 66:38-9
  13. Claudius, Behar and Nordt in Herbert (2020) EM:Rap 20(9): 5-7

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