Integrating Herbs and Botanicals Into Patient Care Pharmacists are well positioned to help consumers use herbal products wisely and to safely integrate these treatments into their standard medical care.
In a 1993 study published by the New England Journal of Medicine, 34% of Americans surveyed acknowledged using some form of complementary or alternative medicine (CAM). Since then, the use of CAM has grown, with a more recent poll showing that 59% of Americans had used herbal supplements. This symposium explored herbal and botanical remedies, focusing on the ways in which phannacists can help patients responsibly integrate these products into health care regimens.
under the Good Manufacturing Processes Certification Program have met these requirements.
Adverse Reactions to Herbal Medicines
Mary Hardy, MD, and June McDermott, MSPhann, MBA, FASHP, jointly presented this session, which began with a discussion of common misperceptions about phytomedicines. The speakers first addressed the myth that the therapeutic effects of these agents have not been investigated or documented. They pointed out that there have been many studies on their safety and efficacy, although most have appeared in the European medical literature. Another common misperception is that these agents are unsafe because their manufacturing practices vary and they lack standardization. Under current law, herbs and botanicals are considered dietary supplements and are not subject to the regulations governing prescription drugs. However, the Dietary Supplement Health and Education Act of 1994 does include standards for good manufacturing practices and, in recent years, responsible manufacturers have taken important steps to test product purity and monitor batch-to-batch consistency. Consumers therefore have some assurance that companies certified
Where manufacturers have not met these standards, consumers must exercise caution. Mislabeling, in which a substituted ingredient such as atropine is included in the formulation but not on the label, has been reported. Lead and other heavy metals, as well as bacterial contamination, have been found in certain preparations. Chinese medicine has on occasion been intentionally adulterated with such substances as steroids, indomethacin, phenylbutazone, and diazepam. As with other medications, adverse reactions also can occur with phytomedicines. Allergic reactions are possible, and may occur, for example, with feverfew and members of the daisy ·family. Drug interactions are also a significant concern. As with other pharmacologically active agents, phytomedicines can: • Decrease the absorption of other pharmaceuticals • Duplicate the action of other medications (for example, gingko and garlic are natural anticoagulants that can enhance the effect of warfarin) • Alter the metabolism of coadministered medications (for example, Saint John's wort increases cytochrome P-450 activity and can thus increase metabo1ism of cyclosporine, oral contraceptives, protease inhibitors, and many other drugs)
Based on presentations by Mary Hardy, MD, medical director, Cedars-Sinai Integrative Medicine Medical Group, Cedars-Sinai Hospital, and associate clinical professor of medicine, University of Southern California, Los Angeles; and June McDermott, MSPharm, MBA, FASHP, clinical assistant professor, University of North Carolina School of Pharmacy, Chapel Hill.
Although safety data are limited, some herbs should be avoided or used with caution during pregnancy (see Table 1). For example, black cohosh can cause uterine contractions. Many herbal constituents also are excreted in breast milk and thus may be transmitted from mother to baby during lactation. Pharmacists are in a unique position to question patients
Supplement to the Journal of the American Phannaceutical Association
Vol. 40, No.5, SuppJ. 1
Integrating Herbs and Botanicals Into Patient Care
Table 1. Common Herbs to Avoid During
Pregnancy Alo e Black cohosh Buckthorn Ca scara sagrada Ch amomile, Roman Ch aste tree berry Do ng quai Feverfew Gol denseal Gotu kola Guggul Horehound Horseradish (fresh) Kava kava Licorice Ma huang Pen nyroyal Ru e Sa ge Sen na St. John's wort Stinging nettle Tan sy W ormwood Ya rrow
U se With Caution *" G arlic Gi nger Tu meric
* A void excessive consumption relative to usual and
• Treatment for a medical condition that seems questionable • Use of phytomedicines as a substitute for necessary medical care Pharmacists can encourage patients to approach herbs and botanicals as "integrative medicine"-that is, to use herbal medicines in conjunction with therapies prescribed by a physician, rather than in place of those treatments. Pharmacists can also help to ensure that reliance on herbal medicines does not preclude patients from following other important preventive or therapeutic measures. For example, a menopausal woman who has controlled her hot flashes with black cohosh may not realize that bone density and cholesterol testing are also important in her postmenopausal years. Additionally, pharmacists can work to dispel common misperceptions about phytomedicine, such as the beliefs that "natural is always better" and "if it's natural, it can't hurt you." Dr. Hardy and Ms. McDermott closed the session with some specific guidelines to share with patients interested in herbs and botanicals: • Supplements do not replace a healthy diet. • Use of multiple supplements is best avoided. Encourage patients to establish their objectives and make a few appropriate choices. • Supplements achieve their effects over time. Advise patients to keep a journal to follow their progress. • If the product has not had an effect in a few months, suggest trying a different brand or formulation. If there is still no positive benefit, disconti!lue the supplement. • Encourage consumers to be skeptical of miracle cures and the latest fads.
c ustomary food use.
R eprinted from Hardy ML. Herbs of special interest to w om.en. J Amer Pharm Assoc. 2000; 40:234-42.
about their use of herbs and botanicals, particularly when dispensing pharmaceuticals with which various phytomedicines may interact.
Talking to Patients Because 15% to 20% of herbs and botanicals are now sold in pharmacies, phannacists are well positioned to provide education about these agents. Patients often make decisions to use particular phytomedicines solely on the advice of a friend or a clerk in a health food store. Pharmacists can help ensure that such patients do not have warning signs of medical problems that should be evaluated by a physician. Red flags that generally warrant referral for medical evaluation include: • Signs or symptoms of a severe or undiagnosed condition • Symptoms that may appear minor, but are persistent or recurrent Vol. 40, No.5, Suppl. 1
Judging from their current popUlarity, herbs and botanicals appear to have established a permanent place in the American health care armamentarium. Many of these products have proven positive effects. Pharmacists are well positioned to help ensure that patients use these products wisely and to their best advantage in promoting good health.
Summary • Consumer use of herb and botanical preparations is burgeoning. • Many common herbal remedies have proven efficacy, reported mainly in the European scientific literature. • Although not mandated by law, responsible manufacturers of herbal products are working to establish efficacy, safety, and good manufacturing standards. • Pharmacists should be alert for possible drug interactions between phytomedicines and pharmaceuticals, as well as potential adverse effects. • Well-informed pharmacists can provide useful counseling and education about herbs and botanicals.
Supplement to the Journal of the American Pharmaceutical Association