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Supporting Evidence, Potential Adverse Effects, and Known Drug ISSN: 2469-5742 Deol et al. Int Arch Urol Complic 2018, 4:047 DOI: 10.23937/2469-5742/1510047 Volume 4 | Issue 2 International Archives of Open Access Urology and Complications RESEARCH ARTICLE Supporting Evidence, Potential Adverse Effects, and known Drug Interactions of the Complementary Alternative Medicines which are Frequently used by Prostate Cancer Patients Harmeet Deol1, Alan Truong2, Tibebe Woldemariam3, Xiaodong Feng3 and Ruth Vinall3* 1PGY1 Resident, Corpus Christi Medical Center, USA 2Pharmacy student, California Northstate University College of Pharmacy (CNUCOP), Elk Grove, USA Check for 3Associate Professor, California Northstate University College of Pharmacy (CNUCOP), Elk Grove, USA updates *Corresponding author: Ruth Vinall, Associate Professor, California Northstate University College of Pharmacy (CNUCOP), Elk Grove, CA 95757, USA Abstract tory, and race (it is more common in African American A significant number of prostate cancer patients use com- plementary alternative medicines (CAMs) as an adjunct to men) [1]. In 2015, there were approximately 1,735,350 their conventional treatment. Examples of CAMs that are new cases diagnosed and it is estimated that 11.6% of frequently used by prostate cancer patients include green men will be diagnosed with PC at some point during tea extract, lycopene, and pomegranate fruit extract. In their lifetime [2]. Advances in early detection and treat- many cases there is little if any clinical study-based evi- dence to support the efficacy of CAMs in this setting, and, ment have contributed to improved patient outcomes; importantly, some CAMs can cause serious adverse effects in 1980 the 5-year survival rate was ~70.2%, the most when taken a high doses and/or have significant drug in- recent statistics estimate 5-year survival at 99.0% [2,3]. teractions. The latter is an important consideration in this These advances have resulted in there being a huge patient group as most patients are older and take multiple number of men in the US living with PC. Many of these medications in addition to their anti-cancer drugs. This re- view summaries prostate cancer patient clinical trial data patients (estimated at between 9 - 64% by various stud- that is available for CAMs which are commonly used by ies), as well as men at high risk of developing PC, use prostate cancer patients, and provides dose, dose form, complementary alternative medicines (CAMs) as an ad- adverse effect, and drug interaction data. Providing evi- junct to their treatment, and the majority of patients dence-based guidance regarding CAMs to prostate cancer patients can potentially improve patient outcomes, includ- (estimated at 75%) will do so without informing their ing the avoidance of adverse effects and drug interactions doctor [4-7]. Questionnaire-based studies indicate that which impact drug efficacy. PC patients take CAMs for a variety of reasons, includ- ing to ameliorate treatment-associated side effects, to Keywords reduce the risk of disease progression, and to increase Prostate cancer, Complementary alternative medicines, Ef- their sense of having control over their disease and its ficacy, Drug interactions, Adverse effects treatment [8]. A major issue is that typically patients assume, often incorrectly, that CAMs are completely Introduction harmless and will not cause any adverse effects. This Prostate cancer (PC) is the second most frequently review names and describes several CAMs that are fre- diagnosed cancer in men [1]. The median age at diag- quently used by men with PC and/or men at high risk of nosis is 66 and major risk factors include age, family his- PC; green tea, modified citrus pectin (MCP), pomegran- Citation: Deol H, Truong A, Woldemariam T, Feng X, Vinall R (2018) Supporting Evidence, Potential Adverse Effects, and known Drug Interactions of the Complementary Alternative Medicines which are Frequently used by Prostate Cancer Patients. Int Arch Urol Complic 4:047. doi.org/10.23937/2469- 5742/1510047 Accepted: October 16, 2018: Published: October 18, 2018 Copyright: © 2018 Deol H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Deol et al. Int Arch Urol Complic 2018, 4:047 • Page 1 of 11 • DOI: 10.23937/2469-5742/1510047 ISSN: 2469-5742 ate fruit extract (PFE), lycopene, soy, vitamin D, sulph- CAMs as well as information regarding dosage forms, oraphane, selenium, vitamin E, and saw palmetto. Data dosing, potential side effects and potential drug interac- from peer-reviewed questionnaire studies which report tions. While none of the CAMs discussed have a validat- the frequency of CAM usage by PC patients is available ed drug interaction with PC standard of care therapies, for some of these; selenium (4.1-26.6%; 11 studies, to- PC patients often have comorbidities (e.g. hypertension tal n = 7,109 patients), vitamin E (5-53.3%; 8 studies, (~42% of patients), diabetes (~11% of patients), and con- total n = 3,261), saw palmetto (1.9-24.5%; 11 studies, gestive heart failure (CHF)/valvular disease (~5% of pa- total n = 6,525 patients), green tea (51%; 1 study, n = tients) [10], and an interaction with a drug used to treat 451 patients), lycopene (31%; 1 study, n = 451 patients) these co-morbidities could thereby indirectly impact [5,9]. The other CAMs reviewed here are frequently dis- their PC treatment and outcomes. For example, green cussed in online PC patient discussion boards and have tea, PFE, soy, vitamin D, vitamin E, and lycopene all have been the focus of multiple clinical, epidemiological, and validated drug interactions with drugs commonly used in vitro studies indicating that they are also relevant to to treat hypertension (Table 1). A summary of the dose the PC community. This review provides information re- forms available for each CAM as well as potential side garding the clinical evidence supporting usage of these effects and potential drug interactions are provided in Table 1: Potential benefits, dose forms available, and potential side effect/drug interaction data for CAMs used by prostate cancer patients as part of their treatment regimen (note that the potential drug interaction list does not include drugs which are used to treat prostate cancer, however, many of these drugs are used to treat co-morbidities that prostate cancer patients frequently experience and may therefore meaning these CAMs may indirectly interfere with their prostate cancer treatment). A drug interaction is defined as an interaction between the CAM and the drug which may either increase treatment-associated toxicity and/or decrease drug efficacy. Name and proposed Dose form(s) Potential side effects Potential drug interactions1 mechanisms of action (MOA) Green tea and green tea Liquid (brewed May cause acute liver Bortezomib and other proteasome constituents (e.g. EGCG) tea, some energy injury, nausea, insomnia, inhibitors, dipyridamole, disulfiram, drinks), powder, and/or abdominal pain at ephedrine, estrogens, fluconazole, Proposed MOAs include; capsules, tablets EGCG doses of 30 - 90 fluvoxamine, hepatotoxic drugs, lithium, anti-oxidant, inhibits PC cell mg/kg/day mg/kg per day mexiletine, midazolam, MAOIs, nadolol, proliferation and metastasis, [12,13] nicardipine, nicotine, pentobarbital, promotes PC cell apoptosis phenylpropanolamine, riluzole, stimulants, theophylline, verapamil, warfarin Modified citrus pectin (MCP) Capsules, powder May cause abdominal Oral medications, digoxin, lovastatin, cramping and/or diarrhea tetracyclines Proposed MOAs include; inhibits at doses of > 14 g per day metastasis, promotes PC cell [18] apoptosis Pomegranate fruit extract (PFE) Capsules, powder May cause diarrhea at Ace inhibitors, antihypertensives, doses of > 3 g per day carbamazepine, CYP 2D6 substrates, Proposed MOAs include; [30] warfarin, rosuvastatin, tolbutamide anti-oxidant, inhibits PC cell proliferation, promotes PC cell apoptosis Soy Capsules, tablets, No side effects observed Antibiotics, antidiabetic, antihypertensives, powder in clinical trials (1 - 16 mg/ CYP 2C9 substrates, diuretics, estrogens, Proposed MOAs include; kg per day) [66] levothyroxine, MAOIs, progestrones, inhibits metastasis and PC cell tamoxifen, warfarin proliferation, promotes PC cell apoptosis Selenium Capsules, liquid At high levels may Anticoagulants, antiplatelets, barbiturates, concentrate cause GI disturbances, contraceptives, gold salts, statins, Proposed MOAs include; teeth decay, hair loss, immunosuppressants, niacin, warfarin Anti-oxidant, improves immune neurological disturbances system function, inhibits PC cell (2upper tolerable dose for proliferation, promotes PC cell adults is 400 ug per day) apoptosis Saw palmetto Capsules and Minimal to no toxicity has Anticoagulants, antiplatelets, softgels been reported at doses as contraceptives, estrogens Proposed MOAs include; inhibits high as 960 mg per day PC cell proliferation [79] Vitamin D Tablets, softgels Constipation, nausea, Aluminum, atorvastatin, calcipotriene, vomiting cimetidine, CYP 3A4 substrates, digoxin, Proposed MOAs include; improves diltiazem, heparin LMWH, thiazides, immune function, decreases (2upper tolerable dose is verapamil inflammation, inhibits PC cell 400 ug per day) proliferation and metastasis Deol et al. Int Arch Urol Complic 2018, 4:047 • Page 2 of 11 • DOI: 10.23937/2469-5742/1510047 ISSN: 2469-5742 Vitamin E Capsules, tablets, May cause
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