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The Herbal Medicine Boom

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The Herbal Medicine Boom MEDICAL GRAND ROUNDS WILLIAM S. WILKE, MD, EDITOR TAKE-HOME POINTS FROM EDUCATIONAL PRESENTATIONS BY CLEVELAND CLINIC FACULTY AND VISITING Fear or distrust of physicians. One pam- PROFESSORS The herbal phlet touts "health secrets your doctor doesn't want you to know," and hints that physicians medicine boom: and pharmaceutical companies are conspiring to suppress information about unconventional Understanding what therapies. "Natural is better." Popular mythology holds that allopathic medicine is unnatural patients are taking and therefore bad, while herbal cures are nat- ANA VANN, PharmD ural and therefore good. Natural cures help Drug information clinical pharmacist, Cleveland Clinic. one "build resistance" to disease, according to this thinking. F PHYSICIANS WERE TO ASK every patient Disappointment with allopathic care. if he or she is taking herbal medica- Many persons who seek alternative therapies tions, one in three would answer yes, accord- have chronic conditions for which there is no ing to a 1993 survey.1 Sales of herbal medi- effective cure; they often use herbal prepara- cines are booming, totaling $2.5 billion in tions as an adjunct to allopathic therapies. For 1996 and growing 25% per year.2 such persons, taking an herbal medication is a Unfortunately, the herbal medicine indus- way of helping themselves while exerting more try is not sufficiently regulated to guarantee control over their own health care. that an herbal preparation is safe for con- Other influences. Some cultures have a sumption. Although some herbal prepara- tradition of using herbal medicine. Other peo- tions, such as homeopathic remedies, contain ple may be swayed by false advertising, word- no active ingredients at all, others contain of-mouth, and peer influences prevalent in substances that do produce effects—including their society. adverse reactions and interactions with pre- In the world scription drugs. Claims of efficacy are unsub- • WHAT PRODUCTS DO PEOPLE TAKE? of herbal stantiated, based mostly on anecdotal evi- dence. Worse, there is frequently no way to Data compiled from manufacturers indicate that medicine, let ascertain exactly what an herbal preparation ginseng accounts for 20% of herbal medications the buyer contains, as labeling is often inadequate or taken, garlic preparations for 18%, ginkgo for inaccurate, and some manufacturers continue 10%, melatonin (which is not an herb) for 19%, beware to use potentially dangerous herbs. and all others for 33%.4-6 However, hundreds of Obtaining information about the effects substances are available, and many products of herbal medications is difficult. Herbs often contain multiple substances. have several different names, and herbs with The following section lists some common similar or even identical names sometimes herbal medications, their reputed effects, and belong to different species entirely. There is what is known about possible side effects and no regulation of the purity of the substances, drug interactions. and no standardization of dosages. They are If a physician has questions about an sold over-the-counter with no instructions as unfamiliar herbal medicine, he or she should to possible side effects or interactions. call a local drug information center, the FDA consumer hotline (800-FDA-4010), or the • WHY DO PEOPLE TAKE HERBAL MEDICINES? National Institutes of Health Office of Alternative Medicine (888-644-6226). The There may be a number of explanations, from Lawrence Review of Natural Products, published a failure to understand the scientific process3 by Facts and Comparisons in St. Louis, to skepticism about modern medicine. Among Missouri, is a reliable reference of herbal med- factors that may be at work: icines' known therapeutic and adverse effects. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 65 • NUMBER 3 MARCH 1998 15 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. MEDICAL GRAND ROUNDS Garlic Ginkgo (Panax schinseng) (Allium sativum) (Qinkgo biloba, maidenhair) Ginseng is sold as an "adaptogen" to "normal- Garlic reduces total and LDL cholesterol and ize" the body and build resistance to stress, and triglycerides and raises HDL. It may have also as an aphrodisiac. However, its effective- antibacterial, antifungal, antithrombotic, hypo- ness is not adequately documented. It may tensive, hypoglycemic, antihyperlipidemic, lower total and low-density lipoprotein (LDL) anti-inflammatory, and anticancer activity.14 cholesterol levels. Some ingredients raise Precautions and interactions. Garlic has blood pressure, and some lower it.7 been shown to inhibit platelet aggregation Complicating the issue: there are eight species and therefore may interact with anticoagu- of ginseng, and one of them—Siberian gin- lants. It reduces blood sugar, and may there- seng—is completely different from the others. fore affect glucose control. Rarely, it causes For questions These issues may be moot for some products allergic reactions.15 about herbal labeled as ginseng: one study looked at 10 "gin- seng" products and found that seven contained Ginkgo has been used in China since ancient products, call no ginseng at all.8 A study from the late 1970s times.16'17 It dilates arteries, capillaries, and the NIH Office analyzed 54 ginseng products; of these, 60% veins, and has been shown to have significant contained less than the therapeutically effec- beneficial effects on cognitive function, of Alternative tive levels, and an astounding 20% contained enhance various CNS functions such as short- Medicine at no active ingredient.9 term memory, concentration, and alertness,18 Precautions and interactions. Nervous- and improve cognition in Alzheimer's dis- (888)644-6226 ness and excitation can occur for the first few ease.19 There are data in animals that ginkgo days of intake. Overuse can cause headache, protects against cerebral ischemic damage, and insomnia, and palpitations. Patients with may enhance blood flow to the brain.20.21 hypertension should be cautious of ginseng People are also using it to treat varicosity, cere- because of its unpredictable effect on blood bral vascular insufficiency, dementia, tinni- pressure. One case10 has been reported of an tus,22 vertigo, and sexual dysfunction induced interaction between ginseng and furosemide by selective serotonin reuptake inhibitors. (decreased diuretic effect probably caused by Precautions and interactions. Ginkgo- germanium contamination), which resulted in lide is a selective antagonist of platelet aggre- hospitalization. Estrogenic effects have caused gation. A few case reports of bilateral subdural vaginal bleeding and mastalgia; patients should hematomas have been reported. These cases not take ginseng with hormonal therapy in were all linked with prolonged use of this light of cases of uterine bleeding.11-13 Patients herbal remedy (longer than 2 years).23 It may should be discouraged from using ginseng long- cause minor GI disturbances. Rarely, ginkgo term (more than 3 months). causes headache, dizziness, or vertigo.24 130 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 65 • NUMBER 3 MARCH 1998 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. CS Saw Palmetto (Echinacea uugustifolia, purple coneflower) (Serenoa repens) Echinacea, also known as purple coneflower Lipid extracts of saw palmetto contain and snakeroot, has been promoted for pre- fatty acids and sterols that have antiandro- venting cold and flu symptoms. Although its genic activity in vitro. However, human stud- mechanism of immune stimulation is ies have been inconclusive. These studies also unknown, it may work by stimulating the used very high doses of the extracts; therefore, production of phagocytes.25 the levels of active ingredient may be exces- Precautions and interactions. This herb sive in humans.27 may cause immunosuppression with continu- Precautions and interactions. Side effects ous use (6 to 8 weeks).26 It is contra indicated are minimal. Saw Palmetto may, in theory, in patients with autoimmune diseases. have a synergistic effect with the hormonal therapy used in BPH. Always ask if Ma huang (Ephedra sinica and others). the patient More than 40 species of Ephedra are known, St. John's wort is pharmacologically similar some of which contain alkaloids including to monoamine oxidase inhibitors, and is used is taking any ephedrine and pseudoephedrine. It is used in as an antidepressant and to treat menopausal herbal asthma and to treat colds. It is used alone and premenstrual symptoms. The FDA lists it and in combination with St. John's wort in as a new investigational agent (it was previ- medicines weight-loss products, although it has not ously listed as unsafe). Several small studies been shown to be safe or effective for this found St. John's wort to be more effective purpose. than placebo for treating mild to moderate Precautions and interactions are similar depression.28 to those for ephedrine and pseudoephedrine. Precautions and interactions. To avoid Doses used in herbal weight-loss products and the risk of a hypertensive crisis, patients tak- herbal cold preparations containing ma huang ing St. John's wort should observe the same are typically excessive, and the range of side precautions as with the monoamine oxidase effects is unpredictable. Patients are strongly inhibitors, avoiding not only foods that con- discouraged from taking any herbal remedy tain tyramine (eg, aged meats and cheese), but containing this herb. also
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