Contamination of botanical dietary supplements by Digitalis lanata

Complementary medicine in intensive care: ethical and legal perspectives

Complementary medicine continues to increase in popularity in the general community. As a result it is likely that requests for the administration of complementary medicine to intensive care patients will be more frequent in the future. It is therefore prudent for intensive care clinicians to address this issue and develop an approach that is consistent. Complementary medicine has not been subjected to well conducted trials to determine its efficacy and risks. Consequently decisions about its use cannot be based on risk/benefit analyses and genuine informed consent cannot be achieved. Therefore complementary medicine should not be incorporated into intensive care practice. Strict adherence to a policy of negating requests for administration of complementary medicine in intensive care patients may result in significant conflicts between intensive care clinicians, patients and families. On occasions the patient or family may insist on the use of complementary medicine and it may be seen as important to their psychological wellbeing to accede to the request. The intensive care clinician is still legally responsible for any treatment administered to the patient, even if it is against medical advice. Nevertheless if there is no demonstrable risk to the patient, complementary medicine can be administered following appropriate counselling and documentation. This review addresses the legal and ethical difficulties that may arise and an approach that may be followed when requests are made for complementary medicine in intensive care patients.

Variability in commercial ginseng products: an analysis of 25 preparations

BACKGROUND

Because dietary supplements are not subject to the same regulations that pharmaceuticals are, there is concern among medical professionals that these products may lack purity or potency.

OBJECTIVE

To determine the variability in a range of ginseng herbal products available in the United States, we identified and measured the concentration of marker compounds by using HPLC and liquid chromatography-tandem mass spectrometry.

DESIGN

Twenty-five commercial ginseng preparations from the genera Panax or Eleutherococcus were obtained from a local health food store and analyzed for 7 ginsenosides (marker compounds for Panax species, which include Asian and American ginseng) and 2 eleutherosides (marker compounds for Eleutherococcus senticosus, also known as Siberian ginseng).

RESULTS

All plant products were correctly identified by botanical plant species (ie, Panax species or E. senticosus); however, concentrations of marker compounds differed significantly from labeled amounts. There was also significant product-to-product variability: concentrations of ginsenosides varied by 15- and 36-fold in capsules and liquids, respectively, and concentrations of eleutherosides varied by 43- and 200-fold in capsules and liquids, respectively. Although a systematic search for adulterants was not conducted, review of the HPLC and liquid chromatography-tandem mass spectrometry data suggest that no substances other than ginsenosides or eleutherosides were extracted from the plant material.

CONCLUSION

Our data suggest that US ginseng products are correctly labeled as to plant genus; however, variability in concentrations of marker compounds suggests that standardization may be necessary for quality assurance and that characterization of herbal products should be considered in the design and evaluation of studies on herbal products.

Herbs and supplements in dialysis patients: panacea or poison?

The safety of herbal remedies and supplement use is of particular concern in patients with renal disease, and reliable information is not always easy to find. Predialysis patients may be drawn to complementary and alternative medicine (CAM) because they believe it can help prevent the progression of their renal disease. The purpose of this series of articles on alternative medicine for nephrologists is to address concerns and issues specific to CAM use in dialysis patients and to provide a guide to reliable sources of information. This introductory article emphasizes safety issues with a focus primarily on herbal medicine. Lack of regulation means that patients may not actually be taking what they think they are. Independent laboratory analyses have shown a lack of stated label ingredients and many instances of supplements and traditional remedies being contaminated with pesticides, poisonous plants, heavy metals, or conventional drugs. While certain supplements are always unsafe (carcinogenic, hepatotoxic, glandular extracts), others are specifically contraindicated in renal disease. Supplement use may be especially hazardous in renal disease because of unpredictable pharmacokinetics, drug interactions, negative effects on kidney function, nephrotoxicity, hemodynamic alterations, unpredictable effects on blood pressure or blood glucose, or potentiation of electrolyte abnormalities. There are no data on potential dialyzability of either active compounds, or their potentially active or toxic metabolites. Many supplements contain metal ions and other minerals. Transplant recipients are also at risk from potential unpredictable effects on immune function. Recommendations and information resources are listed.

The importance of using scientific principles in the development of medicinal agents from plants

The authors review the major scientific milestones and the legislative framework that have made possible the spectacular successes of many modern therapies that trace their origins to plants. They emphasize that drugs used in mainstream medicine, in contrast to most of those used in alternative medicine, are required to meet stringent federal requirements for purity, safety, and efficacy before they can be distributed to the public, and that the necessary testing requires much time and effort. Yet alternative medicines based on plant substances are extremely popular, even though their safety and efficacy have not been scientifically proven. Reasons for this are reviewed and numerous examples and case histories are cited illustrating both successes in the scientific development of drugs from plants and the dangers of unregulated drugs. Such drugs are more easily available because of the deregulating effect of the 1994 Dietary Supplement Health and Education Act (DSHEA), which has substantially weakened the authority of the Food and Drug Administration to ensure the safety of dietary supplements. The authors describe the rigorous scientific investigations of curcumin, from the ginger family, and of sulforaphane, from crucifers, to illustrate the long and demanding scientific process that is required to establish the safety and effectiveness of potential drugs from plants. They re-emphasize the necessity for strict scientific review of all drugs. They also recommend that all providers of care be required to question patients about their intakes of dietary supplements. The authors close by saying that the DSHEA is "a disaster waiting to happen," but warn that any attempts to strengthen current legislation will be opposed by special interests.

In the midst of confusion lies opportunity: fostering quality science in dietary supplement research

The Office of Dietary Supplements (ODS) was established at the National Institutes of Health (NIH) by Congress through the Dietary Supplement Health and Education Act (DSHEA) of 1994. The mission of the ODS is to strengthen knowledge and understanding of dietary supplements by evaluating scientific information, stimulating and supporting research, disseminating research results and educating the public, all in an effort to foster an enhanced quality of life and health for the U.S. population. In pursuit of this mission, ODS takes into account an array of dietary supplement ingredients and products. This includes vitamin and mineral supplements and botanicals, as well as non-nutrient supplements. Toward that end, ODS has taken a number of steps. In collaboration with other Institutes and Centers at NIH, ODS has established a network of Dietary Supplement Research Centers around the country that provide the focus for multidisciplinary research efforts; it supports research activities and scientific conferences, it supports evidence-based reviews of supplements, and it maintains a public database of scientific literature on dietary supplements. The lack of credible information from well-controlled studies of many dietary supplements raises issues of caution and concern. The ODS is committed to providing and disseminating accurate and reliable scientific information on dietary supplements.

Regulatory and ethical issues with dietary supplements

Dietary supplements are commonly used, and many are effective or hold promise for treating various conditions. However, they do not require Food and Drug Administration (FDA) approval. Impurities and adulterants have been found in the products, mostly due to the lack of requirements for good manufacturing practices. In addition, as no standardization is required, the active ingredient may be absent or highly variable among manufacturers. The FDA published its 10-year plan for dietary supplements that addresses safety, labeling, boundaries, enforcement, research, and outreach. This endeavor, if put into place, will be instrumental in providing consumers with more confidence in the safety, composition, and labeling of dietary supplements.

Herbal and alternative medicine

An extensive range of herbal and dietary supplements is now available, and use of these products by ED patients is fairly common. Emergency physicians should be familiar with some of the products used more frequently for common complaints. Emergency personnel also should be vigilant for toxic syndromes resulting from ingestion of certain of these products and be wary of possible toxicity from any of these supplements owing to their minimal quality control and absence of FDA regulation.

Herbal Medicine: Is it an Alternative or an Unknown? A Brief Review of Popular Herbals Used by Patients in a Pain and Symptom Management Practice Setting

This article will briefly discuss herbals frequently used by patients in a pain and symptom management practice setting with regard to common indications, potential side effects, and drug interactions, as well as a review of available research on each substance. An overview of the regulatory morass that continues to surround the herbal products industry will be presented. The author will examine possible ethic implications of providing care to patients utilizing alternative therapies. Future developments and studies in the field of herbal therapies will be considered.

Drug interaction between St. John's wort and cyclosporine

OBJECTIVE

To report a probable drug interaction between the herbal dietary supplement St. John's wort and cyclosporine.

CASE REPORT

A 29-year-old white woman who received a cadaveric kidney and pancreas transplant, with stable organ function and stable cyclosporine concentrations began self-medicating with St. John's wort. After taking St. John's wort supplements for four to eight weeks, her cyclosporine concentrations became subtherapeutic; this was associated with organ rejection. Four weeks after stopping St. John's wort, her cyclosporine concentrations again became therapeutic. Subsequent to this rejection episode, she has developed chronic rejection and now has returned to dialysis.

DISCUSSION

St. John's wort is suspected to be a significant inducer of CYP3A4 isoenzyme activity and of P-glycoprotein (P-gp) expression, both of which are important in the metabolism and absorption of cyclosporine. Cyclosporine exhibits a relatively small therapeutic window and is sensitive to medications that can modulate the CYP3A4 isoenzyme and P-gp in both the liver and small intestines.

CONCLUSIONS

Patients taking St. John's wort concomitant with other prescription medications whose absorption and metabolism are mediated by the CYP3A4 isoenzyme and P-gp require close monitoring. Patient medication histories should include inquiries into the use of herbal dietary supplements.

Herbal therapy: what a clinician needs to know to counsel patients effectively

The use of herbal medicine in the United States has been increasing at a steady pace over the past decade. Most recent estimates suggest that the US population spends $5 billion per year for herbal supplements alone. Herbal supplements are receiving increasing exposure through national media, in lay journals, and more recently in the scientific press. Interest in herbal medicine has been facilitated by multiple factors, including the perception that pharmaceutical medications are expensive, overprescribed, and often dangerous. Alternatively, herbal medicine is often perceived as being "natural" and is therefore considered safe. While the growth of the herbal medicine industry in the United States can probably not continue at this accelerated pace indefinitely, there is little indication of any major slowing. Therefore, patients will continue to use herbal medications. Knowledge of these preparations (including their potential benefits and risks as well as their ability to interact with pharmaceutical medications) will enable physicians to provide a balanced and objective view to patients seeking information on herbal therapy.

The knowledge, attitudes, and practices of dietitians licensed in Oregon regarding functional foods, nutrient supplements, and herbs as complementary medicine

OBJECTIVE

To examine the perceived knowledge and attitudes of dietitians licensed in Oregon (LDs) regarding the effectiveness and safety of functional foods, nutrient supplements, and herbs as complementary medicine as well as their personal use, recommendations for the use of others, and training needs.

DESIGN

A mailed survey was used to gather data. The questionnaire was developed and face-validated after a focus group discussion.

SUBJECTS/SETTING

A geographically stratified, random sample of 202 Oregon LDs was surveyed; usable data were collected from 162 LDs (80%).

STATISTICAL ANALYSES

Descriptive statistics and chi 2 tests were used to analyze data. The data were weighted to take account of the sampling method and yield population estimates.

RESULTS

LDs considered themselves to be knowledgeable of functional foods and nutrient supplements. More than 80% were confident of the effectiveness of functional foods and nutrient supplements for prevention of illness and treatment of chronic illness, and at least 89% were confident of their safety for these uses. Fewer than 75% considered herbs to be safe and only about 50% were confident of the effectiveness of herbs. Only 10% or fewer LDs considered themselves to be knowledgeable about herbs for prevention and treatment of illness. Interest in training about each of these less-traditional nutrition therapies was high.

APPLICATIONS/CONCLUSIONS

Oregon LDs consider themselves to be actively practicing in the area of complementary medicine and have a strong desire for further training. The dietetics profession can capitalize on this interest by taking the lead in training dietitians about the role of functional foods, nutrient supplements, and herbs in health.

Nonvitamin, nonmineral dietary supplements: issues and findings from NHANES III

The Commission on Dietary Supplement Labels encourages nutrition professionals to become knowledgeable about all dietary supplements. The Dietary Supplement Health and Education Act of 1995 (DSHEA) expanded the definition of dietary supplements beyond essential nutrients while distinguishing them from drugs or food additives. In order to give practical advice to consumers and policymakers, dietetics professionals need to understand the implications resulting from this less-restrictive regulatory environment for supplements. Dietetics professionals must also become familiar with claims made by manufacturers, retailers, and others regarding popular nonvitamin, nonmineral (NVNM) supplements, as well as usage prevalence and trends. However, NVNM supplements currently are classified inconsistently, and information on the prevalence of use is limited. Sales data suggest that total intake is increasing, and garlic and ginseng are consistently among the most popular supplements. Reported use of NVNM supplements in the third National Health and Nutrition Examination Survey was highest for garlic and lecithin. The data suggest associations of NVNM supplement use with age and more healthful lifestyles; however, there is also a reported link with higher alcohol consumption and obesity. Associations with education, income, region, and urbanization are not evident from the sales data. Standardized survey procedures regarding question phraseology, referent time period, and supplement categorization--along with use of representative samples--will improve our ability to assess supplement use, prevalence, and trends.

Anti-digoxin Fab fragments in cardiotoxicity induced by ingestion of yellow oleander: a randomised controlled trial

BACKGROUND

Severe cardiac glycoside cardiotoxicity after ingestion of yellow oleander seeds is an important problem in rural areas of Sri Lanka. Currently, patients must be transferred to the capital for temporary cardiac pacing. We did a randomised controlled trial to investigate whether anti-digoxin Fab could reverse serious oleander-induced arrhythmias.

METHODS

After a preliminary dose-finding study, 66 patients who presented to hospital with a serious cardiac arrhythmia were randomised to receive either 1200 mg of anti-digoxin Fab or a saline placebo. A 12-lead electrocardiogram, 3 min rhythm strip, and blood sample for measurement of electrolytes and cardiac glycosides were taken before treatment and at 12 timepoints thereafter.

FINDINGS

34 patients received anti-digoxin Fab and 32 received placebo. The presenting arrhythmia had resolved completely after 2 h in 15 antibody-treated patients and two controls (p<0.001); 24 and five patients, respectively, were in sinus rhythm at 8 h (p<0.001). Kaplan-Meier analysis of time to first reversal showed a significant response to anti-digoxin Fab. The heart rate increased in cases, from 49.1 per min at baseline to 66.8 at 2 h, but not in controls (50.6 per min at baseline to 51.5; p<0.001). Mean serum potassium concentrations decreased from 4.9 mmol/L to 4.1 mmol/L at 2 h in cases; no such decrease occurred in controls.

INTERPRETATION

Anti-digoxin Fab fragments are a safe and effective treatment for serious cardiac arrhythmias induced by yellow oleander. Their use in small rural hospitals in Sri Lanka should minimise costly transfer of patients and reduce the numbers of deaths; however, further study will be required to confirm this reduction.

Safety issues with herbal medicine

As herbal medicines are used by increasing numbers of people, pharmacists must be knowledgeable about their safety. This requires appreciation of the magnitude of use, as well as regulations under which the products are marketed that may affect their safety. Unexpected effects of many popular herbal products are described in the literature. Thus the pharmacist's role in ensuring protection of the consumer continues to grow.

Safety issues with herbal products

OBJECTIVE

To review safety issues associated with the use of herbal products.

DATA SOURCES

Literature accessed through MEDLINE and other Internet search engines. Key search terms included herbs, dietary supplements, and safety.

DATA SYNTHESIS

A misconception exists among consumers that herbal remedies are safe because they are natural. In an effort to provide healthcare practitioners with information necessary for a patient discussion, a review of safety concerns with herbal products was conducted.

CONCLUSIONS

Several safety concerns exist with herbal products including lack of safety data, absence of quality-control requirements for potency and purity, and lenient labeling standards.

Effects of ginseng components on c-DNA-expressed cytochrome P450 enzyme catalytic activity

Because little is known about the interactions between herbal products and standard medications, the effects of seven ginsenosides and two eleutherosides (active components of the ginseng root) on the catalytic activity of c-DNA expressed cytochrome P450 isoforms were studied in in vitro experiments. Increasing concentrations of ginsenosides Rb1, Rb2, Rc, Rd, Re, Rf, and Rg1 and eleutherosides B and E were incubated with a panel of recombinant human CYP isoforms (CYP1A2, CYP2C9, CYP2C19, CYP2D6 and CYP3A4) and their effects on the conversion of specific surrogate substrates measured fluorometrically in a 96-well plate format. For each test substance, the IC50 (the concentration required to inhibit the metabolism of the surrogate substrates by 50%) was estimated and this value compared with that obtained for positive control inhibitory drugs furafylline, sulfaphenazole, tryanylcypromine, quinidine, and ketoconizole. Of the components tested, three ginsenosides (Rd, Rc, and Rf) modified the activity of the recombinant enzymes. Ginsenoside Rd produced weak inhibitory activity against the surrogate substrates for CYP3A4 and CYP2D6 and even weaker inhibitory activity against the surrogate substrates for CYP2C19 and CYP2C9. The IC50 values of 58 and 74 uM for the two substrates for CYP3A4 are orders of magnitude higher than that for the potent inhibitor ketoconazole used as a positive control. Ginsenoside Rc produced an increase in the activity of CYP2C9 (70% at 200 uM) and ginsenoside Rf produced an increase in the activity of CYP3A4 (54% at 200 uM). The biological significance of this is unclear at this time. Enzyme "activation", the process by which direct addition of one compound to an enzyme enhances the rate of reaction of the substrate, has been observed in a number of cases with P450 enzymes; however, a matrix effect caused by the test compound fluorescing at the same wavelength as the metabolite of the marker substrate cannot be ruled out. In summary, these studies suggest that the ginsenosides and eleutherosides tested are not likely to inhibit the metabolism of coadministered medications in which the primary route of elimination is via cytochrome P450; the potential of ginsenosides to enhance the catalysis of certain substrates requires further investigation.

Talking with patients about alternative and complementary medicine

The growing use of alternative and complementary therapies in the United States as well as other parts of the world is a trend that the responsible rheumatologist cannot ignore. With chronic musculoskeletal conditions being the leading indication for the use of alternative and complementary therapies, rheumatologists must become experts on talking to patients and advising them about the use or avoidance of such therapies. Currently, there is a growing body of literature on the safety and efficacy of the multiple alternative and complementary therapies available. Much of this information is reliable and of high methologic quality; however, much of it is not. With an increase in the budget of the Office of Alternative Medicine from $20 to $50 million in 1999 and the status of the office changing to an independent center, an important step has been taken to try to assure improved research in the near future to validate or disprove many of the current alternative and complementary therapies. In the meantime, our patients are using these therapies and are likely to continue to do so, with or without our guidance. We must get beyond the "don't ask, don't tell" approach that characterizes many physicians' attitudes toward the subject of alternative and complementary therapies. Although all discussions need not end in agreement, they are still opportunities for shared decision making and "relationship-centered care." Ultimately, we should not be concerned with practicing what is perceived to be traditional versus alternative and complementary medicine or biomedicine versus naturalistic medicine but only with what is truly "good" medicine.

Epidemiology of complementary and alternative practices in rheumatology

The increasing prevalence of complementary and alternative medicine usage by the general population and rheumatic patients worldwide is reviewed. The many potential concerns about this type of therapy are addressed, ranging from toxicity issues to changes in behavioral attitudes. Finally, the authors speculate on some major socioeconomic outcomes associated with these therapies.

Physician-patient communication about complementary and alternative medical therapies: a survey of physicians caring for patients with human immunodeficiency virus infection

OBJECTIVE

To examine frequency and correlates of physicians' reports of discussions with patients with human immunodeficiency virus (HIV) about complementary and alternative medical (CAM) therapies.

DESIGN

Mailed physician survey.

SETTING

The setting was Eastern Massachusetts.

PARTICIPANTS

Participants included 89 physicians caring for patients with HIV.

MEASUREMENTS AND MAIN RESULTS

Physicians were asked how common the use of CAM therapies was among their patients, how useful these therapies were, how often they discussed the use of CAM therapies with new and follow-up patients, and whether they had used a CAM therapy themselves in the last year. We also collected information on physicians' sociodemographic and practice characteristics. Sixty-eight percent (89/130) of physicians responded, and 26% and 5% reported discussing CAM therapies with HIV-infected patients at most new and follow-up visits, respectively. Respondents' attitudes toward the use of CAM therapies were generally positive, and they believed their HIV-infected patients used CAM therapies more than their non-HIV infected patients. The majority (63%) believed that CAM therapies may be helpful for HIV-infected patients. Thirty-six percent (36%) had used a CAM therapy themselves in the last year. In multivariate analyses, only the belief that CAM therapies are helpful was correlated with discussion of CAM therapies (p = 0.006). Respondents' demographic characteristics, training, personal use of CAM therapies, reported visit length, and satisfaction with visit length were not associated with discussion of CAM therapies.

CONCLUSIONS

Despite awareness that their HIV-infected patients commonly use CAM therapies and positive attitudes towards such therapies, most of these physicians did not routinely discuss CAM therapies with them. Barriers to physician-patient communication about CAM therapies merit further investigation.

Use of complementary therapies for arthritis among patients of rheumatologists

BACKGROUND

Use of complementary and alternative medicine (CAM) is common among persons with chronic conditions.

OBJECTIVE

To identify correlates of and describe patients' perspective on use of CAM for rheumatologic conditions.

DESIGN

Telephone survey.

SETTING

Three university practices and three private rheumatology practices.

PATIENTS

232 of 428 eligible consecutive patients (54%) with scheduled appointments.

MEASUREMENTS

Patients answered questions on CAM use, functional status, pain, provider satisfaction, and health services utilization. Chart reviews provided demographic information and rheumatologic diagnoses. Bivariate analyses identified correlates of four CAM outcomes (history, magnitude, and frequency of CAM use and communication about CAM use with a physician), and multiple logistic regression identified independent correlates of regular CAM use.

RESULTS

Approximately two thirds of the respondents (n = 146) had used CAM. Of these 146 respondents, 82 (56%) currently used CAM and 132 (90%) regularly used CAM or had done so in the past. Fifty-five respondents (24%) had used three or more types of CAM. In multivariate analyses, persons who used CAM regularly were more likely to have osteoarthritis (odds ratio, 5.6 [95% CI, 1.9 to 16.8]), severe pain (odds ratio, 2.5 [CI, 1.4 to 4.8]), and a college degree (odds ratio, 2.6 [CI, 1.3 to 5.4]) than patients who had never used CAM. Nearly half of the respondents discussed CAM use with their physicians. The most common reasons for not disclosing CAM use were that the physician had not asked about it and that the patient forgot to tell the physician; fear of disapproval was rarely cited. Discussions about CAM use between patient and physician occurred more frequently among patients with fibromyalgia and persons who regularly used CAM or used several types of CAM.

CONCLUSIONS

Patients with rheumatologic conditions frequently use CAM. Severe pain and osteoarthritis predict regular use of CAM but do not predict a greater likelihood of discussing CAM use with physicians. Routine inquiry by physicians will probably detect CAM use.

The placebo effect

Placebos have been traditionally regarded as deceptive therapies and have not been understood in the broader context of social symbols and of interpersonal factors that surround the healing process itself. Although the power of inert substances to heal is well recognized, the placebo effect also influences the outcome of conventional therapies. The role of the placebo in modern medicine is poorly defined because of a lack of a common understanding of what the placebo effect is and because of the negative connotions associated with its use. The response rate to placebo varies by illness. The natural course of disease and patient or physician bias can be misinterpreted as a placebo response. In research, the placebo effect is therapeutic noise to be removed by placebo-controlled trials. Few studies are designed to measure the placebo response rate directly. Placebos are a reminder of how little is known about mind-body interaction. The placebo effect may be one of the most versatile and underused therapeutic tools at the disposal of physicians.

Expectations about alternative therapies and women with gynecological cancer

Women with gynecological cancers are exploring and using 'alternative medicine(s)', as are other cancer patients and much of Western society. On behalf of their patients, physicians must understand something of its history, terms, types, who uses it and why and where to find answers, as well as being prepared to open and engage in dialogue about alternative medicine with their patients.