Use and Safety of Anthroposophic Medicinal Products: An Analysis of 44,662 Patients from the EvaMed Pharmacovigilance Network

Stability of psychological wellbeing during the COVID-19 pandemic among people with an anthroposophical worldview: the influence of wondering awe and perception of nature as resources

Background

During the COVID-19 pandemic, differences in responses and behaviors were observed among specific groups. We aimed to address how people with an anthroposophical worldview behaved with respect to the perception of burden, fears, and wellbeing. As it is an integral part of their lifestyle and convictions, we addressed the influence of wondering awe and gratitude and perception of nature and times of mindful quietness as resources to cope.

Methods

In two cross-sectional surveys with standardized instruments, participants were recruited in 2020 (n = 1,252) and 2021 (n = 2,273).

Results

Psychological wellbeing was much higher than in other studied groups and populations, with slightly lower scores in 2021 compared to the 2020 sample (Eta2 = 0.020), while the perception of the COVID-19-related burden and fear of the future were low in 2020 with a slight increase in 2021 (Eta2 = 0.033 and 0.008, respectively). Their transcendence conviction was negatively related to fears of their own infection or the infection of others. Best predictors of their wellbeing were low burden and awe/gratitude, while the best predictors of their burden were low wellbeing and lack of social contacts.

Conclusion

Compared to the general population in Germany, the anthroposophical lifestyle and related convictions may have buffered some of the COVID-19-related burden and helped them to stabilize their psychological wellbeing.

Anthroposophic Medicinal Products: A Literature Review of Features, Similarities and Differences to Conventional Medicinal Products, Scientific and Regulatory Assessment

Background

Regulatory assessment of anthroposophic medicinal products (AMPs) can be challenging due to their specific features.

Objective

The aim of this paper is therefore to provide adequate scientific information on AMPs for regulatory purposes.

Methods

A literature review was executed with database searches in PubMed, Cinahl, Merkurstab, Anthromedics, and https://iaap-pharma.org/. Search terms were: anthroposophic medicinal products, anthroposophic medicines, anthroposophic pharmacy. There was no language restriction; searches were executed from onset until June 11, 2020. In addition, experts were invited to suggest relevant literature.

Results

Eighty-seven of 660 identified publications were included. The system of anthroposophic medicine (AM) with its conceptual background and various aspects of AMPs was described: definition, pharmaceutical properties, an example of AMP development, use in clinical practice, similarities with and differences to conventional medicinal products, societal aspects, scientific and regulatory assessment.

Conclusion

AMPs are part of the integrative whole medical system of AM. AMPs are manufactured according to Good Manufacturing Practice and national drug regulations and have an excellent safety status; the limited available evidence suggests clinical benefits. Current drug regulation of AMPs in the EU and most European countries does not take the special properties of AMPs into account. Future research should focus on appropriate methodologies for the evaluation of effects of AMPs as part of the AM whole medical system, the scientific quality of its non-atomistic holistic ontological position, and the integration of AM and conventional medicine in clinical practice. Future policies should focus on appropriate ways of addressing regulatory challenges to AMPs.

Neurodoron® for Stress Impairments: A Prospective, Multicenter Non-Interventional Trial

Introduction

Stress is associated with a multitude of physical and psychological health impairments. To tackle these health disorders, over-the-counter (OTC) products like Neurodoron® are popular since they are considered safe and tolerable. Experience reports and first studies indicate that Neurodoron® is efficient in the treatment of stress-associated health symptoms. To confirm this, a non-interventional study (NIS) with pharmacies was conducted.

Methods

The NIS was planned to enroll female and male patients who suffered from nervous exhaustion with symptoms caused by acute and/or chronic stress. The main outcome measures were characteristic stress symptoms, stress burden, and perceived stress. Further outcome measures included perceived efficacy and tolerability of the product as assessed by the patients and collection of adverse drug reactions (ADRs). A study duration of about 21 days with a recommended daily dose of 3–4 tablets was set.

Results

279 patients were enrolled at 74 German pharmacies. The analyzed set (AS) included 272 patients (mean age 44.8 ± 14.4 years, 73.9% female). 175 patients of the AS completed the NIS. During the study, all stress symptoms declined significantly (total score 18.1 vs. 12.1 (of max. 39 points), p < 0.0001). Furthermore, a reduction of stress burden (relative difference in stress burden, VAS = −29.1%, p < 0.0001) was observed. For most patients, perceived stress was reduced at the study end (PSQ total score decreased in 70.9% of the patients). 75.9% of the study population rated the product efficacy as “good” or “very good” and 96.6% rated its tolerability as “good” or “very good.” One uncritical ADR was reported. Discussion/Conclusion. This study adds information on the beneficial effects of Neurodoron® in self-medication. The results from this NIS showed a marked reduction in stress burden and perceived stress, along with an excellent safety profile of the medicinal product (MP) Neurodoron®. Further trials are required to confirm these results.

¿Qué es la medicina alternativa, complementaria e integrativa?

El concepto de medicina alternativa fue creado por la medicina occidental para identificar prácticas médicas diferentes a la medicina convencional, tales como la medicina tradicional china y acupuntura, homeopatía, terapia neural, medicina osteopática y quiropráctica, medicina ayurveda y la medicina tradicional indígena, que también tienen fundamentos filosóficos, científicos y terapéuticos. Desafortunadamente, con el tiempo se estableció la creencia de que la medicina alternativa comprende todas las prácticas médicas que no son parte de la medicina convencional, lo que ha causado muchas inexactitudes y controversias. La medicina surgió como necesidad de auto preservación del ser humano y que considera a la salud como bienestar completo y a la enfermedad, como pérdida de esta condición. A lo largo de su evolución han emergido diversas racionalidades y algunas de ellas se han convertido en sistemas médicos. La medicina convencional se estructuró en Occidente, fundamentada en racionalidades médicas existentes para la época y enfocada en modificar la enfermedad, lo que resultó en marcadas diferencias conceptuales con sistemas de tratamiento ya existentes que se centraban en el individuo y en modificar los procesos de la enfermedad. Todos los sistemas médicos han generado un impacto en diversos campos sociales. Asimismo, han surgido tendencias y estrategias de integración de la medicina convencional con otros sistemas médicos comoLa electroacupuntura de Voll, la homotoxicología, el balance polar electromagnético, la antroposofía, la sintergética y la biofotónica. Actualmente se considera que el objetivo de la medicina es integrar y complementar conocimientos de diferentes racionalidades médicas dentro del concepto de una sola medicina. Teniendo en cuenta lo anterior, el objetivo del presente artículo es clarificar los conceptos de las diferentes formas de medicina, plantear algunas definiciones al respecto, y proponer una definición de medicina alternativa, complementaria e integrativa.

Metabolic Toxification of 1,2-Unsaturated Pyrrolizidine Alkaloids Causes Human Hepatic Sinusoidal Obstruction Syndrome: The Update

Saturated and unsaturated pyrrolizidine alkaloids (PAs) are present in more than 6000 plant species growing in countries all over the world. They have a typical heterocyclic structure in common, but differ in their potential toxicity, depending on the presence or absence of a double bond between C1 and C2. Fortunately, most plants contain saturated PAs without this double bond and are therefore not toxic for consumption by humans or animals. In a minority of plants, however, PAs with this double bond between C1 and C2 exhibit strong hepatotoxic, genotoxic, cytotoxic, neurotoxic, and tumorigenic potentials. If consumed in error and in large emouns, plants with 1,2-unsaturated PAs induce metabolic breaking-off of the double bonds of the unsaturated PAs, generating PA radicals that may trigger severe liver injury through a process involving microsomal P450 (CYP), with preference of its isoforms CYP 2A6, CYP 3A4, and CYP 3A5. This toxifying CYP-dependent conversion occurs primarily in the endoplasmic reticulum of the hepatocytes equivalent to the microsomal fraction. Toxified PAs injure the protein membranes of hepatocytes, and after passing their plasma membranes, more so the liver sinusoidal endothelial cells (LSECs), leading to life-threatening hepatic sinusoidal obstruction syndrome (HSOS). This injury is easily diagnosed by blood pyrrolizidine protein adducts, which are perfect diagnostic biomarkers, supporting causality evaluation using the updated RUCAM (Roussel Uclaf Causality Assessment Method). HSOS is clinically characterized by weight gain due to fluid accumulation (ascites, pleural effusion, and edema), and may lead to acute liver failure, liver transplantation, or death. In conclusion, plant-derived PAs with a double bond between C1 and C2 are potentially hepatotoxic after metabolic removal of the double bond, and may cause PA-HSOS with a potential lethal outcome, even if PA consumption is stopped.

Safety of Anthroposophic Medicinal Products: An Analysis of Adverse Drug Reactions from German Pharmacovigilance Databases

BACKGROUND

Anthroposophic medicinal products (AMPs) are widely used in Europe and world-wide.

OBJECTIVE

To determine the frequency of reported adverse drug reactions (ADRs) from all AMPs on the market, in absolute numbers and relative to the maximum daily administration doses (MDADs).

PATIENTS AND METHODS

Retrolective safety analysis of AMP-related ADRs in pharmacovigilance databases of four AMP Marketing Authorisation Holders in Germany. For each ADR, information about the patient, outcome, causality and AMP was retrieved. Primary outcome was the frequency of reported ADRs relative to MDADs sold.

RESULTS

In the period 2010-2017, a total of 5506 ADRs were reported that had occurred in 2765 different patients, comprising 370 different AMPs. A total of 104 ADRs (1.9%) were classified as serious. The frequency of ADRs for all AMPs was 1.50 per million MDADs. For serious ADRs the frequency was 0.03 per million MDADs. ADRs were more frequently reported with parenteral AMP administration (injections) than with oral or local administration (18.85 vs. 0.59 vs. 1.61 ADRs per million MDADs, respectively; p < 0.0001). The large majority of users (91.9%) had recovered or were recovering from the ADRs and there were no reports with a fatal outcome. Most frequently reported ADR symptom was injection site inflammation for parenteral AMPs (4.66 ADRs per million MDADs), nausea for oral AMPs (0.03 ADRs per million MDADs), and eye irritation for locally administered AMPs (0.23 ADRs per million MDADs).

CONCLUSIONS

In this retrolective safety analysis of pharmacovigilance data, the frequency of ADRs to AMPs was 1.50 per million MDADs. Notably, the ADR frequency in this study based on spontaneous reporting is not directly comparable to frequencies in prospective clinical studies nor to frequencies based on other measures of patient exposure than MDADs.

Symptomatic fever management in children: A systematic review of national and international guidelines

INTRODUCTION

Divergent attitudes towards fever have led to a high level of inconsistency in approaches to its management. In an attempt to overcome this, clinical practice guidelines (CPGs) for the symptomatic management of fever in children have been produced by several healthcare organizations. To date, a comprehensive assessment of the evidence level of the recommendations made in these CPGs has not been carried out.

METHODS

Searches were conducted on Pubmed, google scholar, pediatric society websites and guideline databases to locate CPGs from each country (with date coverage from January 1995 to September 2020). Rather than assessing overall guideline quality, the level of evidence for each recommendation was evaluated according to criteria of the Oxford Centre for Evidence-Based Medicine (OCEBM). A GRADE assessment was undertaken to assess the body of evidence related to a single question: the threshold for initiating antipyresis. Methods and results are reported according to the PRISMA statement.

RESULTS

74 guidelines were retrieved. Recommendations for antipyretic threshold, type and dose; ambient temperature; dress/covering; activity; fluids; nutrition; proctoclysis; external applications; complementary/herbal recommendations; media; and age-related treatment differences all varied widely. OCEBM evidence levels for most recommendations were low (Level 3-4) or indeterminable. The GRADE assessment revealed a very low level of evidence for a threshold for antipyresis.

CONCLUSION

There is no recommendation on which all guidelines agree, and many are inconsistent with the evidence-this is true even for recent guidelines. The threshold question is of fundamental importance and has not yet been answered. Guidelines for the most frequent intervention (antipyresis) remain problematic.

Anthroposophic Medicine: A Short Monograph and Narrative Review-Foundations, Essential Characteristics, Scientific Basis, Safety, Effectiveness and Misconceptions

INTRODUCTION

Anthroposophic medicine is a form of integrative medicine that originated in Europe but is not well known in the US. It is comprehensive and heterogenous in scope and remains provocative and controversial in many academic circles. Assessment of the nature and potential contribution of anthroposophic medicine to whole person care and global health seems appropriate.

METHODS

Because of the heterogenous and multifaceted character of anthroposophic medicine, a narrative review format was chosen. A Health Technology Assessment of anthroposophic medicine in 2006 was reviewed and used as a starting point. A Medline search from 2006 to July 2020 was performed using various search terms and restricted to English. Books, articles, reviews and websites were assessed for clinical relevance and interest to the general reader. Abstracts of German language articles were reviewed when available. Reference lists of articles and the author's personal references were also consulted.

RESULTS

The literature on anthroposophic medicine is vast, providing new ways of thinking, a holistic view of the world, and many integrating concepts useful in medicine. In the last ∼20 years there has been a growing research base and implementation of many anthroposophical concepts in the integrated care of patients. Books and articles relevant to describing the foundations, scientific status, safety, effectiveness and criticisms of anthroposophic medicine are discussed.

DISCUSSION

An objective and comprehensive analysis of anthroposophic medicine finds it provocative, stimulating and potentially fruitful as an integrative system for whole person care, including under-recognized life processes and psychospiritual aspects of human beings. It has a legitimate, new type of scientific status as well as documented safety and effectiveness in some areas of its multimodal approach. Criticisms and controversies of anthroposophic medicine are often a result of lack of familiarity with its methods and approach and/or come from historically fixed ideas of what constitutes legitimate science.

eHealth technologies assisting in identifying potential adverse interactions with complementary and alternative medicine (CAM) or standalone CAM adverse events or side effects: a scoping review

BACKGROUND

While there are several existing eHealth technologies for drug-drug interactions and stand-alone drug adverse effects, it appears that considerably less attention is focussed on that of complementary and alternative medicine (CAM). Despite poor knowledge of their potential interactions and side effects, many patients use CAM. This justifies the need to identify what eHealth technologies are assisting in identifying potential 1) adverse drug interactions with CAM, 2) adverse CAM-CAM interactions or 3) standalone CAM adverse events or side effects.

METHODS

A scoping review was conducted to identify eHealth technologies assisting in identifying potential adverse interactions with CAM or standalone CAM adverse events or side effects, following Arksey and O'Malley's five-stage scoping review framework. MEDLINE, EMBASE, and AMED databases and the Canadian Agency for Drugs and Technologies in Health website were systematically searched. Eligible articles had to have assessed or referenced an eHealth technology assisting in identifying potential one or more of the three aforementioned items. We placed no eligibility restrictions on type of eHealth technology.

RESULTS

Searches identified 3467 items, of which 2763 were unique, and 2674 titles and abstracts were eliminated, leaving 89 full-text articles to be considered. Of those, 48 were not eligible, leaving a total of 41 articles eligible for review. From these 41 articles, 69 unique eHealth technologies meeting our eligibility criteria were identified. Themes which emerged from our analysis included the following: the lack of recent reviews of CAM-related healthcare information; a large number of databases; and the presence of government adverse drug/event surveillance.

CONCLUSIONS

The present scoping review is the first, to our knowledge, to provide a descriptive map of the literature and eHealth technologies relating to our research question. We highlight that while an ample number of resources are available to healthcare providers, researchers, and patients, we caution that the quality and update frequency for many of these resources vary widely, and until formally assessed, remain unknown. We identify that a need exists to conduct an updated and systematically-searched review of CAM-related healthcare or research resources, as well as develop guidance documents associated with the development and evaluation of CAM-related eHealth technologies.

Mapping Physicians' Experiences with Medicinal Products from Whole Medical Systems: A Descriptive Analysis of the Vademecum of Anthroposophic Medicines

BACKGROUND

Therapy in whole medical systems involves a large number of medicinal products. One source of knowledge of clinical properties of such products is the experience of therapy providers. A systematic approach to documentation, assessment, and aggregation of physicians' experiences with anthroposophic medicinal products (AMPs) has been developed: the Vademecum of Anthroposophic Medicines.

MATERIAL AND METHODS

The Vademecum contains structured information on AMPs, including therapeutic rationale, indications, and therapy recommendations. The information is based on a 17-item questionnaire of physicians' therapy experiences, which is peer-reviewed by an interdisciplinary editorial board. We conducted a descriptive analysis of the Vademecum, 4th edition.

RESULTS

The Vademecum comprised 799 different AMPs, used for 1,773 indications, based on 2,543 questionnaires submitted by 274 physicians from 19 countries. The 799 AMPs comprised 52.6% of all AMPs marketed in Germany in 2015-2016. The 1,773 indications corresponded to 544 different ICD-10 three-digit codes, amounting to 29.3% (n = 544/1,854) of all three-digit codes. A total of 30.6% (n = 542/1,773) of indications were supported by ≥2 questionnaires.

CONCLUSIONS

The current Vade-mecum covers more than half of all AMPs, used for more than one fourth of all ICD-10 three-digit codes. The Vademecum approach may be relevant for medicinal products from other whole medical systems.

Contributing to Global Health: Development of a Consensus-Based Whole Systems Research Strategy for Anthroposophic Medicine

Background

Whole medicine and health systems like traditional and complementary medicine systems (T&CM) are part of healthcare around the world. One key feature of T&CM is its focus on patient-centered and multimodal care and the integration of intercultural perspectives in a wide range of settings. It may contribute to good health and well being for people as part of the Sustainable Development Goals of the United Nations. The authentic, rigorous, and fair evaluation of such a medical system, with its inherent complexity and individualization, imposes methodological challenges. Hence, we propose a broad research strategy to test and characterize its possible contribution to health.

Methods

To develop a research strategy for a specific T&CM system, Anthroposophic Medicine (AM), applying multimodal integrative healthcare based on a four-level concept of man, we used a three-phase consensus process with experts and key stakeholders, consisting of (1) premeeting methodological literature and AM research review and interviews to supplement or revise items of the research strategy and tailor them to AM research, (2) face-to-face consensus meetings further developing and tailoring the strategy, and (3) postmeeting feedback and review, followed by finalization.

Results

Currently, AM covers many fields of medical specialties in varied levels of healthcare settings, such as outpatient and inpatient; primary, secondary, and tertiary care; and health education and pedagogy. It is by definition integrated with conventional medicine in the public healthcare system. It applies specific medicines, nursing techniques, arts therapies, eurythmy therapy, rhythmical massage, counseling, and psychotherapy, and it is provided by medical doctors, nurses, therapists, midwives, and nutritionists. A research strategy authentic to this level of complexity should comprise items with a focus on (I) efficacy and effectiveness, divided into (a) evaluation of the multimodal and multidisciplinary medical system as a whole, or of complex multimodal therapy concept, (b) a reasonable amount of methodologically rigorous, confirmatory randomized controlled trials on exemplary pharmacological and nonpharmacological therapies and indications, (c) a wide range of interventions and patient-centered care strategies with less extensive formats like well-conducted small trails, observational studies, and high-quality case reports and series, or subgroup analyses from whole-system studies, or health service research; (II) safety; (III) economics; (IV) evidence synthesis; (V) methodologic issues; (VI) biomedical, physiological, pharmacological, pharmaceutical, psychological, anthropological, and nosological issues as well as innovation and development; (VI) patient perspective and involvement, public needs, and ethics; (VII) educational matters and professionalism; and (IX) disease prevention, health promotion, and public health.

Conclusion

The research strategy extends to and complements the prevailing hierarchical system by introducing a broad “evidence house” approach to evaluation, something many health technology assessment boards today support. It may provide transparent and comprehensive insight into potential benefits or risks of AM. It can serve as a framework for an evidence-informed approach to AM for a variety of stakeholders and collaborating networks with the aim of improving global health.

The Contribution of Complementary and Alternative Medicine to Reduce Antibiotic Use: A Narrative Review of Health Concepts, Prevention, and Treatment Strategies

AIM

The aim of this narrative review was to explore the potential contributions of CAM to reduce antibiotic use.

METHODS

We searched PubMed, Embase, and Cochrane Database of Systematic Reviews with a specific, limited set of search terms and collected input from a group of expert CAM researchers to answer the question: What is known about the contribution of CAM health and health promotion concepts, infection prevention, and infection treatment strategies to reduce antibiotic use? Results. The worldview-related CAM health concepts enable health promotion oriented infection prevention and treatment aimed at strengthening or supporting the self-regulating ability of the human organism to cope with diseases. There is some evidence that the CAM concepts of health (promotion) are in agreement with current conceptualization of health and that doctors who practice both CAM and conventional medicine prescribe less antibiotics, although selection bias of the presented studies cannot be ruled out. There is some evidence that prevention and some treatment strategies are effective and safe. Many CAM treatment strategies are promising but overall lack high quality evidence.

CONCLUSIONS

CAM prevention and treatment strategies may contribute to reducing antibiotic use, but more rigorous research is necessary to provide high quality evidence of (cost-)effectiveness.