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Elvir Lazo OL, White PF, Lee C, Cruz Eng H, Matin JM, Lin C, Del Cid F, Yumul R. Use of herbal medication in the perioperative period: Potential adverse drug interactions. J Clin Anesth 2024; 95:111473. [PMID: 38613937 DOI: 10.1016/j.jclinane.2024.111473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 02/26/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
Use of herbal medications and supplements has experienced immense growth over the last two decades, with retail sales in the USA exceeding $13 billion in 2021. Since the Dietary Supplement Health and Education Act (DSHEA) of 1994 reduced FDA oversight, these products have become less regulated. Data from 2012 shows 18% of U.S. adults used non-vitamin, non-mineral natural products. Prevalence varies regionally, with higher use in Western states. Among preoperative patients, the most commonly used herbal medications included garlic, ginseng, ginkgo, St. John's wort, and echinacea. However, 50-70% of surgical patients fail to disclose their use of herbal medications to their physicians, and most fail to discontinue them preoperatively. Since herbal medications can interact with anesthetic medications administered during surgery, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend stopping herbal medications 1-2 weeks before elective surgical procedures. Potential adverse drug effects related to preoperative use of herbal medications involve the coagulation system (e.g., increasing the risk of perioperative bleeding), the cardiovascular system (e.g., arrhythmias, hypotension, hypertension), the central nervous system (e.g., sedation, confusion, seizures), pulmonary (e.g., coughing, bronchospasm), renal (e.g., diuresis) and endocrine-metabolic (e.g., hepatic dysfunction, altered metabolism of anesthetic drugs). During the preoperative evaluation, anesthesiologists should inquire about the use of herbal medications to anticipate potential adverse drug interactions during the perioperative period.
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Affiliation(s)
| | - Paul F White
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; White Mountain Institute, The Sea Ranch, CA 95497, USA.
| | - Carol Lee
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Hillenn Cruz Eng
- Department of Anesthesiology, Adena Health System, Chillicothe, OH, USA.
| | - Jenna M Matin
- Tulane University School of Medicine, New Orleans, LA, USA.
| | - Cory Lin
- Department of Anesthesiology and Perioperative Care, University of California Irvine, CA, USA.
| | - Franklin Del Cid
- Department of Anesthesiology, Hospital Escuela, Tegucigalpa, Honduras.
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; David Geffen School of Medicine-UCLA, Charles R, Drew University of Medicine and Science, Los Angeles, CA, USA.
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Karimi SM, Bayat M, Rahimi R. Plant-derived natural medicines for the management of osteoporosis: A comprehensive review of clinical trials. J Tradit Complement Med 2024; 14:1-18. [PMID: 38223808 PMCID: PMC10785263 DOI: 10.1016/j.jtcme.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 01/16/2024] Open
Abstract
Background Osteoporosis is a chronic and systemic skeletal disease that is defined by low bone mineral density (BMD) along with an increase in bone fragility and susceptibility to fracture. This study aimed to overview clinical evidence on the use of herbal medicine for management of osteoporosis. Methods Electronic databases including Pubmed, Medline, Cochrane library, and Scopus were searched until November 2022 for any clinical studies on the efficacy and/or safety of plant-derived medicines in the management of osteoporosis. Results The search yielded 57 results: 19 on single herbs, 16 on multi-component herbal preparations, and 22 on plant-derived secondary metabolites. Risk of fracture, bone alkaline phosphatase, BMD, and specific bone biomarkers are investigated outcomes in these studies. Medicinal plants including Acanthopanax senticosus, Actaea racemosa, Allium cepa, Asparagus racemosus, Camellia sinensis, Cissus quadrangularis, Cornus mas, Nigella sativa, Olea europaea, Opuntia ficus-indica, Pinus pinaster, Trifolium pretense and phytochemicals including isoflavones, ginsenoside, Epimedium prenyl flavonoids, tocotrienols are among plant-derived medicines clinically investigated on osteoporosis. It seems that multi-component herbal preparations were more effective than single-component ones; because of the synergistic effects of their constituents. The investigated herbal medicines demonstrated their promising results in osteoporosis via targeting different pathways in bone metabolism, including balancing osteoblasts and osteoclasts, anti-inflammatory, immunomodulatory, antioxidant, and estrogen-like functions. Conclusion It seems that plant-derived medicines have beneficial effects on bone and may manage osteoporosis by affecting different targets and pathways involved in osteoporosis; However, Future studies are needed to confirm the effectiveness and safety of these preparations.
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Affiliation(s)
- Seyedeh Mahnaz Karimi
- Department of Traditional Pharmacy, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Bayat
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Roja Rahimi
- Department of Traditional Pharmacy, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Płoska A, Wozniak M, Hedhli J, Konopka CJ, Skondras A, Matatov S, Stawarz A, Schuh S, Czerwinski A, Dobrucki LW, Kalinowski L, Dobrucki IT. In Vitro and In Vivo Imaging-Based Evaluation of Doxorubicin Anticancer Treatment in Combination with the Herbal Medicine Black Cohosh. Int J Mol Sci 2023; 24:17506. [PMID: 38139334 PMCID: PMC10743623 DOI: 10.3390/ijms242417506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
As a substitution for hormone replacement therapy, many breast cancer patients use black cohosh (BC) extracts in combination with doxorubicin (DOX)-based chemotherapy. In this study, we evaluated the viability and survival of BC- and DOX-treated MCF-7 cells. A preclinical model of MCF-7 xenografts was used to determine the influence of BC and DOX administration on tumor growth and metabolism. The number of apoptotic cells after incubation with both DOX and BC was significantly increased (~100%) compared to the control. Treatment with DOX altered the potential of MCF-7 cells to form colonies; however, coincubation with BC did not affect this process. In vivo, PET-CT imaging showed that combined treatment of DOX and BC induced a significant reduction in both metabolic activity (29%) and angiogenesis (32%). Both DOX and BC treatments inhibited tumor growth by 20% and 12%, respectively, and combined by 57%, vs. control. We successfully demonstrated that BC increases cytotoxic effects of DOX, resulting in a significant reduction in tumor size. Further studies regarding drug transport and tumor growth biomarkers are necessary to establish the underlying mechanism and potential clinical use of BC in breast cancer patients.
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Affiliation(s)
- Agata Płoska
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.Pl, Medical University of Gdansk, 80-211 Gdansk, Poland; (A.P.); (M.W.); (L.W.D.)
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
| | - Marcin Wozniak
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.Pl, Medical University of Gdansk, 80-211 Gdansk, Poland; (A.P.); (M.W.); (L.W.D.)
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
| | - Jamila Hedhli
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
- Carle-Illinois College of Medicine, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Christian J. Konopka
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Antonios Skondras
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
| | - Sarah Matatov
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
| | - Andrew Stawarz
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Sarah Schuh
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Andrzej Czerwinski
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
| | - Lawrence W. Dobrucki
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.Pl, Medical University of Gdansk, 80-211 Gdansk, Poland; (A.P.); (M.W.); (L.W.D.)
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
- Carle-Illinois College of Medicine, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Leszek Kalinowski
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.Pl, Medical University of Gdansk, 80-211 Gdansk, Poland; (A.P.); (M.W.); (L.W.D.)
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
- BioTechMed Centre, Department of Mechanics of Materials and Structures, Gdansk University of Technology, 80-233 Gdansk, Poland
| | - Iwona T. Dobrucki
- Beckman Institute for Advanced Science and Technology, Urbana, IL 61801, USA; (J.H.); (C.J.K.)
- Carle-Illinois College of Medicine, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Academy of Medical and Social Applied Sciences, 82-300 Elblag, Poland
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Sadahiro R, Matsuoka LN, Zeng BS, Chen KH, Zeng BY, Wang HY, Chu CS, Stubbs B, Su KP, Tu YK, Wu YC, Lin PY, Chen TY, Chen YW, Suen MW, Hopwood M, Yang WC, Sun CK, Cheng YS, Shiue YL, Hung CM, Matsuoka YJ, Tseng PT. Black cohosh extracts in women with menopausal symptoms: an updated pairwise meta-analysis. Menopause 2023; 30:766-773. [PMID: 37192826 DOI: 10.1097/gme.0000000000002196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Menopausal symptoms are common in midlife women and have broad impacts on their daily functioning and quality of life. Black cohosh extracts have been widely used to relieve menopausal symptoms. However, the comparative benefits of different combined black cohosh regimens remain inconclusive. The aim of the current updated meta-analysis is to address the comparative efficacies of different black cohosh regimens in improving menopausal symptoms. METHODS Random-effect model pairwise meta-analysis of randomized controlled trials was conducted to investigate the treatment effect on menopausal symptoms by the black cohosh extract both alone or combined with other related active ingredients. The outcomes studied were changes in menopausal symptoms after treatment with black cohosh extracts in menopausal women. RESULTS Twenty-two articles including information on 2,310 menopausal women were included in the analyses. Black cohosh extracts were associated with significant improvements in overall menopausal symptoms (Hedges' g = 0.575, 95% CI = 0.283 to 0.867, P < 0.001), as well as in hot flashes (Hedges' g = 0.315, 95% CIs = 0.107 to 0.524, P = 0.003), and somatic symptoms (Hedges' g = 0.418, 95% CI = 0.165 to 0.670, P = 0.001), compared with placebo. However, black cohosh did not significantly improve anxiety (Hedges' g = 0.194, 95% CI = -0.296 to 0.684, P = 0.438) or depressive symptoms (Hedges' g = 0.406, 95% CI = -0.121 to 0.932, P = 0.131). The dropout rate for black cohosh products was similar to that for placebo (odds ratio = 0.911, 95% CI = 0.660 to 1.256, P = 0.568). CONCLUSIONS This study provides updated evidence regarding the potentially beneficial effects of black cohosh extracts for relieving menopausal symptoms in menopausal women.
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Affiliation(s)
- Ryoichi Sadahiro
- From the Department of Immune Medicine, National Cancer Center Research Institute, National Cancer Center Japan, Tokyo, Japan
| | | | | | - Keng-Hsu Chen
- Department of Medical Education, E-Da Hospital, I-Shou University, E-Da Healthcare Group, Kaohsiung, Taiwan
| | - Bing-Yan Zeng
- Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Hung-Yu Wang
- Department of Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | | | | | | | | | - Yi-Cheng Wu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | | | | | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology and Neurology, Kaohsiung City, Taiwan
| | | | | | | | | | | | - Yow-Ling Shiue
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | | | - Yutaka J Matsuoka
- Center for Public Health Sciences, National Cancer Center Japan, Japan
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Pandozzi C, Giannetta E, Tarsitano MG. Phytotherapic approach in menopause: light and darkness. Minerva Endocrinol (Torino) 2022; 47:421-436. [PMID: 35420287 DOI: 10.23736/s2724-6507.22.03712-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Menopause is a critical period of the woman life, characterized by a peculiar modification in estrogens concentration and accompanied by different signs and symptoms. To prevent and contrast unfavorable consequences of menopause, different therapeutic approaches could be evaluated. The hormone replacement therapy (HRT) is the most known, but it has several contraindications. The increasing interest in phytotherapy introduces the necessity for endocrinologist involved in menopause to suggest different therapeutic approaches, considering the state of health of patient and the real efficacy of the drugs. We aim to outline the main phytotherapy treatments to choose in menopause. EVIDENCE ACQUISITION This review is based on focused research of the current literature on PubMed and Scopus such as research databases. We selected 4120 papers through these keywords: "MENOPAUSE" AND "phytotherapy," "natural therapy," "phytoterapy drugs." Then, the literature was scanned selecting English papers of last 10 years (last research on October 1, 2021), excluding reviews. Separately, two researchers MGT and CP examined and read 212 full selected papers. We included clinical trials and randomized clinical trials written in English and excluded duplicates, animal studies and studies with lack of group of interest, non-relevant outcomes, inappropriate methodology. Retrospective studies, case reports, case series, original articles, brief communications, and letter to the editor were included in our research. We furthermore completed our research by the examination of every study's bibliography. EVIDENCE SYNTHESIS Phytotherapy involves the use of plants or plant extracts for the treatment of diseases thanks to the activities of their compounds and metabolites. In particular, many of them have an estrogen-like activity and are identified as phytoestrogens, because thanks to their chemical structure are able to bind the estrogen receptors and carry out biological estrogenic or antiestrogenic activities. The supplementing diet with these compounds can ensure an advantage on various aspects of the climacteric syndrome and some of them also have a beneficial impact on cardiovascular risk, bone health and sleep complaint. These substances can be used with safety due to their good tolerability and low rate of side effects. There are no known serious adverse events associated with their consumption, but as a precaution, its use is not recommended during pregnancy and in association with hormonal therapies or in women with hormone responsive cancers. CONCLUSIONS Phytotherapy must be considered an interesting tool in the treatment of signs and symptoms in selected menopause woman.
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Affiliation(s)
- Carla Pandozzi
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Elisa Giannetta
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Maria G Tarsitano
- Department of Clinical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
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Pochet S, Lechon AS, Lescrainier C, De Vriese C, Mathieu V, Hamdani J, Souard F. Herb-anticancer drug interactions in real life based on VigiBase, the WHO global database. Sci Rep 2022; 12:14178. [PMID: 35986023 PMCID: PMC9391489 DOI: 10.1038/s41598-022-17704-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/29/2022] [Indexed: 12/21/2022] Open
Abstract
AbstractCancer patients could combine herbal treatments with their chemotherapy. We consulted VigiBase, a WHO database of individual case safety reports (ICSRs) which archives reports of suspected Adverse Drug Reactions (ADRs) when herbal products are used in conjunction with anti-cancer treatment. We focused on the possible interactions between antineoplastic (L01 ATC class) or hormone antagonists (L02B ATC class) with 10 commonly used herbs (pineapple, green tea, cannabis, black cohosh, turmeric, echinacea, St John’s wort, milk thistle and ginger) to compare ADRs described in ICSRs with the literature. A total of 1057 ICSRs were extracted from the database but only 134 were complete enough (or did not concern too many therapeutic lines) to keep them for analysis. Finally, 51 rationalizable ICSRs could be explained, which led us to propose a pharmacokinetic or pharmacodynamic interaction mechanism. Reports concerned more frequently women and half of the rationalizable ICSRs involved Viscum album and Silybum marianum. 5% of the ADRs described could have been avoided if clinicians had had access to the published information. It is also important to note that in 8% of the cases, the ADRs observed were life threatening. Phytovigilance should thus be considered more by health care professionals to best treat cancer patients and for better integrative care.
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Agnoletti D, Fogacci F, Di Micoli A, Borghi C, Cicero AFG. A case of liver injury during lipid-lowering therapy. Phytother Res 2022; 36:4017-4019. [PMID: 35821650 DOI: 10.1002/ptr.7536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 06/12/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Davide Agnoletti
- Cardiovascular Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federica Fogacci
- Cardiovascular Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Di Micoli
- Cardiovascular Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Borghi
- Cardiovascular Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Arrigo Francesco Giuseppe Cicero
- Cardiovascular Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Castelo-Branco C, Navarro C, Beltrán E, Losa F, Camacho M. Black cohosh efficacy and safety for menopausal symptoms. The Spanish Menopause Society statement. Gynecol Endocrinol 2022; 38:379-384. [PMID: 35403534 DOI: 10.1080/09513590.2022.2056591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE The increasing interest in Western countries regarding phytotherapy use to treat menopause-related symptoms has led the Spanish Menopause Society (AEEM) to update its position statement performed in 2009 on the role of black cohosh (Cimicifuga racemosa) for the treatment of menopausal symptoms. MATERIAL AND METHODS A panel of experts from both clinical and research backgrounds were assembled to investigate the best available evidence. Selected studies were obtained by an electronic search, including the Internet search engines MEDLINE-Pubmed (1997-December 2021) and the Cochrane Controlled Trials Register. RESULTS Most of the well-designed studies published in recent years have been conducted with the isopropanolic extract of black cohosh/C. racemosa. The most common dose is 40 mg/day capable of achieving a significant reduction in hot flushes (particularly in women with intense hot flushes) and an improvement in mood. Used at the recommended doses, C. racemose produces no significant adverse reactions. CONCLUSION Black cohosh is an effective and safe treatment option for the relieving of vasomotor symptoms. Finally, further clinical trials with sufficient patient enrollment and longer study follow-up are needed.
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Affiliation(s)
- Camil Castelo-Branco
- Institut Clinic de Ginecologia, Obstetrícia i Neonatologia, Hospital Clinic Barcelona, Barcelona, Spain
- Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
- Institut d´ Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | | | - Marta Camacho
- Institut Clinic de Ginecologia, Obstetrícia i Neonatologia, Hospital Clinic Barcelona, Barcelona, Spain
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Mohapatra S, Iqubal A, Ansari MJ, Jan B, Zahiruddin S, Mirza MA, Ahmad S, Iqbal Z. Benefits of Black Cohosh (Cimicifuga racemosa) for Women Health: An Up-Close and In-Depth Review. Pharmaceuticals (Basel) 2022; 15:ph15030278. [PMID: 35337076 PMCID: PMC8953734 DOI: 10.3390/ph15030278] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 12/18/2022] Open
Abstract
Women’s health is an imminent concern worldwide, but it remains an ignored segment of research in most developing countries, and is yet to take the center stage in even developed nations. Some exclusive female health concerns revolve around both pathological and physiological aspects. These gender-specific maladies include breast, cervical, and ovarian cancers, and physiological concerns such as menopause and osteoporosis, which are often coexistent. Recently, women’s health issues, including postmenopausal syndrome, have attracted the attention of researchers and practitioners alike, opening newer pharmaceutical research and clinical avenues. Although not counted as a disease, postmenopausal syndrome (PMS) is a female health phenomenon underpinned by hormonal depletion. Enhanced life expectancy in women has added to their suffering, and pharmacological interventions are needed. Amongst the available treatment modalities, the use of numerous botanicals has emerged as an efficient health management tool for women. Cimicifuga racemosa (CR or Black Cohosh) is a plant/herb which has been traditionally exploited and extensively used by women. This review is an attempt to compile and provide a summary of the importance of CR in complementary and alternative therapies for the improvement of various disorders related to women, such as menopausal syndrome, mammary cancer, and osteoporosis. It aims to systematically highlight the bioactive constituents, pharmacology, pharmacokinetics, therapeutic potentials, quality control processes, chromatographic techniques, and possible mechanisms of action of clinically effective phytomedicine for women’s health. Various clinical trials and patents relating to CR and women’s health have been collated. Furthermore, the plant and its related products have been considered from a regulatory perspective to reveal its commercial feasibility. The present review summarizes the existing data on CR focusing on women’s health, which can help to introduce this traditional phytomedicine to the world and provide some reference for future drug development.
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Affiliation(s)
- Sradhanjali Mohapatra
- Nanotechnology Lab, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India;
- Bioactive Natural Product Laboratory, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India; (B.J.); (S.Z.)
| | - Ashif Iqubal
- Department of Pharmacology, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India;
| | - Mohammad Javed Ansari
- Department of Pharmaceutics, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia;
| | - Bisma Jan
- Bioactive Natural Product Laboratory, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India; (B.J.); (S.Z.)
| | - Sultan Zahiruddin
- Bioactive Natural Product Laboratory, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India; (B.J.); (S.Z.)
| | - Mohd Aamir Mirza
- Nanotechnology Lab, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India;
- Correspondence: (M.A.M.); (S.A.); (Z.I.); Tel.: +98-11-733-016 (Z.I.)
| | - Sayeed Ahmad
- Bioactive Natural Product Laboratory, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India; (B.J.); (S.Z.)
- Correspondence: (M.A.M.); (S.A.); (Z.I.); Tel.: +98-11-733-016 (Z.I.)
| | - Zeenat Iqbal
- Nanotechnology Lab, School of Pharmaceutics Education and Research (SPER), Jamia Hamdard University, New Delhi 110062, India;
- Correspondence: (M.A.M.); (S.A.); (Z.I.); Tel.: +98-11-733-016 (Z.I.)
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Fibrous Roots of Cimicifuga Are at Risk of Hepatotoxicity. Molecules 2022; 27:molecules27030938. [PMID: 35164202 PMCID: PMC8840794 DOI: 10.3390/molecules27030938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 02/05/2023] Open
Abstract
The cause of liver damage by using black cohosh preparation has been concerned but remains unclear. After a preliminary investigation, the black cohosh medicinal materials sold in the market were adulterated with Asian cohosh (Cimicifuga) without removing the fibrous roots. The safety of Cimicifuga rhizome and fibrous roots is unknown and has not been reported. Therefore, in this paper, the rhizome and fibrous roots of Cimicifuga dahurica (Turcz.) Maxim (C. dahurica) were completely separated, extracted with 70% ethanol, and freeze-dried to obtain crude rhizome extract (RC) and fibrous roots extract (FRC). UHPLC-Q-TOF-MS was used to identify 39 compounds in the rhizome and fibrous roots of Cimicifuga, mainly saponins and phenolic acids. In the L-02 cytotoxicity experiment, the IC50 of fibrous roots (1.26 mg/mL) was slightly lower than that of rhizomes (1.417 mg/mL). In the 90-day sub-chronic toxicity study, the FRC group significantly increased the level of white blood cells, ALP, ALT, AST, BILI and CHOL (p < 0.05); large area of granular degeneration and balloon degeneration occurred in liver tissue; and the expression of p-NF-kB in the nucleus increased in a dose-dependent manner. Overall, Fibrous roots of Cimicifuga are at risk of hepatotoxicity and should be strictly controlled and removed during the processing.
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Funk JL, Schneider C. Perspective on Improving the Relevance, Rigor, and Reproducibility of Botanical Clinical Trials: Lessons Learned From Turmeric Trials. Front Nutr 2021; 8:782912. [PMID: 34926556 PMCID: PMC8678600 DOI: 10.3389/fnut.2021.782912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Plant-derived compounds, without doubt, can have significant medicinal effects since many notable drugs in use today, such as morphine or taxol, were first isolated from botanical sources. When an isolated and purified phytochemical is developed as a pharmaceutical, the uniformity and appropriate use of the product are well defined. Less clear are the benefits and best use of plant-based dietary supplements or other formulations since these products, unlike traditional drugs, are chemically complex and variable in composition, even if derived from a single plant source. This perspective will summarize key points-including the premise of ethnobotanical and preclinical evidence, pharmacokinetics, metabolism, and safety-inherent and unique to the study of botanical dietary supplements to be considered when planning or evaluating botanical clinical trials. Market forces and regulatory frameworks also affect clinical trial design since in the United States, for example, botanical dietary supplements cannot be marketed for disease treatment and submission of information on safety or efficacy is not required. Specific challenges are thus readily apparent both for consumers comparing available products for purchase, as well as for commercially sponsored vs. independent researchers planning clinical trials to evaluate medicinal effects of botanicals. Turmeric dietary supplements, a top selling botanical in the United States and focus of over 400 clinical trials to date, will be used throughout to illustrate both the promise and pitfalls associated with the clinical evaluation of botanicals.
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Affiliation(s)
- Janet L Funk
- Department of Medicine, University of Arizona, Tucson, AZ, United States
| | - Claus Schneider
- Department of Pharmacology, Vanderbilt University, Nashville, TN, United States
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Guida M, Raffone A, Travaglino A, Neola D, Reppuccia S, Borgo M, Vitale C, Limone A, D'Alessandro P, Massaro G, Mollo A. Cimicifuga racemosa isopropanolic extract for menopausal symptoms: an observational prospective case-control study. Gynecol Endocrinol 2021; 37:1132-1137. [PMID: 34477029 DOI: 10.1080/09513590.2021.1974381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE We aimed to investigate the effectiveness of isopropanolic extract of Cimicifuga Racemosa (iCR) on reducing menopausal symptoms. MATERIALS AND METHODS A single-center observational prospective case-control study was performed to assess the improvement of menopausal symptoms in menopausal women undergone iCR administration (cases) or no treatment (controls). Menopausal symptoms were assessed through a modified version of the Menopause Rating Scale questionnaire (mMRS) at T0 (baseline), T1 (1-month follow-up), and T2 (3 months follow-up). Univariate comparisons between cases and controls were performed by using the unpaired T test for two-tailed P value with α = 0.05 significance level. RESULTS A total of 163 women (83 cases and 80 controls) were enrolled in the study. The difference in menopausal symptoms between cases and controls from T0 to T2, and from T0 to T1, was found significant for all analyses. In particular, the difference in all menopausal symptoms was 20.56 ± 0.90 points (95%CI: 18.77-22.33, p < .001) from T0 to T2, and 10.69 ± 0.6 (95%CI: 9.49-11.88, p < .001) from T0 to T1. CONCLUSION iCR may be effective in reducing menopausal symptoms, both after 1 month and after 3 months of treatment. The improvement was higher in vasomotor symptoms, sleep problems, and irritability.
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Affiliation(s)
- Maurizio Guida
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Daniele Neola
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Sabrina Reppuccia
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Maria Borgo
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Clorinda Vitale
- Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Andrea Limone
- Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Pietro D'Alessandro
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giulia Massaro
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Italy
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De Franciscis P, Guida M, Schiattarella A, Riemma G, Colacurci N. Safety of non-hormonal medications for managing hot flashes. Expert Opin Drug Saf 2021; 21:215-221. [PMID: 34304686 DOI: 10.1080/14740338.2021.1960310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Menopausal complaints are a critical aspect of women's lives. In particular vasomotor symptoms, such as hot flashes, may seriously impact quality of life and are considered the most bothersome complaint by patients. Although Menopausal Hormone Therapy (MHT) is considered the best option, women increasingly ask for a natural and more tailored treatment approach.Areas covered: Nutraceutical compounds represent the most widespread alternative therapy for vasomotor symptoms, and their use is somewhat increasing. In this review, the authors analyzed the mechanism of action and the related safety of non-hormonal treatments, including new approaches and future aspects.Expert opinion: MHT represents the traditional therapy for menopausal complaints, especially for severe and moderate symptoms; however, evidence has not defined a safety profile for all patients. To address this issue, nutraceuticals could represent a compelling and useful non-hormonal approach in selected patients.
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Affiliation(s)
- Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maurizio Guida
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gaetano Riemma
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
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Salari S, Amiri MS, Ramezani M, Moghadam AT, Elyasi S, Sahebkar A, Emami SA. Ethnobotany, Phytochemistry, Traditional and Modern Uses of Actaea racemosa L. (Black cohosh): A Review. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1308:403-449. [PMID: 33861455 DOI: 10.1007/978-3-030-64872-5_24] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Actaea racemosa (AR) also known as Cimicifuga racemosa, is a perennial plant from Ranunculaceae family which was used as traditional remedies in treatment of various condition like rheumatoid muscular pain, headache, inflammation and dysmenorrhea. Actaea racemosa was basically native to Canada and the Eastern United State. This chapter proposed the ethnopharmacological uses of Actaea racemosa, and its phytochemical properties. Specifically, in this article we focused on use of Actaea racemose for menopausal and post-menopausal symptoms management. Electronic databases including PubMed and Scopus were searched for studies on Actaea racemose and its administration in management of menopausal symptoms. Chem Office software was also used in order to find chemical structures. The key words used as search terms were Cimicifuga racemose, Actaea racemose, Ranunculaceae, Black cohosh, Menopausal symptoms. We have included all relevant animal and human studies up to the date of publication. The analysis on Actaea racemose showed various indications for different plant's extracts. Approximately 131 chemical compounds have been isolated and identified from Actaea racemosa. According to recently studies, the most important chemicals known of the Actaea racemosa are phenolic compounds, chromones, triterpenoids, nitrogen-containing constituents. In addition, in vivo and in vitro studies reported wide range of pharmacological activities for Black cohosh like attenuating menopausal symptoms. Mechanism of action for some ethnomedicinal indications were made clear while some of its activities are not confirmed by pharmacological studies yet. Further investigations on its pharmacological properties are necessary to expand its clinical effective use. Also, additional large clinical trials are recommended for clarifying the effect of Black cohosh.
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Affiliation(s)
- Sofia Salari
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mahin Ramezani
- Nanotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Tafazoli Moghadam
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sepideh Elyasi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. .,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran. .,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran. .,Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland.
| | - Seyed Ahmad Emami
- Department of Traditional Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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Castelo-Branco C, Gambacciani M, Cano A, Minkin MJ, Rachoń D, Ruan X, Beer AM, Schnitker J, Henneicke-von Zepelin HH, Pickartz S. Review & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms – an update on the evidence. Climacteric 2020; 24:109-119. [DOI: 10.1080/13697137.2020.1820477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- C. Castelo-Branco
- Clinic Institute of Gnyecology, Obstetrics and Neonatology, Faculty of Medicine, University of Barcelona, Hospital Clinic-Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M. Gambacciani
- Menopause Center, Department of Obstetrics and Gynecology, University of Pisa, Pisa, Italy
| | - A. Cano
- Department of Obstetrics and Gynecology, University of Valencia, Valencia, Spain
| | - M. J. Minkin
- Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - D. Rachoń
- Department of Clinical and Experimental Endocrinology, Medical University of Gdańsk, Gdańsk, Poland
| | - X. Ruan
- Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - A.-M. Beer
- Hospital for True Naturopathy, Katholisches Klinikum Bochum, Blankenstein Hospital, Hattingen, Germany
| | - J. Schnitker
- Institut für Angewandte Statistik (IAS) GmbH, Bielefeld, Germany
| | | | - S. Pickartz
- Medical Service, Schaper & Brümmer GmbH & Co. KG, Salzgitter, Germany
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16
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Fernandes ES, Celani MFS, Fistarol M, Geber S. Effectiveness of the short-term use of Cimicifuga racemosa in the endothelial function of postmenopausal women: a double-blind, randomized, controlled trial. Climacteric 2019; 23:245-251. [PMID: 31691621 DOI: 10.1080/13697137.2019.1682542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: This study aimed to assess the effects of daily use of Cimicifuga racemosa on endothelial function through flow-mediated dilation of the brachial artery, when used for 28 days by healthy postmenopausal women.Methods: The double-blind, randomized, placebo-controlled study included two groups of postmenopausal women (n = 31 each). The subjects were clinically assessed and flow-mediated dilation of the brachial artery was measured before and after 28 days of treatment. Patients received dry extract corresponding to 160 mg C. racemosa (extract with 4 mg of triterpene glycosides) or placebo.Results: Mean age, time since menopause, and body mass index in the two groups were similar. The measurements of flow-mediated dilation of the brachial artery, pre and post treatment, respectively, showed a significant increase in patients who used C. racemosa (p = 0.006), unlike patients who used placebo, who did not present changes in the outcome of flow-mediated dilation of the brachial artery after 28 days of use (p ≥ 0.05). When comparing the number of women in both groups who showed an increase in flow-mediated dilation, a significant difference was found in the measurements of the treated group after the use of the medication (p = 0.018).Conclusions: Daily use of 160 mg C. racemosa extract by postmenopausal women for 28 days beneficially influences endothelial function by promoting elasticity of the brachial artery.
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Affiliation(s)
- E S Fernandes
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - M F S Celani
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - M Fistarol
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - S Geber
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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17
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No Author. Chapitre 9 : Médecine complémentaire et parallèle. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41 Suppl 1:S122-S129. [DOI: 10.1016/j.jogc.2019.02.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Biglia N, Bounous VE, De Seta F, Lello S, Nappi RE, Paoletti AM. Non-hormonal strategies for managing menopausal symptoms in cancer survivors: an update. Ecancermedicalscience 2019; 13:909. [PMID: 31123492 PMCID: PMC6445536 DOI: 10.3332/ecancer.2019.909] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Indexed: 01/08/2023] Open
Abstract
Vasomotor symptoms, particularly hot flushes (HFs), are the most frequently reported symptom by menopausal women. In particular, for young women diagnosed with breast cancer, who experience premature ovarian failure due to cancer treatments, severe HFs are an unsolved problem that strongly impacts on quality of life. The optimal management of HFs requires a personalised approach to identify the treatment with the best benefit/risk profile for each woman. Hormonal replacement therapy (HRT) is effective in managing HFs but it is contraindicated in women with previous hormone-dependent cancer. Moreover, many healthy women are reluctant to take HRT and prefer to manage symptoms with non-hormonal strategies. In this narrative review, we provide an update on the current available non-oestrogenic strategies for HFs management for women who cannot, or do not wish to, take oestrogens. Since isoflavones have oestrogenic properties and it is not known if they can be safely consumed by women with previous hormone-dependent cancer, they were excluded. Selective serotonin reuptake inhibitors/selective serotonin-norepinephrine reuptake inhibitors, as well as other neuroactive agents, some herbal remedies and behavioural strategies are considered.
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Affiliation(s)
- Nicoletta Biglia
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, School of Medicine, University of Torino, Largo Turati 62, 10128 Torino, Italy
| | - Valentina E Bounous
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, School of Medicine, University of Torino, Largo Turati 62, 10128 Torino, Italy
| | - Francesco De Seta
- Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', University of Trieste, via dell'Istria 65/1, 34137 Trieste, Italy
| | - Stefano Lello
- Department of Woman and Child Health, Policlinico Gemelli Foundation, Largo Gemelli 1, 00168 Rome, Italy
| | - Rossella E Nappi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Anna Maria Paoletti
- Department of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, University Hospital of Cagliari, SS 554 km 4,500, 09042 Monserrato, Italy
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Teschke R. Top-ranking drugs out of 3312 drug-induced liver injury cases evaluated by the Roussel Uclaf Causality Assessment Method. Expert Opin Drug Metab Toxicol 2018; 14:1169-1187. [PMID: 30354694 DOI: 10.1080/17425255.2018.1539077] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION A list presenting a valid ranking of drugs most commonly implicated is hardly to be found. Areas covered: Published cases of drug-induced liver injury (DILI) with verified causality using RUCAM (Roussel Uclaf Causality Assessment Method) were used for a ranking of drugs most commonly implicated in causing DILI. Expert opinion: RUCAM-based DILI cases were retrieved from 15 reports published by six international databases of DILI registries and three large medical centers, which provided 3312 cases. Overall 48 drugs with the highest number of DILI cases were listed. Among the top 10 ranking drugs implicated in causing DILI were, in decreasing order: amoxicillin-clavulanate, flucloxacilllin, atorvastatin, disulfiram, diclofenac, simvastatin, carbamazepine, ibuprofen, erythromycin, and anabolic steroids as bodybuilding agents. For these 10 drugs, respective DILI case numbers were highest for Amoxicillin-clavulanate (n=333) and lowest for anabolic steroids (n=26). The author classifies the databases of national DILI registries and large medical centers as best sources of drugs implicated in DILI. Presently discouraged is the use of the LiverTox website because many cases were derived from published cases of poor quality and could previously not be classified as DILI, calling for the inclusion of DILI cases with established causality by the updated RUCAM.
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Affiliation(s)
- Rolf Teschke
- a Department of Internal Medicine II, Division of Gastroenterology and Hepatology , Klinikum Hanau , Hanau , Germany.,b Academic Teaching Hospital of the Medical Faculty , Goethe University Frankfurt/Main , Frankfurt/Main , Germany
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20
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Gao L, Zheng T, Xue W, Wang Y, Deng Y, Zuo H, Sun A. Efficacy and safety evaluation of Cimicifuga foetida extract in menopausal women. Climacteric 2017; 21:69-74. [PMID: 29198157 DOI: 10.1080/13697137.2017.1406913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and safety of long-term treatment with Cimicifuga foetida extract in menopausal women. METHODS A prospective, randomized, controlled clinical trial was conducted. A total of 96 early postmenopausal women were randomly assigned to three groups: group A received 1 mg estradiol valerate daily plus 4 mg medroxyprogesterone acetate on days 19-30; group B received 1 mg estradiol valerate daily plus 100 mg micronized progesterone on days 19-30; group C received 100 mg C. foetida extract daily. The efficacy was evaluated. Safety parameters were recorded. RESULTS A total of 81 patients completed the treatment and follow-up visit. The modified Kupperman Menopausal Index scores decreased after 3 months in all groups. No significant changes were observed in the liver, renal function and components of metabolic syndrome in group C (p > 0.05). There were no significant differences in the incidences of metabolic syndrome among the three groups (p > 0.05). After 24 months, the endometrial thickness increased significantly in group B (p = 0.014), but not in the C. foetida extract group (p > 0.05). CONCLUSIONS C. foetida extract is safe and effective for the treatment of menopausal symptoms in postmenopausal women.
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Affiliation(s)
- L Gao
- a Department of Obstetrics and Gynecology , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China.,b Department of Obstetrics and Gynecology , Jiaxing Maternity and Child Health Care Hospital , Jiaxing , China
| | - T Zheng
- a Department of Obstetrics and Gynecology , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - W Xue
- a Department of Obstetrics and Gynecology , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Y Wang
- a Department of Obstetrics and Gynecology , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Y Deng
- a Department of Obstetrics and Gynecology , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - H Zuo
- c Department of Obstetrics and Gynecology , The Second Hospital of Hebei Medical University , Hebei , China
| | - A Sun
- a Department of Obstetrics and Gynecology , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
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60 years of Cimicifuga racemosa medicinal products : Clinical research milestones, current study findings and current development. Wien Med Wochenschr 2017; 167:147-159. [PMID: 28155126 PMCID: PMC5409920 DOI: 10.1007/s10354-016-0537-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/15/2016] [Indexed: 11/08/2022]
Abstract
Cimicifuga racemosa (CR) extracts are important worldwide as therapy for menopausal symptoms. The first medicinal product from CR has been available since 1956 (Germany, Remifemin® [Schaper & Brümmer, Salzgitter, Germany], isopropanolic extract iCR). This review describes how CR developed, via clinical studies on safety (breast, breast cancer, endometrium, liver) and efficacy, into a successful and safe medicinal product in Germany, Europe and the world. In line with developing legal frameworks for medicinal products in Germany and Europe, clinical studies on CR were observational during the 50s and 70s, and controlled studies since the 80s. The first placebo-controlled study emerged 1986. From 2000 to 2015, a total of 28 clinical studies in Europe, America and Asia were published on the efficacy of CR. In these studies, 11,073 patients received a CR-based medicinal product, 93% thereof iCR. A meta-analysis of all nine placebo-controlled studies published until 2013 confirmed the reliable efficacy of CR-based medicinal products for menopausal symptoms.
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Abstract
The increase in the use of herbal and dietary supplements (HDSs) over the last decades has been accompanied by an increase in the reports of HDS-associated hepatotoxicity. The spectrum of HDS-induced liver injury is diverse and the outcome may vary from transient liver test increases to fulminant hepatic failure resulting in death or requiring liver transplant. There are no validated standardized tools to establish the diagnosis, but some HDS products have a typical clinical signature that may help to identify HDS-induced liver injury.
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Affiliation(s)
- Ynto S. de Boer
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
,Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Averell H. Sherker
- Liver Diseases Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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Frenzel C, Teschke R. Herbal Hepatotoxicity: Clinical Characteristics and Listing Compilation. Int J Mol Sci 2016; 17:E588. [PMID: 27128912 PMCID: PMC4881436 DOI: 10.3390/ijms17050588] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 03/31/2016] [Accepted: 04/11/2016] [Indexed: 12/13/2022] Open
Abstract
Herb induced liver injury (HILI) and drug induced liver injury (DILI) share the common characteristic of chemical compounds as their causative agents, which were either produced by the plant or synthetic processes. Both, natural and synthetic chemicals are foreign products to the body and need metabolic degradation to be eliminated. During this process, hepatotoxic metabolites may be generated causing liver injury in susceptible patients. There is uncertainty, whether risk factors such as high lipophilicity or high daily and cumulative doses play a pathogenetic role for HILI, as these are under discussion for DILI. It is also often unclear, whether a HILI case has an idiosyncratic or an intrinsic background. Treatment with herbs of Western medicine or traditional Chinese medicine (TCM) rarely causes elevated liver tests (LT). However, HILI can develop to acute liver failure requiring liver transplantation in single cases. HILI is a diagnosis of exclusion, because clinical features of HILI are not specific as they are also found in many other liver diseases unrelated to herbal use. In strikingly increased liver tests signifying severe liver injury, herbal use has to be stopped. To establish HILI as the cause of liver damage, RUCAM (Roussel Uclaf Causality Assessment Method) is a useful tool. Diagnostic problems may emerge when alternative causes were not carefully excluded and the correct therapy is withheld. Future strategies should focus on RUCAM based causality assessment in suspected HILI cases and more regulatory efforts to provide all herbal medicines and herbal dietary supplements used as medicine with strict regulatory surveillance, considering them as herbal drugs and ascertaining an appropriate risk benefit balance.
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Affiliation(s)
- Christian Frenzel
- Department of Medicine I, University Medical Center Hamburg Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, 63450 Hanau, Germany.
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Avigan MI, Mozersky RP, Seeff LB. Scientific and Regulatory Perspectives in Herbal and Dietary Supplement Associated Hepatotoxicity in the United States. Int J Mol Sci 2016; 17:331. [PMID: 26950122 PMCID: PMC4813193 DOI: 10.3390/ijms17030331] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 01/06/2023] Open
Abstract
In the United States (US), the risk of hepatotoxicity linked to the widespread use of certain herbal products has gained increased attention among regulatory scientists. Based on current US law, all dietary supplements sold domestically, including botanical supplements, are regulated by the Food and Drug Administration (FDA) as a special category of foods. Under this designation, regulatory scientists do not routinely evaluate the efficacy of these products prior to their marketing, despite the content variability and phytochemical complexity that often characterizes them. Nonetheless, there has been notable progress in the development of advanced scientific methods to qualitatively and quantitatively measure ingredients and screen for contaminants and adulterants in botanical products when hepatotoxicity is recognized.
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Affiliation(s)
- Mark I Avigan
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA.
| | - Robert P Mozersky
- Office of Dietary Supplement Products, Center for Food Safety and Applied Nutrition, 5100 Paint Branch Parkway, College Park, MD 20740, USA.
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25
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Wuttke W, Seidlová-Wuttke D. Black cohosh (Cimicifuga racemosa) is a non-estrogenic alternative to hormone replacement therapy. CLINICAL PHYTOSCIENCE 2015. [DOI: 10.1186/s40816-015-0013-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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26
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Wegener T, Deitelhoff B, Silber-Mankowsky A. Drug safety aspects of herbal medicinal products. Wien Med Wochenschr 2015; 165:243-50. [DOI: 10.1007/s10354-015-0370-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/23/2015] [Indexed: 11/25/2022]
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Jiang K, Jin Y, Huang L, Feng S, Hou X, Du B, Zheng J, Li L. Black cohosh improves objective sleep in postmenopausal women with sleep disturbance. Climacteric 2015; 18:559-67. [DOI: 10.3109/13697137.2015.1042450] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Teschke R, Eickhoff A. Herbal hepatotoxicity in traditional and modern medicine: actual key issues and new encouraging steps. Front Pharmacol 2015; 6:72. [PMID: 25954198 PMCID: PMC4407580 DOI: 10.3389/fphar.2015.00072] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/18/2015] [Indexed: 12/19/2022] Open
Abstract
Plants are natural producers of chemical substances, providing potential treatment of human ailments since ancient times. Some herbal chemicals in medicinal plants of traditional and modern medicine carry the risk of herb induced liver injury (HILI) with a severe or potentially lethal clinical course, and the requirement of a liver transplant. Discontinuation of herbal use is mandatory in time when HILI is first suspected as diagnosis. Although, herbal hepatotoxicity is of utmost clinical and regulatory importance, lack of a stringent causality assessment remains a major issue for patients with suspected HILI, while this problem is best overcome by the use of the hepatotoxicity specific CIOMS (Council for International Organizations of Medical Sciences) scale and the evaluation of unintentional reexposure test results. Sixty five different commonly used herbs, herbal drugs, and herbal supplements and 111 different herbs or herbal mixtures of the traditional Chinese medicine (TCM) are reported causative for liver disease, with levels of causality proof that appear rarely conclusive. Encouraging steps in the field of herbal hepatotoxicity focus on introducing analytical methods that identify cases of intrinsic hepatotoxicity caused by pyrrolizidine alkaloids, and on omics technologies, including genomics, proteomics, metabolomics, and assessing circulating micro-RNA in the serum of some patients with intrinsic hepatotoxicity. It remains to be established whether these new technologies can identify idiosyncratic HILI cases. To enhance its globalization, herbal medicine should universally be marketed as herbal drugs under strict regulatory surveillance in analogy to regulatory approved chemical drugs, proving a positive risk/benefit profile by enforcing evidence based clinical trials and excellent herbal drug quality.
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Affiliation(s)
- Rolf Teschke
- Division of Gastroenterology and Hepatology, Department of Internal Medicine II, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty of the Goethe University Frankfurt MainFrankfurt, Germany
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Seeff LB, Bonkovsky HL, Navarro VJ, Wang G. Herbal products and the liver: a review of adverse effects and mechanisms. Gastroenterology 2015; 148:517-532.e3. [PMID: 25500423 DOI: 10.1053/j.gastro.2014.12.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 12/02/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023]
Abstract
Herbal products have been used for centuries among indigenous people to treat symptoms and illnesses. Recently, their use in Western countries has grown significantly, rivaling that of prescription medications. Currently, herbal products are used mainly for weight loss and bodybuilding purposes but also to improve well-being and symptoms of chronic diseases. Many people believe that because they are natural, they must be effective and safe; however, these beliefs are erroneous. Few herbal products have been studied in well-designed controlled trials of patients with liver or other diseases, despite testimony to the contrary. Moreover, current highly effective antiviral drugs make efforts to treat hepatitis C with herbal products redundant. Herbal products are no safer than conventional drugs and have caused liver injury severe enough to require transplantation or cause death. Furthermore, their efficacy, safety, and claims are not assessed by regulatory agencies, and there is uncertainty about their reported and unreported contents. We review the history of commonly used herbal products, as well as their purported efficacies and mechanisms and their adverse effects.
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Affiliation(s)
| | - Herbert L Bonkovsky
- Liver Digestive & Metabolic Disorders Laboratory, Carolinas HealthCare System, Charlotte, North Carolina
| | - Victor J Navarro
- Jefferson Medical College, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Guqi Wang
- Carolinas HealthCare System, Charlotte, North Carolina
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Nikolić D, Lankin DC, Cisowska T, Chen SN, Pauli GF, van Breemen RB. Nitrogen-Containing Constituents of Black Cohosh: Chemistry, Structure Elucidation, and Biological Activities. RECENT ADVANCES IN PHYTOCHEMISTRY 2015; 45:31-75. [PMID: 27795590 PMCID: PMC5084696 DOI: 10.1007/978-3-319-20397-3_2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The roots/rhizomes of black cohosh (Actaea racemosa L. syn. Cimicifuga racemosa [L]. Nutt., Ranunculaceae) have been used traditionally by Native Americans to treat colds, rheumatism, and a variety of conditions related to women's health. In recent years black cohosh preparations have become popular dietary supplements among women seeking alternative treatments for menopausal complaints. The popularity of the plant has led to extensive phytochemical and biological investigations, including several clinical trials. Most of the phytochemical and biological research has focused on two abundant classes of compounds: the triterpene glycosides and phenolic acids. A third group of phytoconstituents that has received far less attention consists of the alkaloids and related compounds that contain nitrogen. This chapter summarizes the current state of knowledge of the chemistry and biological activities associated with this group of constituents and provides some perspective on their significance for future research on this interesting plant.
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Affiliation(s)
- Dejan Nikolić
- UIC/NIH Center for Botanical Dietary Supplements Research, Department of Medicinal Chemistry and Pharmacognosy, University of Illinois College of Pharmacy, 833 S Wood Street, Chicago, IL 60612-7231, USA
| | - David C. Lankin
- UIC/NIH Center for Botanical Dietary Supplements Research, Department of Medicinal Chemistry and Pharmacognosy, University of Illinois College of Pharmacy, 833 S Wood Street, Chicago, IL 60612-7231, USA
| | - Tamara Cisowska
- UIC/NIH Center for Botanical Dietary Supplements Research, Department of Medicinal Chemistry and Pharmacognosy, University of Illinois College of Pharmacy, 833 S Wood Street, Chicago, IL 60612-7231, USA
| | - Shao-Nong Chen
- UIC/NIH Center for Botanical Dietary Supplements Research, Department of Medicinal Chemistry and Pharmacognosy, University of Illinois College of Pharmacy, 833 S Wood Street, Chicago, IL 60612-7231, USA
| | - Guido F. Pauli
- UIC/NIH Center for Botanical Dietary Supplements Research, Department of Medicinal Chemistry and Pharmacognosy, University of Illinois College of Pharmacy, 833 S Wood Street, Chicago, IL 60612-7231, USA
| | - Richard B. van Breemen
- UIC/NIH Center for Botanical Dietary Supplements Research, Department of Medicinal Chemistry and Pharmacognosy, University of Illinois College of Pharmacy, 833 S Wood Street, Chicago, IL 60612-7231, USA
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Masada-Atsumi S, Kumeta Y, Takahashi Y, Hakamatsuka T, Goda Y. Evaluation of the botanical origin of black cohosh products by genetic and chemical analyses. Biol Pharm Bull 2014; 37:454-60. [PMID: 24583864 DOI: 10.1248/bpb.b13-00844] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Despite the increasing sales of black cohosh (the dried rhizome and root of Cimicifuga racemosa L.) in the world herbal market, these products have continuous adulteration issues. The botanical authenticity of the black cohosh products is the first important step for ensuring their quality, safety and efficacy. In this study, we genetically identified the botanical sources of 10 black cohosh products and 5 Cimicifuga Rhizome crude drugs of Japanese Pharmacopoeia grade, and analyzed the metabolic profiling of 25 black cohosh products using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Consequently, we found that C. dahurica and possibly C. foetida are misused as sources of the black cohosh products and in some cases, the extracts of black cohosh were adulterated with the plant materials of C. dahurica. We demonstrated that these three species can be distinguished by three marker compounds in a specific mass range. These results must be helpful in establishing regulations for the safe use of the black cohosh products.
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Affiliation(s)
- Sayaka Masada-Atsumi
- Division of Pharmacognosy, Phytochemistry and Narcotics, National Institute of Health Sciences
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Managing Menopause Chapter 9 Complementary and Alternative Medicine (CAM). JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014. [DOI: 10.1016/s1701-2163(15)30465-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ulbricht C, Windsor RC. An Evidence-Based Systematic Review of Black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration. J Diet Suppl 2014; 12:265-358. [PMID: 25153652 DOI: 10.3109/19390211.2014.946731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
An evidence-based systematic review of black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration consolidates the safety and efficacy data available in the scientific literature using a validated, reproducible grading rationale. This article includes written and statistical analysis of clinical trials, plus a compilation of expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.
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Lindh-Åstrand L, Hoffmann M, Hammar M, Spetz Holm AC. Hot flushes, hormone therapy and alternative treatments: 30 years of experience from Sweden. Climacteric 2014; 18:53-62. [DOI: 10.3109/13697137.2014.915516] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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35
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Black cohosh and liver toxicity: is there a relationship? Case Rep Gastrointest Med 2014; 2014:860614. [PMID: 25093128 PMCID: PMC4100270 DOI: 10.1155/2014/860614] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 06/10/2014] [Accepted: 06/17/2014] [Indexed: 11/17/2022] Open
Abstract
Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians about the use of herbal supplements unless they are specifically asked. As a result, sometimes important information regarding drug side effects is missed in history taking. During our literature search, we found several retrospective studies and other meta-analyses that claim a lacking or weak link between black cohosh use and hepatotoxicity. We present a case of a 44-year-old female who developed subacute liver injury demonstrated on a CT scan and liver biopsy within a month of using the drug to resolve her hot flashes and discuss a possible temporal and causal association between black cohosh use and liver disease. Since the patient was not taking any other drugs, we concluded that the acute liver injury was caused by the use of black cohosh. We agree with the United States Pharmacopeia recommendations that a cautionary warning about hepatotoxicity should be labeled on the drug package.
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Stute P. [Hormone therapy during peri- and postmenopause]. MMW Fortschr Med 2014; 156:37-39. [PMID: 24851443 DOI: 10.1007/s15006-014-2974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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37
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Beer AM. [Phytotherapy in menopausal symptoms]. MMW Fortschr Med 2014; 156:40-41. [PMID: 24851444 DOI: 10.1007/s15006-014-2975-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Teschke R, Genthner A, Wolff A, Frenzel C, Schulze J, Eickhoff A. Herbal hepatotoxicity: analysis of cases with initially reported positive re-exposure tests. Dig Liver Dis 2014; 46:264-9. [PMID: 24315480 DOI: 10.1016/j.dld.2013.10.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Positive re-exposure tests are diagnostic hallmarks for hepatotoxicity. OBJECTIVE To test validity of positive re-exposures in herb induced liver injury. METHODS We searched Medline database for cases of herb induced liver injury with positive re-exposures and analysed 34 cases for positive re-exposure test criteria of baseline alanine aminotransferase< 5N before re-exposure, and re-exposure alanine aminotransferase ≥ 2× baseline alanine aminotransferase. Re-exposure test was negative, if baseline alanine aminotransferase< 5N combined with re-exposure alanine aminotransferase< 2× baseline alanine aminotransferase, or if baseline alanine aminotransferase≥ 5N regardless of the re-exposure alanine aminotransferase including no available re-exposure alanine aminotransferase result. RESULTS In 21/34 cases (61.8%), criteria for a positive re-exposure were fulfilled, with negative tests in 6/34 cases (17.6%) or uninterpretable ones in 7/34 cases (20.6%). Confirmed positive re-exposure tests established potential of herb induced liver injury for Aloe, Chaparral, Chinese herbal mixtures, Chinese Jin Bu Huan, Chinese Syo Saiko To, Germander, Greater Celandine, Green tea, Kava, Mistletoe, Polygonum multiflorum, and Senna, with up to 4 case reports per herb. CONCLUSIONS Among 34 cases of herb-induced liver injury with initially reported positive re-exposure tests, 61.8% of the cases actually fulfilled established test criteria and provided firm diagnoses of herb induced liver injury by various herbs.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty of the Goethe University, Frankfurt/Main, Germany.
| | - Alexander Genthner
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty of the Goethe University, Frankfurt/Main, Germany
| | - Albrecht Wolff
- Department of Internal Medicine II, Division of Gastroenterology, Hepatology and Infectious Diseases, Friedrich Schiller University Jena, Germany
| | - Christian Frenzel
- Department of Medicine I, University Medical Center Hamburg Eppendorf, Germany
| | - Johannes Schulze
- Institute of Industrial, Environmental and Social Medicine, Medical Faculty, Goethe University Frankfurt/Main, Germany
| | - Axel Eickhoff
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty of the Goethe University, Frankfurt/Main, Germany
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Qiu F, McAlpine JB, Krause EC, Chen SN, Pauli GF. Pharmacognosy of Black Cohosh: The Phytochemical and Biological Profile of a Major Botanical Dietary Supplement. PROGRESS IN THE CHEMISTRY OF ORGANIC NATURAL PRODUCTS 99 2014; 99:1-68. [DOI: 10.1007/978-3-319-04900-7_1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Cui G, Leng H, Wang K, Wang J, Zhu S, Jia J, Chen X, Zhang W, Qin L, Bai W. Effects of remifemin treatment on bone integrity and remodeling in rats with ovariectomy-induced osteoporosis. PLoS One 2013; 8:e82815. [PMID: 24349369 PMCID: PMC3857312 DOI: 10.1371/journal.pone.0082815] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 10/29/2013] [Indexed: 11/18/2022] Open
Abstract
This study aims to evaluate the effects of Remifemin (isopropanolic extract of Cimicifuga Racemosa) on postmenopausal osteoporosis. 120 female Sprague-Dawley rats were randomly assigned to four groups: sham surgery with vehicle, ovariectomy with vehicle, ovariectomy with estradiol valerate, or ovariectomy with Remifemin. Daily oral administrations of the vehicle, estradiol valerate, or Remifemin began 2 weeks after surgery and lasted to 4, 8, or 12 weeks. Ten rats in each group were sacrificed at each timestep with assessment of bone mineral density, trabecular bone structure, and biomechanical parameters of the femur and lumbar vertebra. Bone turnover markers were evaluated 12 weeks after surgery. Both drugs prevented bone density loss in the distal end of the femur and preserved the trabecular bone structure in both the lumbar vertebra and distal end of the femur following ovariectomy. Both drugs protected bone stiffness at the tested regions and reduced bone reabsorption in ovariectomized rats. The preventive effects of Remifemin against bone-loss can rival those of estradiol valerate if treatment duration is adequately extended. In conclusion, Remifemin may demonstrate equivalent effects to estradiol valerate in terms of preventing postmenopausal osteoporosis.
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Affiliation(s)
- Guangxia Cui
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Huijie Leng
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Ke Wang
- Department of Anatomy and Embryology, Peking University Health Science Center, Beijing, China
| | - Jianwei Wang
- Department of Anatomy and Embryology, Peking University Health Science Center, Beijing, China
| | - Sainan Zhu
- Statistics Office, Peking University First Hospital, Beijing, China
| | - Jing Jia
- Department of Stomatology, General Hospital of Armed Police, Beijing, China
| | - Xing Chen
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Weiguang Zhang
- Department of Anatomy and Embryology, Peking University Health Science Center, Beijing, China
| | - Lihua Qin
- Department of Anatomy and Embryology, Peking University Health Science Center, Beijing, China
- * E-mail: (LQ); (WB)
| | - Wenpei Bai
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- * E-mail: (LQ); (WB)
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Beer AM, Neff A. Differentiated Evaluation of Extract-Specific Evidence on Cimicifuga racemosa's Efficacy and Safety for Climacteric Complaints. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2013; 2013:860602. [PMID: 24062793 PMCID: PMC3767045 DOI: 10.1155/2013/860602] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/21/2013] [Indexed: 01/26/2023]
Abstract
Past reviews on Cimicifuga racemosa (CR) without differentiation between extracts, quality, and indication altogether led to inconsistent data. Therefore, for the first time, we meet the requirements of the system's logic of evidence-based phytotherapy by taking into consideration extracts, pharmaceutical quality (reflected in a regulatory status as medicinal product), and indication. A literature search for clinical studies examining CR's efficacy and safety for menopausal complaints was conducted. The results were sorted by type of extract, regulatory status, and indication. Accordingly, Oxford Levels of Evidence (LOE) and Grades of Recommendation (GR) were determined. CR extracts demonstrated a good to very good safety in general, on estrogen-sensitive organs and the liver. However, only registered CR medicinal products were able to prove their efficacy. Best evidence was provided by the isopropanolic CR extract (iCR): the multitude of studies including more than 11,000 patients demonstrated consistent confirmatory evidence of LOE 1b (LOE 1a for safety) leading to GR A. The studies on the ethanolic extract BNO 1055 including more than 500 patients showed exploratory evidence of LOE 2b resulting in GR B. A positive benefit-risk profile is stated and limited to Cimicifuga racemosa products holding a marketing authorisation for treating climacteric complaints.
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Affiliation(s)
- A.-M. Beer
- Department of Naturopathy, Blankenstein Hospital, Im Vogelsang 5-11, 45527 Hattingen, Germany
| | - A. Neff
- Department of Gynecology, Lübbecke Hospital, Virchowstraße 65, 32312 Lübbecke, Germany
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Fisher WI, Johnson AK, Elkins GR, Otte JL, Burns DS, Yu M, Carpenter JS. Risk factors, pathophysiology, and treatment of hot flashes in cancer. CA Cancer J Clin 2013; 63:167-92. [PMID: 23355109 PMCID: PMC3640615 DOI: 10.3322/caac.21171] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Hot flashes are prevalent and severe symptoms that can interfere with mood, sleep, and quality of life for women and men with cancer. The purpose of this article is to review existing literature on the risk factors, pathophysiology, and treatment of hot flashes in individuals with cancer. Electronic searches were conducted to identify relevant English-language literature published through June 15, 2012. Results indicated that risk factors for hot flashes in cancer include patient-related factors (eg, age, race/ethnicity, educational level, smoking history, cardiovascular risk including body mass index, and genetics) and disease-related factors (eg, cancer diagnosis and dose/type of treatment). In addition, although the pathophysiology of hot flashes has remained elusive, these symptoms are likely attributable to disruptions in thermoregulation and neurochemicals. Therapies that have been offered or tested fall into 4 broad categories: pharmacological, nutraceutical, surgical, and complementary/behavioral strategies. The evidence base for this broad range of therapies varies, with some treatments not yet having been fully tested or showing equivocal results. The evidence base surrounding all therapies is evaluated to enhance hot flash treatment decision-making by clinicians and patients.
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Affiliation(s)
- William I Fisher
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, USA
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43
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Teschke R, Schulze J. Suspected herbal hepatotoxicity: requirements for appropriate causality assessment by the US Pharmacopeia. Drug Saf 2013; 35:1091-7. [PMID: 22897137 DOI: 10.2165/11631960-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The aim of this current opinion report is to discuss relevant issues of regulatory causality assessment methods related to initially suspected herb-induced liver injury (HILI). Herbal hepatotoxicity represents a major clinical, regulatory and public challenge since its diagnosis may be difficult to be established, requiring a sophisticated approach that includes a liver-specific and validated causality assessment method. In cases of primarily suspected HILI, however, problems emerged when the US Pharmacopeia (USP) published results with causality assessments of liver disease cases. In these studies, herbal drugs and herbal dietary supplements were considered as causative products based on causality attribution by a shortened version of the Naranjo scale. However, the Naranjo scale is not liver specific and not validated for liver toxicity, and these shortcomings also apply to its shortened and thereby modified version. Consequently, these results were questioned and considered invalid, requiring re-evaluation with a liver-specific causality assessment method validated for hepatotoxicity, such as the scale of the Council for International Organizations of Medical Sciences (CIOMS) or its validated update. In essence, the USP and other regulatory agencies should apply validated liver-specific causality assessment methods rather than liver unspecific and not validated assessment methods in suspected HILI cases.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty of the Goethe University, FrankfurtMain, Germany
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Fritz H, Seely D, McGowan J, Skidmore B, Fernandes R, Kennedy DA, Cooley K, Wong R, Sagar S, Balneaves LG, Fergusson D. Black Cohosh and Breast Cancer. Integr Cancer Ther 2013; 13:12-29. [DOI: 10.1177/1534735413477191] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background. Many women use black cohosh as a natural treatment for menopausal symptoms. However, controversy exists around safety in breast cancer, because of its purported estrogenic activity. We conducted a systematic review of black cohosh use in women with or at risk of breast cancer. Methods. We searched MEDLINE, Embase, the Cochrane Library, and AMED from inception to July 2012 and October 2012 for human interventional or observational data pertaining to the safety and efficacy of black cohosh in patients with or at risk of breast cancer, including an assessment of the effect of black cohosh on estrogen responsive tissues. Results. Of 450 records, we included 26 articles: 14 randomized controlled trials, 7 uncontrolled trials, and 5 observational studies.The evidence on efficacy for ho t flashes is divided, with some benefits seen when compared with baseline, but not when compared with placebo. Two observational studies found no association between black cohosh and risk of breast cancer, whereas 2 studies reported significant reductions in risk of primary breast cancer among postmenopausal women (adjusted odds ratio = 0.47, 95% confidence interval = 0.27-0.82), and risk of recurrence (adjusted hazard ratio = 0.75, 95% confidence interval = 0.63-0.89). Seventeen trials showed no significant impact on circulating hormone levels or proliferation in estrogen responsive tissues. Conclusions. Current evidence does not support an association between black cohosh and increased risk of breast cancer. There is a lack of evidence supporting the efficacy of black cohosh for reduction of hot flashes in breast cancer patients. Given conflicting but promising results, and apparent safety, further research is warranted.
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Affiliation(s)
- Heidi Fritz
- The Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
| | - Dugald Seely
- The Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Ottawa Integrative Cancer Center, Ottawa, Ontario, Canada
| | - Jessie McGowan
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- The Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
| | | | - Deborah A. Kennedy
- The Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
- The University of Toronto, Toronto, Ontario, Canada
| | - Kieran Cooley
- The Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
- The University of Toronto, Toronto, Ontario, Canada
| | - Raimond Wong
- Juravinski Cancer Center, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Stephen Sagar
- Juravinski Cancer Center, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | | | - Dean Fergusson
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Abstract
This overview of systematic reviews (SRs) aims to evaluate critically the evidence regarding the adverse effects of herbal medicines (HMs). Five electronic databases were searched to identify all relevant SRs, with 50 SRs of 50 different HMs meeting our inclusion criteria. Most had only minor weaknesses in methods. Serious adverse effects were noted only for four HMs: Herbae pulvis standardisatus, Larrea tridentate, Piper methysticum and Cassia senna. The most severe adverse effects were liver or kidney damage, colon perforation, carcinoma, coma and death. Moderately severe adverse effects were noted for 15 HMs: Pelargonium sidoides, Perna canaliculus, Aloe vera, Mentha piperita, Medicago sativa, Cimicifuga racemosa, Caulophyllum thalictroides, Serenoa repens, Taraxacum officinale, Camellia sinensis, Commifora mukul, Hoodia gordonii, Viscum album, Trifolium pratense and Stevia rebaudiana. Minor adverse effects were noted for 31 HMs: Thymus vulgaris, Lavandula angustifolia Miller, Boswellia serrata, Calendula officinalis, Harpagophytum procumbens, Panax ginseng, Vitex agnus-castus, Crataegus spp., Cinnamomum spp., Petasites hybridus, Agave americana, Hypericum perforatum, Echinacea spp., Silybum marianum, Capsicum spp., Genus phyllanthus, Ginkgo biloba, Valeriana officinalis, Hippocastanaceae, Melissa officinalis, Trigonella foenum-graecum, Lagerstroemia speciosa, Cnicus benedictus, Salvia hispanica, Vaccinium myrtillus, Mentha spicata, Rosmarinus officinalis, Crocus sativus, Gymnema sylvestre, Morinda citrifolia and Curcuma longa. Most of the HMs evaluated in SRs were associated with only moderately severe or minor adverse effects.
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Affiliation(s)
- Paul Posadzki
- Peninsula Medical School, Veysey Building, Exeter, Devon.
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Bunchorntavakul C, Reddy KR. Review article: herbal and dietary supplement hepatotoxicity. Aliment Pharmacol Ther 2013; 37:3-17. [PMID: 23121117 DOI: 10.1111/apt.12109] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Revised: 09/18/2012] [Accepted: 10/06/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Herbal and dietary supplements are commonly used throughout the World. There is a tendency for underreporting their ingestion by patients and the magnitude of their use is underrecognised by Physicians. Herbal hepatotoxicity is not uncommonly encountered, but the precise incidence and manifestations have not been well characterised. AIMS To review the epidemiology, presentation and diagnosis of herbal hepatotoxicity. This review will mainly discuss single ingredients and complex mixtures of herbs marketed under a single label. METHODS A Medline search was undertaken to identify relevant literature using search terms including 'herbal', 'herbs', 'dietary supplement', 'liver injury', 'hepatitis' and 'hepatotoxicity'. Furthermore, we scanned the reference lists of the primary and review articles to identify publications not retrieved by electronic searches. RESULTS The incidence rates of herbal hepatotoxicity are largely unknown. The clinical presentation and severity can be highly variable, ranging from mild hepatitis to acute hepatic failure requiring transplantation. Scoring systems for the causality assessment of drug-induced liver injury may be helpful, but have not been validated for herbal hepatotoxicity. Hepatotoxicity features of commonly used herbal products, such as Ayurvedic and Chinese herbs, black cohosh, chaparral, germander, greater celandine, green tea, Herbalife, Hydroxycut, kava, pennyroyal, pyrrolizidine alkaloids, skullcap, and usnic acid, have been individually reviewed. Furthermore, clinically significant herb-drug interactions are also discussed. CONCLUSIONS A number of herbal medicinal products are associated with a spectrum of hepatotoxicity events. Advances in the understanding of the pathogenesis and the risks involved are needed to improve herbal medicine safety.
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Affiliation(s)
- C Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
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Laakmann E, Grajecki D, Doege K, zu Eulenburg C, Buhling KJ. Efficacy of Cimicifuga racemosa, Hypericum perforatum and Agnus castus in the treatment of climacteric complaints: a systematic review. Gynecol Endocrinol 2012; 28:703-9. [PMID: 22385322 DOI: 10.3109/09513590.2011.650772] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The systematic review examines whether Cimicifuga racemosa (CR), Hypericum perforatum (HP), Agnus castus, vitamins and minerals, either as monotherapy or in combination, have an evidence-based impact on vasomotor, genital and psychological climacteric complaints. DATA SOURCES AND METHODS OF STUDY SELECTION: We searched in the databases EMBASE, OVID and PubMed using the keywords "vasomotor symptoms, hot flashes, vaginal atrophy, psychological problems, endometrium, sleep, concentration, cognition in combination with vitamins, multivitamins, minerals, multiminerals, black cohosh, Cimicifuga, Agnus castus, chasteberry, chaste tree, monk's pepper and menopause" for randomized controlled trials (RCT). Relevant studies were reviewed by four independent reviewers qualitatively. RESULTS Most of the studies with a comparison of CR vs. placebo do not show an evidence-based significant effect of CR on climacteric symptoms. The combination of CR and HP shows an improvement of climacteric complaints in comparison to placebo. In some RCTs, there was no significant difference between CR and hormone-replacement therapy. The combination of HP and Agnus castus showed no significant difference in the treatment of climacteric complaints. CONCLUSION CR monotherapy as well as HP and Agnus castus showed no better effect than placebo. The combination of CR with HP demonstrated a positive effect on climacteric complaints.
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Affiliation(s)
- Elena Laakmann
- Department of Gynecological Endocrinology, Clinic of Gynecology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Umland EM, Falconieri L. Treatment options for vasomotor symptoms in menopause: focus on desvenlafaxine. Int J Womens Health 2012; 4:305-19. [PMID: 22870045 PMCID: PMC3410701 DOI: 10.2147/ijwh.s24614] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Vasomotor symptoms (VMS), including hot flashes and night sweats, occur in as many as 68.5% of women as a result of menopause. While the median duration of these symptoms is 4 years, approximately 10% of women continue to experience VMS as many as 12 years after their final menstrual period. As such, VMS have a significant impact on the quality of life and overall physical health of women experiencing VMS, leading to their pursuance of treatment to alleviate these symptoms. Management of VMS includes lifestyle modifications, some herbal and vitamin supplements, hormonal therapies including estrogen and tibolone, and nonhormonal therapies including clonidine, gabapentin, and some of the serotonin and serotonin-norepinephrine reuptake inhibitors. The latter agents, including desvenlafaxine, have been the focus of increased research as more is discovered about the roles of serotonin and norepinephrine in the thermoregulatory control system. This review will include an overview of VMS as they relate to menopause. It will discuss the risk factors for VMS as well as the proposed pathophysiology behind their occurrence. The variety of treatment options for VMS will be discussed. Focus will be given to the role of desvenlafaxine as a treatment option for VMS management.
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Affiliation(s)
- Elena M Umland
- Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
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Mahady G, Low Dog T, Sarma ND, Griffiths J, Giancaspro GI. Response to Teschke et al. Pharmacoepidemiol Drug Saf 2012. [PMID: 22407603 DOI: 10.1002/pds.3209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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