Herbs and alternative therapies: Relevance to hypertension and cardiovascular diseases

Herbal remedies, supplements, and alternative therapeutic items are used by many patients with hypertension and cardiovascular diseases. Scientific knowledge about their efficacy and safety is lacking, and unfortunately, physicians are frequently not aware that patients are using these nontraditional forms of medical care. Patients may anticipate physicians’ disapproval of their use, or not realize that it is important for the physician to know what they are taking. Therefore, it is imperative that patients are asked nonjudgmental questions about current and past use of herbals and alternative therapies. Even when physicians are aware of such use, they feel poorly trained to identify the constituents and effects. Although many such therapies are innocuous, several herbal or alternative therapeutic items can significantly elevate blood pressure or cause interactions with cardiovascular drugs. Practitioners in cardiovascular medicine should be competent and know current scientific evidence for the benefits and adverse effects of herbal supplements and provide patients reasonable advice. In this brief article, we review the epidemiology of alternative therapy use, and select several important herbal or other supplements that patients with hypertension and cardiovascular diseases may be taking. We discuss the therapies considered biological in nature as opposed to mind-body interventions or manipulative body or energy therapies.     

Adverse effects of herbal treatment of cardiovascular disease: what the physician must know

The increasing use of herbal products by patients with cardiovascular disease represents a clinical challenge to physicians. The use of herbal products is increasing in our society, and less than 50% of patients using herbal products report this information to their physicians. In addition, physicians often lack the knowledge base for herbal medications to effectively counsel patients regarding adverse effects and potential herb-drug interactions. This article reviews Western and traditional Chinese herbs that are commonly used by patients with cardiovascular diseases, herbs noted to have adverse cardiovascular effects, and herbs that may potentially interact with commonly prescribed cardiovascular medications.     

Herbal Medicine in the United States: Review of Efficacy,Safety, and Regulation

Introduction  Herbal products have gained increasing popularity in the last decade, and are now used by approximately 20% of the population. Herbal products are complex mixtures of organic chemicals that may come from any raw or processed part of a plant, including leaves, stems, flowers, roots, and seeds. Under the current law, herbs are defined as dietary supplements, and manufacturers can therefore produce, sell, and market herbs without first demonstrating safety and efficacy, as is required for pharmaceutical drugs. Although herbs are often perceived as “natural” and therefore safe, many different side effects have been reported owing to active ingredients, contaminants, or interactions with drugs. Results  Unfortunately, there is limited scientific evidence to establish the safety and efficacy of most herbal products. Of the top 10 herbs, 5 (ginkgo, garlic, St. John’s wort, soy, and kava) have scientific evidence suggesting efficacy, but concerns over safety and a consideration of other medical therapies may temper the decision to use these products. Conclusions  Herbal products are not likely to become an important alternative to standard medical therapies unless there are changes to the regulation, standardization, and funding for research of these products.     

Alternative medicine in atrial fibrillation treatment—Yoga,acupuncture, biofeedback and more

The last decade has seen a significant improvement in the management of atrial fibrillation (AF) with the development of newer medications and improvement in catheter ablation techniques. Recurrence of AF remains a significant problem in these patients and medications offer limited supportive role. Complementary and alternative treatment strategies therefore remain a viable option for these AF patients. Several studies have shown improvement in AF symptoms with yoga therapy, acupuncture and biofeedback. There are also several herbal medicine and supplements such as omega-3 fatty acids, antioxidant vitamins, barberry, motherwort, cinchona, Shensongyangxin, hawthorn, Kella and Wenxin Keli that have been evaluated as potential therapeutic options in AF. These studies are however limited by small sample sizes with mixed results. Besides the pharmacological action, metabolism, interactions with other medications and the adverse effects of the herbal medications and supplements remain poorly understood. In spite of the above limitations, complementary therapies remain a promising option in the management of AF and further studies are necessary to validate their safety and efficacy.     

Commonly used herbal medicines in the United States: a review

Herbal medicines are widely used in the United States, with approximately one quarter of adults reporting use of an herb to treat a medical illness within the past year. Herbs contain complicated mixtures of organic chemicals, the levels of which may vary substantially depending upon many factors related to the growth, production, and processing of the herbal product. While many manufacturers attempt to provide products with consistent levels of suspected active ingredients through a process known as standardization, this technique has uncertain effects on the safety and efficacy of the final product. Herbs are considered to be dietary supplements in the United States and therefore are subjected to a very limited form of regulation and oversight. Although herbs are often believed to be "natural" and therefore safe, many dangerous and lethal side effects have recently been reported, including direct toxic effects, allergic reactions, effects from contaminants, and interactions with drugs and other herbs. Of the ten most commonly used herbs in the United States, systematic reviews have concluded that only four are likely to be effective, and there is very limited evidence to evaluate the efficacy of the approximately 20,000 other available herbal products. Because herbs may contain potent bioactive substances and are often marketed to treat specific diseases, many have argued that they should be subject to more stringent regulation, similar to over-the-counter drugs. To improve the safety and consistency of herbs, additional research is needed to define the pharmacology, stability, and bioavailability of these products.     

Physicians' understanding of the regulation of dietary supplements

BACKGROUND: After passage of the Dietary Supplement Health and Education Act, herbs and other supplements were allowed to be sold to the public without Food and Drug Administration (FDA) approval or premarket evaluation. Data suggest that many people are unaware of this lack of governmental oversight and may rely on their physicians for education in this arena. This study was designed to evaluate physicians' level of understanding of dietary supplement regulation and the adverse event reporting process and to determine whether an interactive online curriculum could aid in improving knowledge. METHODS: A multicenter online educational intervention was developed and administered to physicians at 15 internal medicine residency programs throughout the United States between March 1, 2006, and June 30, 2006. Pretest performance was used to measure baseline knowledge, while posttest performance compared with pretest performance measured the effectiveness of the educational intervention. RESULTS: A total of 335 physicians completed the module. Ninety percent of those completing the module were residents, while 10% were attending physicians. Baseline knowledge of dietary supplement regulatory issues was poor. The total average pretest score was only 59% (986/1675). The average score rose to 91% (1526/1675) after completion of the curriculum (P<.001). With regard to specific content areas, about one third of physicians were unaware that dietary supplements did not require FDA approval or submission of safety and efficacy data before being marketed. Similar percentages believed that there are regulations in place to ensure supplement quality. Most physicians were unaware that serious adverse events due to the use of supplements should be reported through the FDA MedWatch system. CONCLUSIONS: Physician knowledge of dietary supplement regulation and adverse event reporting is poor. An online didactic module may improve knowledge and potentially enhance patient-physician communication regarding the use of such products.     

Acute liver failure caused by 'fat burners' and dietary supplements: a case report and literature review

Globally, people are struggling with obesity. Many effective, nonconventional methods of weight reduction, such as herbal and natural dietary supplements, are increasingly being sought. Fat burners are believed to raise metabolism, burn more calories and hasten fat loss. Despite patient perceptions that herbal remedies are free of adverse effects, some supplements are associated with severe hepatotoxicity. The present report describes a young healthy woman who presented with fulminant hepatic failure requiring emergent liver transplantation caused by a dietary supplement and fat burner containing usnic acid, green tea and guggul tree extracts. Thorough investigation, including histopathological examination, revealed no other cause of hepatotoxicity. The present case adds to the increasing number of reports of hepatotoxicity associated with dietary supplements containing usnic acid, and highlights that herbal extracts from green tea or guggul tree may not be free of adverse effects. Until these products are more closely regulated and their advertising better scrutinized, physicians and patients should become more familiar with herbal products that are commonly used as weight loss supplements and recognize those that are potentially harmful.     

Herbal therapies in rheumatology: the persistence of ancient medical practices

OBJECTIVE: To determine how frequently herbal remedies are employed as alternative therapies in rheumatic diseases, and the historical justification for their use. METHODS: We conducted a survey in 250 outpatients in the rheumatology clinic of a teaching hospital in México. We registered general demographic information and the previous use of herbal remedies for rheumatic conditions, how effective they were, and the presence of adverse effects during their use. We identified the herbs employed, and cross-checked them with medical texts from the 16th through the 18th centuries on the use of herbal remedies. RESULTS: Of 250 surveyed patients, 126 (51%) had used herbal remedies for their rheumatic conditions. 63% of all users reported them to be effective for the purpose they had been prescribed. 12% reported adverse effects, none of them life-threatening. Being a user had no relation with the patients' formal education. Three patients did not answer the survey. We were able to identify 67 plants. One third of these are either prescribed for rheumatic conditions in the consulted bibliography, or else were used for the same purpose by ancient Mexican cultures. CONCLUSION: Herbal remedies are frequently used for rheumatic conditions. Some of them have an historical antecedent for their use in rheumatic conditions. They deserve a cautious evaluation as adjunctive therapies in rheumatic diseases.     

Herbal medications commonly used in the practice of rheumatology: mechanisms of action, efficacy, and side effects

OBJECTIVE: To review the literature on herbal preparations commonly utilized in the treatment of rheumatic indications. METHODS: Search of MEDLINE (PubMed) was performed using both the scientific and the common names of herbs. Relevant articles in English were collected from PubMed and reviewed. RESULTS: This review summarizes the efficacy and toxicities of herbal remedies used in complementary and alternative medical (CAM) therapies for rheumatologic conditions, by elucidating the immune pathways through which these preparations have antiinflammatory and/or immunomodulatory activity and providing a scientific basis for their efficacy. Gammalinolenic acid suppresses inflammation by acting as a competitive inhibitor of prostaglandin E2 and leukotrienes (LTs) and by reducing the auto-induction of interleukin1alpha (IL-1alpha)-induced pro-IL-1beta gene expression. It appears to be efficacious in rheumatoid arthritis (RA) but not for Sjogrens disease. The antiinflammatory actions of Harpagophytum procumbens is due to its action on eicosanoid biosynthesis and it may have a role in treating low back pain. While in vitro experiments with Tanacetum parthenium found inhibition of the expression of intercellular adhesion molecule-1, tumor necrosis factor alpha (TNF-alpha), interferon-gamma, IkappaB kinase, and a decrease in T-cell adhesion, to date human studies have not proven it useful in the treatment of RA. Current experience with Tripterygium wilfordii Hook F, Uncaria tomentosa, finds them to be efficacious in the treatment of RA, while Urtica diocia and willow bark extract are effective for osteoarthritis. T. wilfordii Hook F extract inhibits the production of cytokines and other mediators from mononuclear phagocytes by blocking the up-regulation of a number of proinflammatory genes, including TNF-alpha, cyclooxygenase 2 (COX-2), interferon-gamma, IL-2, prostaglandin, and iNOS. Uncaria tomentosa and Urtica diocia both decrease the production of TNF-alpha. At present there are no human studies on Ocimum spp. in rheumatic diseases. The fixed oil appears to have antihistaminic, antiserotonin, and antiprostaglandin activity. Zingiber officinale inhibits TNF-alpha, prostaglandin, and leukotriene synthesis and at present has limited efficacy in the treatment of osteoarthritis. CONCLUSIONS: Investigation of the mechanism and potential uses of CAM therapies is still in its infancy and many studies done to date are scientifically flawed. Further systematic and scientific inquiry into this topic is necessary to validate or refute the clinical claims made for CAM therapies. An understanding of the mechanism of action of CAM therapies allows physicians to counsel effectively on their proper and improper use, prevent adverse drug-drug interactions, and anticipate or appreciate toxicities. RELEVANCE: The use of CAM therapies is widespread among patients, including those with rheumatic diseases. Herbal medications are often utilized with little to no physician guidance or knowledge. An appreciation of this information will help physicians to counsel patients concerning the utility and toxicities of CAM therapies. An understanding and elucidation of the mechanisms by which CAM therapies may be efficacious can be instrumental in discovering new molecular targets in the treatment of diseases.     

When is a herb a drug?

With the growing popularity and use of herbal remedies in the industrial countries there has been an increasing recognition and reporting of adverse reactions. Drug development represents discovery and characterization of naturally occurring plant metabolites or their synthetic analogues. Therefore, a herbal remedy should be considered a drug for all clinical purposes. The liver, being central to the metabolism of virtually all xenobiotics, is inevitably exposed to reactive metabolites and liver injury is a potential complication of nearly every medication, including herbal remedies. Recognition of herb induced hepatotoxicity depends on clinical awareness of the problem, a suspicion that a herbal preparation is involved, and detailed enquiry regarding the use of all supplements and remedies. Herbal medicines should be regulated more systematically and monitoring for adverse reaction should improve.     

Complementary and alternative medicine (CAM) use by older adults: a comparison of self-report and physician chart documentation

BACKGROUND: Older adults are increasingly using complementary and alternative medicine (CAM) dietary supplements and herbal remedies, but may not discuss this with their physicians. When patients do report using CAM, their physicians may not record this information in patient charts. METHODS: This cross-sectional analysis compared results of a convenience sample survey with medical charts. Participants were older than 65 and from an urban academic hospital's ambulatory geriatrics practice. We measured (i) prevalence of CAM use; (ii) proportion of CAM supplements and herbs (CAMsh) reported by patients and documented in patients' charts; (iii) percentage of patients reporting taking CAMsh with anticoagulant activity (ginger, ginkgo, garlic, and vitamin E) while concomitantly taking prescribed anticoagulant medications, as per chart; and (iv) percentages of those patients for whom the CAM anticoagulant was or was not documented in the chart. RESULTS: We surveyed 212 patients; of those, 182 had available charts. Prevalence of CAM use was 64%. Only 35% of all self-reported supplements were documented in the charts. Of 182 patients, 84 (46%) reported taking CAM with anticoagulant properties: of these, 52% took a prescribed anticoagulant (per chart), while 48% took CAM but not prescribed anticoagulants. CONCLUSION: CAM use is highly prevalent among older adults. Physicians do not consistently record the use of CAMsh on patients' charts. This may lead to unrecognized, potentially harmful drug-herb/drug-supplement interactions. Physicians should elicit and document information on CAM use from older adult patients, both to provide sound medical care and to advance knowledge about drug-herb/drug-supplement interactions.     

Complementary and alternative therapies for fibromyalgia

Fibromyalgia (FM) is a syndrome of chronic widespread musculoskeletal pain that is accompanied by sleep disturbance and fatigue. Clinical treatment usually includes lifestyle modifications and pharmacologic interventions meant to relieve pain, improve sleep quality, and treat mood disorders. These therapies are often ineffective or have been shown in clinical studies to have only short-term effectiveness. Pharmacologic treatments have considerable side effects. Patients may have difficulty complying with exercise-based treatments. Thus, patients seek alternative therapeutic approaches and physicians are routinely asked for advice about these treatments. This article reviews nontraditional treatment alternatives, from use of nutritional and herbal supplements to acupuncture and mindbody therapy. Little is known about efficacy and tolerance of complementary and alternative therapies in FM and other chronic musculoskeletal pain syndromes. Most studies on these treatments have been performed for osteoarthritis, rheumatoid arthritis, or focal musculoskeletal conditions. Clinical trials are scarce; the quality of these trials is often criticized because of small study population size, lack of appropriate control interventions, poor compliance, or short duration of follow-up. However, because of widespread and growing use of alternative medicine, especially by persons with chronic illnesses, it is essential to review efficacy and adverse effects of complementary and alternative therapies.