10 Herbal Remedies To Recommend Melissa Hemphill MD

10 Herbal Remedies To Recommend Melissa Hemphill MD 4/17/2015 OAFP Spring Conference

Disclosures & Scope No disclosures Scope is Herbs that are commonly used, safe and accessible to patients & maybe a couple you haven’t heard about Not going to cover really common known/utilized (ginger, cranberry…)

Quality Consumerlab. com NSF seal USP seal Philosophy about herbal medicine: If it doesn’t hurt, and it might help, worth a try.

Tumeric Uses: GI: Reduce indigestion; IBD sx. May be linked to lower rate of colon cancer. May reduce pain from osteoarthritis May be linked to lower rate of Alzheimer’s dementia Proposed mechanism: Anti-inflammatory through COX-2 inhibition, anti-oxidant, can suppress cytokine production, alter gene expression, and induce apoptosis. Crosses BBB. Doses: 400 mg curcumin extract three times a day Curcumin often stays within GI tract; increase absorption with fatty meals, or mixing with black pepper (up to 2000% absorption). Clinically tested in US: Cur-Cure, Doctor’s Best Curcumin C 3, Nutrigold Tumeric Curcumin Gold, NOW Curcumin Potential concerns: “GRAS” Safety profile is excellent.

Chamomile - Matricaria recutita Uses: Calmative – used in pediatric populations often gastrointestinal anti-spasmodic Topical anti-inflammatory for eczema, etc. Proposed mechanism: anti-inflammatory, inhibits COX-2, limits histamine, may interact with GABA-receptors; may compete for estrogen receptors Dose: Used as tea, tincture, balm, etc. Easy to make at home. Potential concerns: Generally recognized as safe “GRAS” Do not confuse with Roman chamomile

Elderberry – Sambucus nigra Uses: influenza A & B Proposed mechanism: neuraminidase inhibitor-like properties, anti-viral & anti-inflammatory anthocyanidins, Dose: LIQUID: 15 m. L (1 tablespoon) 4 times daily given within 48 hours of initial symptoms Clinically tested in US: Sambucol by Nature’s Way Potential concerns: Caution with autoimmune diseases and immunosuppressant medications Do not consume uncooked, unripened berries or leaves

Rhodiola Uses: fatigue, mild depression, anxiety. An “adaptogen” Proposed mechanism: Antioxidant like tannins, flavonoids; phenylpropanoid glycoside called salidroside are “adapteogenic”; effects cardiac c. AMP cycle; alpha-glucosidase activity; reduces lipid peroxidation; inhibits staph in vitro Dose: 340 mg BID for depression, 50 -100 mg BID for fatigue, up to 400 mg/d Evidence: Clinically tested in US: SHR-5 Darbinyan et al, Phytomedicine 2000 – improved fatigue index in nightfloat physicians! My favorite study. Potential concerns: May cause dry mouth or dizziness. Can lower blood sugar and blood pressure (ACEIlike), CYP interactions

St John’s Wort – Hypericum perforatum Uses: mild to moderate depression Proposed mechanism: contains and stimulates production of melatonin Dose: Clinically tested products in US: Kira by Lichtwer, Perika by Nature’s Way, St John’s Wort Ze 117 by Zeller AG Evidence: Several studies suggest equal or better efficacy to SSRI; but my favorite shows they are both inferior to placebo. Potential concerns: Fewer side effects: 26% vs 45% for SSRI (Linde & Murrow 1998). Those reported included photosensitivity, pruritis. Many drug-drug interactions due to CYP 3 A 4 induction (HIV & antineoplastics). Possibly induction of P 2 C 9 (warfarin). Possibly induction of P-glycoprotein drug transporter (digoxin). May decrease efficacy of OCP's.

Licorice – Glycyrrhiza spp. Uses: cough, colds, sore throat, “gastroprotectant” GERD/gastritis or IBD. Proposed mechanism: increase prostaglandins that stimulate stomach cell proliferation and mucus lining. Dose: DGL 700 -800 mg 20 min before a meal for 3 -4 weeks There are no clinically tested products available in the US. Potential concerns: Contraindicated in cholestatic liver disease or cirrhosis, hypokalemia, renal disease, pregnancy, and ill advised if CHF or edema due to pseudoaldosteronism. However preparations without glycyrrhizin are called DGL and have no such safety concerns. May interact with diuretics, corticosteroids, anti-hypertensives Safe for periodic short-term use, up to 3 g/d for 3 -4 weeks

Ginseng – Panax quinquefolis & ginseng Uses: Mental and physical fatigue (cancer related fatigue); shortening URIs; poor concentration; lowers blood sugar Proposed mechanism: ginsennosides activate monocytes, NK’s, Interferongamma, stimulates IL 2 production, induce tumor necrosis factor (TNF)-alpha; may sensitize to insulin, may be estrogenic & decrease LH. Dose: Infusion of 5 oz boiling water over 1 -2 grams powdered root and steeped for 10 minutes Clinically tested in US: Ginsana by Pharmaton; Prince of Peace American Ginseng Potential concerns: British guidelines contraindicate use during pregnancy; German do not. Overdose may cause diarrhea, jitters, insomnia, menopausal bleeding, hypertony Pesticides are a problem in production Russian or Siberian Ginseng does not count.

Feverfew - Tanacetum arthenium Uses: migraine prevention. Sometimes combined with riboflavin, magnesium, or butterbur Proposed mechanism: parthenolide inhibits COX-2, TNF-a, and IL-1. But parthenolide probably not active, but a surrogate marker Dose: Optimal doses have not been established, but most recommend 125250 mg/day of parthenolide. Of herb, fresh leaf is 1 -2 leaves per day; dried leaf is 50 -250 mg per day. Potential concerns: Contraindicated during pregnancy due to uterine stimulation. Inhibits serotonin-induced platelet aggregation. Rebound headache upon discontinuation. Ragweed family.

Valerian root – Valeriana officinalis Uses: for restless or anxiety-induced sleep disturbances Proposed mechanism: no agreement on this Dose: most benefit from 400 -500 mg 2 hours before bedtime Homemade infusion: pour 5 oz water over 1 tsp of root & steep 10 -15 minutes Tincture: 1 -3 m. L 1 -3 times a day Clinically tested products: Sedonium, Valerian Night Time by Nature’s Way, Alluna Sleep Potential concerns: Safety profile is good, caution with other sedatives. Overdose may cause agitative sx (HA, vision, restless, nausea) and cardiac disturbances *

Chasteberry - Vitex agnus-castu Uses: premenstrual syndrome, irregular menses, mastodynia Proposed mechanism: reducing prolactin via binding D 2 receptors, increasing progesterone in the luteal phase, increasing dopamine, and binding opiate receptors. Dose: highly variable 500 mg dried fruit in AM; or fluid extract 0. 5 -1 m. L per day. Vitex Nature’s Way 400 mg BID-TID; Prefemin 20 -40 mg daily Concerns: Uncertain hormonal effects during pregnancy, may reduce lactation in animal models. Do not use with other dopaminergic agonists. Theoretical concern about use with OCP.

Arnica Uses: topically for sprains, bruises Proposed mechanism: sesquiterpene lactones have anti-inflammatory, analgesic, and platelet-inhibitory effects Dose: thin layer topically Potential concerns: GRAS in food, but not for internal use in supplement doses. Orally, arnica can cause irritation of mucous membranes, drowsiness, stomach pain, vomiting, diarrhea, tachycardia, shortness of breath, coma, and death* *A bad outcome.

Sources Arizona Center for Integrative Medicine monographs Natural Medicines Comprehensive Database Consumer. Lab. com Herb. Clip. com NIH Supplement Fact sheets Individual journal article citations available on request