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Year 3 - Pharmacology > Clinical Pharmacology - Complimentary Medicine > Flashcards

Clinical Pharmacology - Complimentary Medicine Flashcards

1
Q

what is CAM?

A

The World Health Organisation defines complementary and alternative medicine (CAM) as:

a ‘broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system’

The National Center for Complementary and Alternative Medicines Defines CAM as:

“a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine,”

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2
Q

why is the interperation of what constitudes CAM unclear?

A

This means that national, cultural, and ethnic differences, together with the extensive and expanding list of complementary and alternative medicines, make interpretation of what constitutes CAM difficult

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3
Q

CAM approaches are ______ and include modalities such as herbal and homeopathic therapies, acupuncture, aromatherapy, Reiki, Shiatsu and yoga.

Few CAM approaches are supported by robust _______, effectiveness or _____ data

Use is wide-spread, with ______ reportedly the major users both in health and disease

A

diverse

efficacy

safety

women

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4
Q

Key Underlying Dogma (of CAM):

what are the main principles of CAM?

A

The treatments have a long history and have thus stood the ‘test of time’

The treatments enjoy a lot of support

The treatments are natural and therefore safe

The treatments are holistic

The treatments tackle the root causes of the problem

The treatments are being suppressed by the establishment

The treatments are inexpensive and so value for money

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5
Q

are CAMs safe and is there evidence for this?

A

Some CAM modalities have been used for centuries and exponents of CAM cite this as evidence of safety

However there is a real lack of scientifically valid safety and efficacy data

(lack of) Reporting AEs/ADRs

No evidence of harm is not the same as evidence of safety

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6
Q

These issues surrounding CAM are of particular concern in high risk patient groups, who are they?

A

Children

Pregnancy – teratogenesis and fetogenesis

Patients using prescribed medications - Polypharmacy

Multimorbidity

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7
Q

what are some examples of CAM?

(These are just a fraction of CAMs that are available to the public)

A

Herbal medicine = real active ingredient

Homeopathy

Acupuncture

Anthroposophic medicine = Steiner, self healing, homeopathy, etc

Aromatherapy

Ayuveda = traditional Indian medicine

Chiropractic

Hypnosis

Meditation

Naturopathy

Osteopathy

Reflexology

Reiki = healing energy by palm

Shiatsu

Yoga

Chinese Medicine = real active ingredient

Vitamins & Minerals

Massage

Nutraceutical

Acupressure

Spiritual Healing/Prayer

Alexander Technique

Applied Kinesiology

Autogenic Training

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8
Q

What are the main CAMs used in the UK?

A
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9
Q

Why Are We Talking About?

  • Approximately 80% of the population worldwide use CAM
  • Homeopathy is available on NHS: 60% of Scottish GP practices use homeopathic and or herbal preparations

there are a number of concerns around CAM, what are they?

A

Implausibility of most therapies

Lack of evidence for benefit

Lack of evidence for safety

Evidence of harm

Adverse Effects / Herb-Drug Interactions

Unqualified practitioners / Missed diagnoses

Stopping conventional medicine

Cost-effectiveness?

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10
Q

which pateints use CAM in the UK?

A

80% of the UK population

60% of all cancer patients use or have used CAM

60% of all pregnant women in the UK use CAM

1% of children under 1 year of age are prescribed homeopathy

Users tend to be:

  • Affluent
  • Educated
  • Family and friends also use
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11
Q

Why Do People Use CAM?

Desire to have personal ________ over their own health

___________ with conventional treatment

Perception that conventional medicine lacks/disregards an _______ approach

Concerns about the ____ ________ of prescribed medications

A

control

Dissatisfied

holistic

side effects

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12
Q

The majority of CAM users do not appear to be _________ with conventional medicine

But do find these health care alternatives more congruent with their own ______, ______ and philosophical orientations toward health and life

A

dissatisfied

values

beliefs

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13
Q

Why Do People Use CAM?

A

Don’t see any distinctions between US and Them

Think it’s natural, safe and harmless

Philosophical dissatisfaction with conventional medicine

Side effects from conventional medicines

Lack of effective mainstream treatments (for their condition)

Chronic symptoms

Hype

“Holistic”

Promote health

Family and relatives use CAM

Don’t regard CAM as CAM, they think it is part of medicine

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14
Q

60% of Scottish GP practices prescribe homeopathic or herbal medicines and other CAM practices

30% of maternity staff recommend CAM to pregnant women

The Question is:
Why Do Healthcare Professionals Recommend CAM?

A

Patient demand

Placebo effect

“Feel good” factor in terminal illness, distressing hospital experiences

Genuine belief in a therapy

Experience - Seeing is Believing (GP they have seen it work)

Use CAM themselves (the health professional uses them)

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15
Q

what are herbals/natural products?

A

Herbal medicines include herbs, herbal materials, herbal preparations and finished herbal products, that contain as active ingredients parts of plants, or other plant materials, or combinations.

There are differences between countries in the regulatory classification of ‘herbals’.

In the UK some herbal products are classified as food supplements or cosmetics and others as medicines

In the USA all herbal medicines and products are described as ‘Dietary Supplements’

Most ocmmonlu used CAM in the UK

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16
Q

what do herbals contain?

A

All herbals contain active ingredients

Often multiple active compounds

Many contain adulterants :

  • Heavy metals 61%
  • Bacteria
  • Prescription Medicines 24%
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17
Q

what is the usage of CAM in breats cancer patients?

A

70% have used or are using CAM

Two thirds were on adjuvant endocrine therapy and half reported concurrent use of herbal therapies

One third reported the use of a supplement with estrogenic activity (this is something we don’t want)

119 possible herb-drug interactions - 55 with tamoxifen, 66 with anastrazole, 6 with letrozole and 2 with exemestane

The herbal supplements most commonly implicated were - soya, cranberry, echinacea, glucosamine, grapefruit and garlic

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18
Q

Herbals and Early Pregnancy - how are they used?

A

Two thirds of women use CAM during first trimester of pregnancy.

28 different CAM modalities.

Herbal products are the most common (37% of women),

25 different herbal products used.

Strongest predictor for CAM use - Use by family and friends p < 0.001

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19
Q

Late pregnancy - how are CAMs used?

A

Two thirds of women use CAM during the last trimester

A total of 30 different CAM modalities

Oral herbal products the most common (38% of respondents)

40 different products

Strongest predictors for use:

  • Complementary and alternative medicine use before pregnancy P<.001);
  • A university education p<.001),
  • Complementary and alternative medicine use by family or friends P<.001.
20
Q

why does it matter if pregnant women are using CAMs?

A

No safety or efficacy data

Teratogenesis (if used during first trimester of pregnancy)

Fetogenesis (if used during final trimester of pregnancy)

Drug-Herb Interactions:

  • Half of pregnant women use prescribed medication (range1-12) and Half of these use 36 different oral herbal products (range 1-6)
  • 20-25% of all pregnant women concurrently use prescribed and herbal medicines
  • 13% of these suffer from a moderate/severe herb-drug interaction
21
Q

what is the efficacy of herbalism?

A

Very little evidence on effectiveness as practised

Some trials on specific products

Little current NHS use

22
Q

is herbalism safe?

A

Contamination, adulteration and misidentification of herbal remedies

Variation between the labelled content of products and their actual content

Serious toxic effects from some

Biggest problem is lack of data

Drug-herb interactions are a major concern, esp St John’s Wort and multiple herbs with warfarin

23
Q

what is homeopathy?

A

Homeopathy is a “treatment” based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself

A 2010 House of Commons Science and Technology Committee report on homeopathy said that homeopathic remedies perform no better than placebos (dummy treatments)

Hahnemann believed that “like cures like” and that minute concentrations of a particular toxin could cure the very same symptoms it would cause in larger doses. i.e. Find a toxin which produced similar symptoms to a disease and then use that toxin in minute concentrations to cure the disease

Remedies are produced by the repeated dilution and succession (shaking) of the substance

Potency increases with the number of dilutions and succussions

24
Q

how is the dilation process of homeotherapy done?

A

The dilution level is printed on the bottle of medicine

A typical homeopathic dilution is 30X, where the X represents 10. One part toxin is mixed with 10 parts water or alcohol

The mix is shaken; one part of this mix is added to 10 parts of water or alcohol again; The whole process is repeated 30 times.

Dilution is 1030 or 1 in a million trillion trillion

If the dilution is 30C the dilution is 1:10030

Whole process known as Potentisation

25
Q

how doe shomeotherapy work?

A

Homeopathy’s healing powers are attributed to “water memory” — the concept that water has the ability to remember the shape of the toxin it once contained

26
Q

what is the efficacy of homeopathy?

A

Scientifically implausible

Major issues with quality of studies

No convincing evidence

“Now doctors need to be bold and honest with their patients about homeopathy’s lack of benefit, and with themselves about the failings of modern medicine to address patients’ needs for personalised care.”

27
Q

is homepathy safe?

A

Homeopathy is generally regarded as safe and harmless

Rarely reports of adverse effects, including aggravation of symptoms, have been made

28
Q

what are the issues with homeopathy and safety?

A
  • Missed Diagnosis
  • Inappropriate treatment
  • Adulteration
29
Q

what is acupuncture?

A

Based on traditional Chinese medicine

Vital force called “Qi” which circulates along channels called meridians

There are 12 main meridians, and these correspond to 12 major functions or “organs” of the body

Balance of “yin” and “yang”

Trigger points targeted for needling to deal with pain

Acupuncture is a treatment derived from ancient Chinese medicine. Fine needles are inserted at certain sites in the body for therapeutic or preventative purposes

30
Q

what is the process of getting acupuncture done?

A

4 -10 points are needled during a session

Needles are left in place for 10-30 minutes, although can be shorter

Needles may be stimulated by twirling or an electrical current

A typical course of treatment for a chronic condition would be 6 – 12 sessions over 3 months. This might be followed by “top up” treatments

31
Q

what is the efficacy of acupuncture?

A

Partially explicable within conventional physiology of pain.

Stimulates pain fibres entering the dorsal horn of the spinal cord. These cause inhibition of pain impulses

Stimulate release of endogenous opioids and other neurotransmitters such as serotonin

Some research evidence that acupuncture has effects greater than sham treatment or placebo in pain, but little evidence for use in other conditions

32
Q

how is acupuncture used in back pain?

A

Acupuncture is not more effective than other conventional and “alternative” treatments

The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain

Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area

33
Q

is acupuncture beneficial in storke?

A

Acupuncture appeared to be safe but without clear evidence of benefit

34
Q

is acupuncutre beneficial in asthma and epilepsy?

A

The current evidence does not support acupuncture as a treatment for epilepsy

35
Q

is acupuncture safe?

A

The incidence of adverse effects has been reported at around 10%

However in a reasonable well conducted trial from China the incidence of any adverse events was 42.4% with traditional acupuncture,

40.7% with minimal acupuncture and 16.7% with non-invasive sham acupuncture.

Serious adverse events similar to any harm with needle use have been reported - Pneumothorax, Infection, Pneumopericardium, Organ puncture/Cardiac tamponade

36
Q

what is aromatherapy?

A

Aromatherapy is the use of concentrated essential oils extracted from herbs, flowers, and other plants to treat diseases

It is commonly administered by massaging into the skin

37
Q

how are aromatherapy treatments done?

A

Inhalation: dropping several drops of essential oil into a bowl of steaming water and the vapours inhaled for a few moments. The effect is enhanced by placing a towel over both the head and the bowl

Massage: aromatic essential oils combined with a base oil can be applied to a specific problem area or the entire body

Diffusion: oil-containing compounds sprayed into the air or placing a few drops of essential oil in a diffuser and heating

Hot or cold compresses containing essential oils can be used for muscle aches and pains, bruises or headaches

Soaking baths containing essential oils and lasting for 10-20 minutes for skin problems and for calming or soothing nerves

38
Q

how may aromatherapy be dangerous?

A

Skin irritation with frequent use

Photosensitivity - Avoid prolonged exposure to the sun,

Excessive inhalation can cause headaches and fatigue;

Insomnia - peppermint,

Origanum, sage, savory, thyme, and wintergreen, are not safe for home use.

Skin irritation -basil, lemon grass, fennel, rosemary, and verbena

Bronchial spasms, and people with asthma should not use

Abortifacient (precipitate abortion) - Avoid aromatherapy during pregnancy sage, rosemary, juniper

39
Q

what is the efficacy of aromatherapy?

A

“Aromatherapy is pleasant and relatively safe compared with many other ways of spending an hour or so and £20 to £45”

“The data do not undermine a hypothesis that aromatherapy massage is pleasant, slightly anxiolytic, and often enjoyable for patients in stressful situations.

“However, the data do not support a hypothesis that there may be legitimate clinical indications for the prescription of aromatherapy massage in a health care setting; it seems to have no lasting effects, good or bad.”

40
Q

how may aromatherapy be used for cancer symptoms?

A

Massage and aromatherapy massage confer short term benefits on psychological wellbeing

Effect on anxiety supported by limited evidence

Effects on physical symptoms may also occur

Evidence is mixed as to whether aromatherapy enhances the effects of massage. Replication, longer follow up, and larger trials are need to accrue the necessary evidence

41
Q

UK Regulation of CAM:

how is pharmacovigilance odne?

A

yellow card

42
Q

what do doctors need to know?

A

Be aware of what is available via complementary practitioners, on-line and over the counter

Ask patients about CAM use, as may not disclose

Be aware of the potential for significant harm to patients

Be aware of the changing fashion in CAM use

How to evaluate evidence of safety and efficacy

Appropriate use in the NHS

43
Q

whata re the different mindsets that people may have in regards to CAMs?

A

People who believe that alternative medicine works in way that science cannot possibly comprehend – ‘magic’ believers;

People who believe that alternative medicine can be explained by untested or untestable theories – ‘pseudoscience believers’;

People who believe in alternative medicine because they have seen or experienced it’s positive effects – ‘anecdotal believers’-”seeing is believing”

44
Q

what is the key underlying dogma?

A

The treatments have a long history and have thus stood the ‘test of time’

The treatments enjoy a lot of support

The treatments are natural and therefore safe. (this is a false claim)

The treatments are holistic

The treatments tackle the root causes of the problem. (untrue)

The treatments are being suppressed by the establishment. (untrue)

The treatments are inexpensive and so value for money

45
Q

Summary:

A wide range of CAM _________

Concerns over:

  • _______ and ____-effectiveness
  • Safety

Awareness (of their use) important

Critical evaluation needed

A

therapies

Efficacy

cost

Year 3 - Pharmacology (4 decks)

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