Complementary therapies Flashcards

1
Q

What is it

A
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2
Q

Why is it important

A
  • Up to 1 in 4 people in England used some form of CAM in past year
  • Most people do not tell their doctors that they are using CAM
  • Often perceived by the general public as safe as it is natural
  • Community pharmacies sell CAM e.g. herbal, nutritional supplements (good profit margins)
  • Pharmacists often asked for advice about CAM products
  • Need to provide evidence-based advice re-effectiveness and safety
  • May affect conventional therapy e.g. drug interactions
  • Legislation/regulation much improved in past decade
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3
Q

What is good evidence

A
  • Gold standard in conventional medicine is the RCT
  • Large RCTs
  • Even stronger evidence are lots of RCTs together- a meta-analysis or systematic review
  • Published in peer reviewed journals
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4
Q

Difficulties faced by CAM researchers

A
  • Treatment often not just one intervention
  • Often difficult to have a comparator placebo
  • Difficult to blind, so clinician and patient basis
  • Lack of funding, so trial often small
  • CAM easily purchased, so how to control
  • Lack of standardisation of therapies
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5
Q

Herbal medicines (rational phytotherapy)

A
  • Often a complex mixture of ingredients
  • Not clear what is the active ingredient
  • Concentration of plant constituents may vary depending on environment (climate, altitude, growing conditions) or genetic factors
  • Harvesting and storage can affect quality
  • Part of the plant used => varying strength of active ingredient
  • Patients purchase, so less structured system for reporting ADRs
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6
Q

Herbal therapy

A
  • Variation in amount of active ingredient between products and even between batches
  • Only recommend licensed preparations
  • If unlicensed, at least use a well known quality manufacturer
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7
Q

Reference sources- medicines complete

A
  • Stockleys drug interaction
  • Stockleys herbal medicines interactions
  • Herbal medicines
  • Dietary supplements
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8
Q

An example- St Johns wort

A
  • Extract from the leaves and flowers of the plant hypericum perforatum
  • Main active constituents- hypericin and hyperforin
  • Indication- mild depression and lots of other claims
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9
Q

Is it effective

A
  • Evidence for use in depression
  • Cochrane systematic review in 2008 looked at 29 studies in 5489 patients (with mild to moderate symptom) that compared treatment with SJW for 4-12 weeks with placebo or standard anti-depressants
  • SJW superior to placebo
  • Similarly effective to standard anti-depressants
  • Results more favourable in German studies
  • Concluded effective but can only apply to the preparations included in the studies
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10
Q

Is it effective

A
  • NICE found evidence from RCTs suggesting that compared to placebo, SJW increased the likelihood of achieving a 50% reduction of symptoms of depression
  • BUT
  • Insufficient evidence to determine if it was effective for achieving remission
  • NICE advises that SJW should NOT be prescribed for treating depression because there is an absence of long term data, dose uncertainty, variability, potency and serious interaction with other medication
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11
Q

Mechanism of action

A
  • Serotonergic 5HT-3 and 4 receptor antagonist
  • Down regulates beta-adrenergic serotonergic 5-HT1 and 2 receptor
  • Hyperforin also inhibits GABA and L-glutamate
  • Hypericin has an affinity for sigma receptors and acts as a receptor antagonist at adenosine, BDZ, GABA-A and B and IP3 receptors
    • Hypericin inhibits COMT and MAO in vitro
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12
Q

Is it safe

A
  • Cochrane review concluded that there were fewer side effects with SJW than with standard antidepressants
  • Most common: GI, insomnia, restlessness, dizziness, fatigue, dry mouth
  • Evidence that taking 2-4g daily can increase the risk of photosensitivity
  • BUT it is a potent inducer of some CYP450 enzymes
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13
Q

Drug interactions

A
  • Differences between preparations make interactions difficult to predict
  • Interacts with (everything)
  • Always ask about patients full drug history
  • Do not co-prescribe with a conventional anti-depressant
  • If switching from SJW to or from conventional anti-depressants you need to allow for a “wash out” period
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14
Q

Conclusion SJW

A
  • Provided patient is not more than mildly depressed and not taking any interacting drugs, not pregnant or breastfeeding SJW can be recommended
  • BUT ideally should see medical help for CBT (proven effective for mild depression)
  • Advice that patient it will take 2-4 weeks before seeing the beneficial effect
  • Stick to the same preparation
  • Report any side effects (then can yellow card report)
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15
Q

An example- Glucosamine

A
  • Extract from marine exoskeletan or made synthetically
  • Commonly available as: Glucosamine sulphate, hydrochloride and in combination with chondroitin sulphate
  • Indication- joint pain in OA
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16
Q

Osteoarthritis

A
  • Glucosamine is sugar which is an important consituent of articular (joint) cartlidge
  • Glucosamine supplements sold for patient with arthritis as in OA
  • OA is a wear and tear condition- cartilage end of bones breaks down
  • Administration of glucosamine thought to stimulate production of cartilage components and allow rebuilding of damage cartilage
17
Q

Is it effective

A
  • Cochrane systematic review- 2008 looked at 25 studies with 4963 patient with OA
  • Analysis restricted to studies with adequate allocation concealment failed to show any benefit for pain
  • Overall, some pain improvement, but no conclusion re functional improvement
  • Health Technology Assessment- 2009 inconsistent findings with only a modest effect on pain and function
  • But concluded there was evidence that glucosamine sulphate shows some clinical effectiveness in the treatment of OA of the knee
  • The benefit of the addition of chondroitin remains uncertain
18
Q

Is it effective

A
  • Natural medicines comprehensive database (NMCD)- for hydrochloride salt conflicting evidence in OA. For sulphate salt, there is better evidence in knee OA, with some studies (>3 years) showing significant improvement in pain & functionality compared to placebo in patients
  • There is a licensed preparation in UK
  • NICE CG177 Oestoarthritis care and management- Glucosamine or chondroitin not recommended for OA
  • BNF- Mechanism of action not understood and there is limited evidence to show it is effective. Marked as a less suitable for prescribing
19
Q

Glucosamine- Is it safe

A
  • Most common: Mild GI disturbance
  • Also headache, drowsiness, insomnia and skin reactions.
  • Generally comparable to placebo
  • Concern re use in diabetic patients- monitor BG more closely
  • Use cautiously in patient with asthma (Unidentified allergic reaction)
  • Use with caution in patients with renal impairment or those taking nephrotoxic medication
20
Q

Drug interactions

A
  • Significant drug interaction with warfarin
  • Theoretical interaction with some anti-mitotic chemotherapy agents such as doxorubicin
21
Q

Conclusion- glucosamine

A
  • Limited evidence for knee OA
  • The only evidence is for glucosamine sulphate
  • Need to give it a trial for several months at a dose of 1500mg dd or 500 tds
  • Products vary in content and strength of active ingredients- stick to the same brand
  • Report any side effects (yellow card)
  • Prescribers in primary care should not initiate glucosamine and chondroitin for any new patient and support prescribers in deprescribing glucosamine and chondroitin in all patients
  • Same recommendation for all herbal product and homoeopathy
22
Q

Cranberry and UTI

A
  • Juice, syrup, capsule and tablets
  • Cranberries prevent bacteria (particularly E.coli) from adhering to uroepithelial cells that line bladder wall, so they cannot infect the mucosal surface of the urinary tract
  • In vitro, this adhesion is mediated by two component fructose, and substances called proanthocyanidins (PAC)
  • Cochrane 2012: No evidence juice helpful in preventing UTIs in most population groups; other preps need standardising
  • Cochrane 2010: No RCTs have been performed to assess the effectiveness of cranberry juice or cranberry product for the treatment of UTI
    • Therefore, at the present time there is no evidence
23
Q

Cranberry juice and UTIs

A
  • NICE CKS
    • Cranberry juice or other cranberry products are not recommended as there is no good evidence to support their use for treating urinary tract infection
    • Or prevention of recurrent cystitis
    • Warfarin interaction
24
Q

Other commonly requested sold herbals

A
  • Echinacea
  • Ginkgo biloba
  • Ginseng
  • Garlic
  • Saw palmetto
  • Evening primrose
  • Red clover
25
Q

Summary

A