Headaches, Herbal and Supplement Therapies

Question 1

classification of headaches

Answer 1

• Do you know why they’re having it or not? If you know why its happening, its secondary!
  
  • If its primary, you don’t know why its happening
• Primary
  
  • No identifiable and treatable underlying cause
  • Most common
• Secondary
  
  • Associated with organic causes
    
    • Dental infection or sinusitis
    • Brain tumor
    • Subarachnoid hemorrhage
• Tension “common”
• Cluster “severe”
• Migraine “debilitating”

Question 2

Tension vs cluster headaches

Answer 2

• Tension
  
  • Mild-moderate, bilateral dull persistent pain
  • Location and duration vary
  • Treatment usually OTC, usually self-directed
    
    • Avoid medication overuse HA!!!
  • Prophylaxis: TCA, stress management therapy
• Cluster
  
  • Severe, unilateral, orbital/temporal pain
  • Recurrent (separated by periods of remission)
    
    • Remission may last months to years
  • Lacrimation, rhinorrhea, facial flushing, ptosis, miosis
  • Treatment: O₂ (standard), triptans
  • Prophylaxis:
    
    • Verapamil, prednisone
• Difference between the two is bilateral vs unilateral! Cluster is UNILATERAL

Question 3

migraine epidemiology

Answer 3

• Typical age of onset 15-35 yo
• Cost of missed workdays: $13 billion per year
• Women of childbearing years are the biggest group associated with migraines
  
  • Migraines are associated with estrogen

Question 4

migraine pathophysiology

Answer 4

• Trigger à cortical spreading depression à trigeminal nerve activation à inflammation à nociception à peripheral sensitization
• The pathophys is still not very well understood

Question 5

migraine phases

Answer 5

• Prodrome:
  
  • 60% occurrence
  • Vague and nonspecific
  • Changes in mood, alertness, appetite, food cravings & increased sensory sensitivity
  • The trouble is that sometimes its associated with a little confusion – many people have told her that when the prodrome happens, they don’t realize it, their friends and families do.
• Aura
  
  • 20% occurrence
  • Progressive neurologic deficits or disturbances with complete recovery
  • Visual disturbance, tingling of lips, lower face, and fingers of hand
  • May cause motor & speech deficits, most auras resolve in > 1 hour
• Headache
  
  • Severe unilateral pulsating/throbbing pain (bilateral & steady in 1/3 of patients)
  • Lasts 4-72 hrs
  • Pain worsen with activity, located in temple, forehead, eye, or back of head
  • Activates sympathetic nervous system (heightened sensitivity to stimuli)
• Headache resolution
  
  • Spontaneous resolution
  • Reverts with sleep or vomiting
• Postdrome
  
  • Rare period of disability, lasting up to 2 days
  • Fatigue, anorexia, muscle soreness, poor concentration

Question 6

migraine aggravating factors

Answer 6

• Stress
• Emotion
• Glare
• Hypoglycemia, hunger
• Altered sleep pattern
• Menses
• Exercise
• Carbon monoxide
• Excess caffeine use or withdrawal
• Alcohol (red wine)
• Foods with…
  
  • MSG, tyramine
  • Nitrites, chocolate
  • Aspartame (artificial sweeteners, diet soda)
• Drugs
  
  • Excess analgesic use or withdrawal
  • Estrogen
  • Cocaine
  • Nitroglycerin

Question 7

acute migraine treatment

Answer 7

• Goal:
  
  • Relieve the pain and non-headache symptoms
  • Allow the patient to resume normal daily activities
• More effective if given early in the course of HA – this is untrue of everything else!!! THIS IS UNIQUE TO MIGRAINE TREATMENT
• Large single dose works better than repetitive small doses
• Oral agents less effective secondary to migraine-induced gastric stasis – poor absorption
• Non-oral route of administration should be selected for migraines associated with early nausea/vomiting
  
  • If you have a patient that has prodrome or aura, then you can use oral

Question 8

migraine therapies

Answer 8

• APAP (Tylenol)
• NSAIDs
• Antiemetics/Dopamine receptor antagonists
• Dexamethasone (reduces recurrence rate) – not fixing the HA today, its to prevent recurrence
• Opiates
• Ergots
• Serotonin agonists (triptans)

Question 9

antiemetics

Answer 9

• Prochlorperazine, metoclopramide, chlorpromazine (thorazine) – all are monotherapy as long as they are not given orally – all given with Benadryl for SE
  
  • Oral and non-oral routes available, Inj can be used as monotherapy, oral should not.
  • Often given with diphenhydramine to prevent akathisia/dystonic reactions (i.e. Benadryl)
• Management of n/v and delayed gastric emptying
• Metoclopramide increases gastric motility (prokinetic)
  
  • Improves absorption of oral migraine agents
  • May have independent anti-migraine action
  • ADRs: Sedation, confusion, dyskinetic movements/restlessness
• Primary role is as an adjunct to other acute therapies – especially because oral routes are not very effective
• Treatment of severe migraine in ED (IV)

Question 10

ergot contraindications

Answer 10

• Coronary artery disease
• Stroke
• Uncontrolled hypertension
• Peripheral vascular disease
• Ischemic bowel disease
• *Pregnancy (category X)*
• Impaired hepatic or renal function
• Avoid within 24 hrs of 5HT agonist (“triptans”) – but when she admits pts, she asks if they’ve had triptans w/I 3 days

Question 11

ergots place in therapy

Answer 11

• IV DHE 45 + IV metoclopramide is an alternative for treatment of intractable severe migraine (>72 hours) in ED
  
  • Raskin protocol*
• IV DHE 45 should not be used as monotherapy
• Ergotamine is not the drug of choice for most patients because of issues of efficacy and side effects
  
  • Place in therapy may be for those with prolonged duration of attacks (>48 hours) and possible frequent headache recurrence

Question 12

choice of triptan

Answer 12

• Few head-to-head trials
• Meta-analysis of 53 trials (over 24,000 patients)*
  
  • Concluded that all of the oral drugs are effective and well tolerated
  • Highest likelihood of consistent success
    
    • Rizatriptan 10 mg
    • Eletriptan 80 mg
    • Almotriptan 12.5 mg
• Bottom line – no efficacy data that definitively support use of one triptan vs. another
• For new onset, she always starts with sumatriptan
  
  • If she has a pt with long lasting she will go straight for the frova, etc.
• TRIPTANS ARE NOT PROPHYLACTIC!!! THEY ARE ABORTIVE!!
• Choice should be individualized
  
  • Different pharmacologic properties/delivery routes
• Sumatriptan offers the most options for drug delivery
• Naratriptan has lowest recurrence rates but slowest onset of action
• Naratriptan and frovatriptan have better side effect profile but possible reduced efficacy
• Highest likelihood of consistent success found with rizatriptan, eletriptan, almotriptan
• Switch to another triptan
  
  • Studies showing patients fail one, respond to another

Question 13

triptans adverse effects

Answer 13

• Adverse effects
  
  • Tingling
  • Sensation of warmth/flushing
  • Weakness/dizziness
  • Somnolence/drowsiness
  • Numbness
  • Malaise
  • Unpleasant taste with nasal spray
  • Feeling of pressure or heaviness in chest & neck – 20%
    
    • Not accompanied by ECG changes
• Pregnancy Category C

Question 14

triptans contraindications

Answer 14

• its vasoconstrictive but not nearly as bad as the ergots
  
  • Coronary artery disease
  • Stroke
  • Uncontrolled hypertension
  • Peripheral vascular disease
  • Ischemic bowel disease
  • Within 24hrs of therapy of other triptan or ergot – many clinicians say within 72hrs
  • Within 2 weeks MAOI
    
    • Except naratriptan, eletriptan, frovatriptan

Question 15

triptans drug interactions

Answer 15

• SSRI (citalopram, fluoxetine, sertraline, paroxetine, fluvoxamine), venlafaxine, sibutramine
  
  • “serotonin syndrome”
    
    • CNS irritability, increased muscle tone, shivering, myoclonus, and altered consciousness
• Sumatriptan, rizatriptan, zolmitriptan, almotriptan + MAOI
  
  • Serum concentrations of 5-HT1 agonists may be elevated
    
    • Increases the risk of cardiac toxicity
• Ergots (DHE 45, ergotamine)
  
  • The risk of vasospastic reactions may be increased
  • Do not use within 24 hours
• Triptans + other triptan
  
  • Concomitant use contraindicated
• Rizatriptan and propranolol
  
  • AUC Rizatriptan ­ 70%
• Eletriptan metabolized by CYP3A4 – significant drug interactions
  
  • ketoconazole, itraconazole, clarithromycin, ritonavir, nelfinavir – avoid eletriptan within 72 hrs

Question 16

migraine prophylaxis

Answer 16

• Indication for use
  
  • Suffer from substantial disability
    
    • HA ≥ 3 days/month
    • HA > 2 days/week or 8 days/month
    • Severe or long-lasting HA > 12 hours
  • Interference with daily activities despite acute treatments
    
    • Abortive medications use > 2 days/week
  • Patient preference
  • Cost of acute medications problematic – they are pretty pricey
  • Patients in whom acute treatments are contraindicated, ineffective, overused, or intolerable
• Principles
  
  • Utilize lowest effective dose – this is different form abortive tx
  • Increase dose slowly until improvement is seen or side effects occur
  • Give adequate trial (2-3 months)
  • If patient has co-existing condition, consider in prophylaxis choice
  • Precipitating medications should be avoided
  • Therapy should be reevaluated after one year by slowly tapering medication
  • Patient compliance is essential
  • PATIENTS MUST KEEP HEADACHE DIARY
• Classes of medications
  
  • Beta-blockers (really propranolol)
  • Calcium-channel blockers
  • Angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs)
  • Antidepressants
  • Dexamethasone (no immediate relief but reduced recurrence up to 72 hours)
  • Anticonvulsants*
• 50-75% of patients will have a 50% reduction in frequency of headaches

Question 17

calcitonin gnee-related peptide receptor antagonist

Answer 17

• Erenumab-aooe (alimovig) – human monoclonal antibody that antagonizes CGRP receptor function
• 70mg to 140mg subQ monthly ($345 to $1400 per month)
• Trial compared 70mg to 140mg to placebo
• Reduction of migraine days per month from 8.3 by:
  
  • 3.2 days in 70mg group
  • 3.7 days in 140mg group
  • 1.8 days in placebo group
• ADEs: constipation, injection site reactions, and ?
• Migraine prophylaxis

Question 18

transcrania magnetic stimulation

Answer 18

• Single-pulse transcranial magnetic stimulation (TMS) has an absolute risk reduction of 17% (pain freedom 2 hours post-treatment vs placebo)
  
  • Limited availability, but may prove useful as 2^nd line or for patients with contraindications/intolerances
  • Not for use in patients with epilepsy

Question 19

cluster headache

Answer 19

• Epidemiology
  
  • 0.01 – 1.5% of population
  • Men:women (6:1)
• Prophylaxis
  
  • Lithium – first line
  • Verapamil
  • Corticosteroids – prednisone and dexamethasone
  • Topiramate
• Treatment
  
  • Triptans
    
    • SC sumatriptan and zolmitriptan – studies
  • Oxygen
    
    • 100% oxygen at 6-7 L/min relieves pain in 50-85% of pts
  • Intranasal lidocaine
    
    • 20-60 mg as a nasal drop or spray
  • Ergotamine

Question 20

tension-type headache

Answer 20

• Most common
  
  • 88% women, 69% men
• Prophylaxis
  
  • Tricyclic antidepressants
    
    • Amitriptyline
• Acute treatment
  
  • Acetaminophen
  • NSAIDs

Question 21

conventional medications with plant origins

Answer 21

• Atropine- Belladona (Atropa belladonna)
• Opioids- Poppy (papaver somniferum)
• Colchicine- Autumn crocus(colchicum autumnale)
• Digoxin- Foxglove (digitalis purpurea)
• Ephedrine- Ephedra (ephedra sinica)
• Salicylic Acid- Willow bark (salix purpurea)
• Scopolamine- Jimson weed (datura stramonium)
• Taxol- Pacific yew (taxus brevifolia)
• Vincristine- Madagascar periwinkle (Catharanthus roseus)

Question 22

10 most common CAM products used

Answer 22

• 10 Most Common Products Used
  
  • Fish Oil Garlic
  • Glucosamine/Chondroitin Ginseng
  • Probiotics Ginkgo Biloba
  • Melatonin Cranberry
  • Coenzyme Q-10
  • Echinacea

Question 23

herbal quality and safety

Answer 23

• Plant species used:
  
  • Studies involving Echinacea with common cold used Echinacea purpurea. E. Pallida and E. angustifolia have unclear pharmacologic activity
  • Serious injuries from misidentification¹
• Plant parts used/purity
  
  • Contaminated from other plant parts
    
    • Echinacea products vary according to proportion of root/aerial parts
  • Reports of lead, mercury, and arsenic contamination in traditional Chinese² and Indian^3-5herbal products
• Harvesting and storage conditions
  
  • Where it was raised, when it was harvested, and how long was it stored?⁶
  • Climatic changes (rainfall/sunlight), microbial contamination from prolonged storage⁷
• Processing:
  
  • Tinctures, teas, caps, creams, etc.

Question 24

herbal quality and safety labeling accuracy

Answer 24

• Ginsenosides varied from 0-300% of labeled concentrations for ginseng¹
• 4 of 17 products tested had no detectable levels of expected valerenic acids while another 4 only had one-half of labeled concentrations²
• Varying daily recommendation dose³
• 47% of samples labeled “standardized” echinacea found content that did not match label⁴

Question 25

Feverfew

Answer 25

• Migraine prophylaxis
• Grade A = “possibly effective”^1-4
  
  • 3/5 trials found efficacy, but well designed trial found no difference than placebo
• Whole leaf products
• Reduce migraine frequency
• Less severe symptoms of pain, n/v, sensitivity to light and noise
• MOA theories
  
  • Inhibits platelet aggregation, serotonin release, leukotrienes, prostaglandin synthesis
• Appears safe for up to 4 months (16 weeks)
• Does not work for acute attacks – ONLY for prophylaxis
• Taper dose to prevent withdrawal
  
  • Increase in frequency and severity of headache
• Do not use if allergic to ragweed or related plants
• May inhibit platelet aggregation – use with caution in patients taking warfarin
• Capsule form decreases irritation to mouth
• Do NOT use during pregnancy/lactation

Question 26

Coenzyme Q10 (ubiquinone)

Answer 26

• Migraine prophylaxis
• Grade C = Conflicting scientific evidence for migraine
• Also for Co-Q10 deficiency, CHF, angina
• Affects mitochondrial function
  
  • Mitochondrial dysfunction in migraine pathogenesis?
  • Might improve mitochondrial oxidative phosphorylation
• Dose: 100 mg TID
• Reduces migraine attack frequency, headache-days, days-with-nausea
• Well tolerated

Question 27

riboflavin (vitamin B2)

Answer 27

• Migraine prophylaxis
• Grade C for headache prevention
• May also affect mitochondrial dysfunction
• High dose of 400 mg per day may reduce the frequency of migraines
• Does not reduce severity or duration and must be used 3 months to see improvement
• Lower doses have not been tested
• Adverse effects
  
  • Higher dose may cause diarrhea and polyuria
  • Yellow-orange discoloration of urine

Question 28

magnesium

Answer 28

• migraine prophylaxis
• Grade C = Conflicting data
• Low Mg levels may induce cerebral arterial vasoconstriction ® increase platelet aggregation ® promote serotonin release
• More likely to benefit patients with low Mg levels
• Adverse effects – diarrhea
• Dose: 300 mg per day
  
  • Recommend slow titration with enteric-coated product (Slo-Mag)

Question 29

st. john’s wort (hypericum perforatum)

Answer 29

• Depression
• Grade A - more effective than placebo
• Hyperforin – major active constituent
• Inhibits reuptake of serotonin, norepinephrine, dopamine
• Most products standardized to hypericin
• May help mild to moderate depression
• Compared to standard antidepressants
• Dose: 300 mg TID (2-4 grams/day)
• Abortifacient! (Do not use during pregnancy)
• Adverse effects
  
  • Incidence similar to placebo and less than conventional antidepressants
  • Sexual dysfunction less than SSRIs
  • Serotonin syndrome can occur alone or with drugs that increase serotonin levels
  • Hypertensive crisis reported with tyramine-containing foods
  • Can induce abortion
• Potent inducer of CYP P450 3A4
  
  • Reduce levels of
    
    • Amitriptyline and nortriptyline
    • Midazolam and alprazolam
    • Cyclosporine and tacrolimus
    • Indinavir and nevirapine
    • Imatinib and irinotecan
    • Digoxin, fexofenadine, methadone, omeprazole, oral contraceptives, simvastatin, theophylline, verapamil, and warfarin
• FDA advises against taking St. John’s wort with all protease inhibitors and non-nucleoside reverse transcriptase inhibitors
• May have additive effects when combined with antidepressants due to effects on neurotransmitter reuptake
  
  • Symptoms of serotonin syndrome, mania, or hypomania have been reported
  • Allow 14 day washout out period after treatment with an MAOI before starting St. John’s wort

Question 30

S-adenosylmethionine (SAMe)

Answer 30

• Depression
• Grade C for depression, B for osteoarthritis
• Amino acid derivative made in the body
  
  • Available from protein sources
• Increase dopamine & norepinephrine levels
• May be as effective as TCAs for depression
• May have additive effect on drugs that increase serotonin levels
  
  • Serotonin syndrome
  • Counsel patients not to combine SAMe with other antidepressants
• Very expensive!

Question 31

osteorthritis CAM

Answer 31

• SAMe (s-adenosylmethionine)^1-4
  
  • See previous slides, doses are lower for osteoarthritis, 800mg PO daily
• Glucosamine / Chondroitin
• MSM (methylsulfonylmethane)

Question 32

glucosamine/chondroitin

Answer 32

• Uses: Osteoarthritis (OA)
• MOA
  
  • Glucosamine: derived from chitin (building block of exoskeletons of crustaceans) and stimulates the manufacturing of substances essential for proper joint function and joint repair stimulation. Also, is reported to have analgesic effect.
    
    • Grade A = mild-moderate knee OA
    • Grade B = general OA
  • Chondroitin: derived from bovine or shark cartilage, and acts a chondroprotectant
    
    • Grade A = OA of knee and other joints
    • Grade B = urinary incontinence/detrusor instability
• Recommended doses: Glucosamine 500mg orally 3 times a day / chondroitin 800 to 1200mg daily
• Adverse effects:
  
  • GI (nausea, indigestion, vomiting), headache, case reports of asthma exacerbations with chondroitin
• Contraindications:
  
  • Allergy to shellfish
• Many well designed studies with adequate power show the glucosamine / chondroitin and glucosamine alone alleviate symptoms and slow joint deterioration in osteoarthritis

Question 33

methylsulfonylmethane (MSM)

Answer 33

• Chemical that, in small amounts, is found in green plants, grains, fruits, vegetables, and some algae. Fresh foods contain MSM naturally but it is destroyed with heat or dehydration or other moderate food processing methods.
• Animal studies have shown analgesic effects and reduced neoplasm rates
• Grade C = Conflicting data
• Small studies (<50 patients) have shown pain relief similar to 600mg ibuprofen daily and better than placebo.
• Dose studied for analgesia is 750mg PO TID
• Little data on adverse effects or drug interactions
• Sometimes added to products containing glucosamine / chondroitin

Question 34

menopausal symptoms

Answer 34

• Black cohosh (Cimicifuga racemosa)
  
  • Grade C = conflicting data
  • May relieve hot flashes
  • Does NOT affect estrogen receptors
  • Doesn’t seem to affect endometrial or breast tissue
    
    • Increase breast cancer risk in animals?
    • Counsel women with hx or family h/o breast CA to avoid
• Soy
  
  • Conflicting data on efficacy for hot flashes
    
    • Genetic component? ability to convert soy isoflavone “daidzein” to “equol” a metabolite with estrogenic activity. 40% of North Americans (higher among Asians/Hispanic)
    • Avoid with estrogen receptor positive breast cancer

Question 35

benign prostatic hyperplasia

Answer 35

• Saw palmetto (Serenoa repens)
  
  • Antiandrogenic, antiproliverative, and anti-inflammatory properties
  • Significantly improves many BPH symptoms
    
    • frequent urination, painful urination, hesitancy, urgency
    • Grade A evidence
  • Well tolerated with few side effects
    
    • Dizziness and gastrointestinal complaints such as nausea, vomiting, constipation, and diarrhea
  • reports of increased INR in patients taking saw palmetto with warfarin
    
    • Does not decrease PSA levels
    • Less incidence of impotence than finasteride

Question 36

Garlic

Answer 36

• Grade A = hyperlipidemia, HTN
• Grade B = decrease of CVD risks
• Antimicrobial, antiviral, immune-enhancing, antispasmodic, antihypertensive, and cholesterol lowering claims
• Allicin and alliin may be responsible for garlic’s biological effects
• Reduces trough and peak plasma concentrations of saquinavir by ~50%
• Advise patients on protease inhibitors not to start or stop garlic supplements without notifying HCP
• Case reports of increased bleeding time and INR with concurrent administration of garlic and warfarin
• May also inhibit platelet aggregation
• Adverse effects:
  
  • Case reports of postoperative bleeding and spinal epidural hematoma linked to garlic supplements
• May have additive effects with any drug that increases bleeding risk

Question 37

ginko biloba

Answer 37

• Widely used for memory enhancement, cognitive improvement, and antiplatelet activity
  
  • Grade A = claudication (PVD), dementia
  • Grade B = cerebral insufficiency
• Ginkgolides are potent inhibitors of platelet-activating factor and may also affect CYP450 enzymes
• Case reports have documented interactions with warfarin, aspirin and ibuprofen
• Adverse effects:
  
  • Intracerebral hemorrhage, spontaneous bleeding in the eye, and postoperative bleeding
• Not recommended if use with antiplatelet agents
• Variable effects on insulin levels
• Patients with diabetes should be encouraged to test blood glucose frequently when starting, stopping, or altering dose of ginkgo
• Ginkgo may have serotonergic effects
  
  • Patients should not take with MAOIs and SSRIs

Question 38

ginseng

Answer 38

• Improve ‘mental performance’ and ‘increase energy’
• Other purported pharmacologic effects include modulation of immune function, antioxidant activity, analgesic effects, improved glucose homeostasis, reduces cancer risk
  
  • Grade B = CV conditions, hyperglycemia in healthy individuals, immune system enhancement, and DM2
• Several species of ginseng
  
  • Panax the most commonly used variety, but Siberian and Brazilian ginseng available too
• Controlled trials have been inconclusive for such effects
• Adverse effects
  
  • Insomnia, nervousness and hypertension have been reported

Question 39

the three G’s and warfarin

Answer 39

• Gingko, garlic, and ginseng all have the potential to prolong the pro-time (elevate the INR).
• Case reports of serious bleeding have been reported when warfarin is used concomitantly with all 3 supplements
• If a patient wishes to begin using gingko, garlic or ginseng more frequent monitoring of the INR is warranted

Question 40

echinacea

Answer 40

• Used as an ‘immune modulating’ agent – in vitro
  
  • Increases production of interleukins and natural killer cell activity
  • Demonstrated weak antibiotic/antiviral/antifungal effects
  • Grade B for URTI prevention/treatment
• Numerous species of plant
  
  • E. purpura the most popular
• Marketed to reduce duration of the common cold if started within 24 hours of the onset of symptoms
• Recent clinical trials have shown no benefit compared to placebo
• Adverse effects
  
  • Flu-like symptoms, unpleasant taste, GI discomfort

Question 41

melatonin

Answer 41

• A serotonin derivative produced by pineal gland
  
  • Helps regulate sleep/wake cycles – its’ release coincides with darkness, release is suppressed by daylight
  • Grade A evidence for jet lag
  • Grade B evidence for delayed sleep phase syndrome, insomnia in elderly, sleep disorders, and sleep enhancement in healthy people
• Give once nightly for insomnia, for jet lag first dose is given on evening of departure and for 1-3 nights after arrival at destination
• Adverse effects
  
  • Very few, rare reports of next day drowsiness, vivid dreams and headache
• Clinical trials have been equivocal

Question 42

supplements in the news

Answer 42

• Vitamin B3 prevents skin cancer?!
  
  • Niacinamide 500mg BID may reduce risk in patients who already have nonmelanoma skin cancer
  • Don’t mix up with niacin or nicotinic acid
  • Oral sunscreen supplements (Heliocare, Sunpill) should not replace topical sunscreen
• Importance of Iodine in pregnancy/breastfeeding
  
  • 1/3 of US women mildly iodine deficient
  • Processed foods often use salt that is not iodized
  • Encourage use of Prenatal with Iodine
  • Iodine rich foods: dairy, meat, eggs, seafood, etc
  • Kosher salt is not iodized
  • Doses over 1100mcg/day can inhibit thyroid hormone synthesis in mom and baby

Question 43

supplements to use cautiously

Answer 43

• Comfrey
  
  • Used for inflammatory disorders
  • Abnormal liver function or damage – irreversible; deaths reported
• Kava
  
  • Used for anxiety and stress
  • Abnormal liver function or damage
  • deaths reported
• Yohimbe
  
  • Used for impotence
  • Changes in blood pressure, arrhythmias, respiratory depression, heart attack
  • Deaths reported