Herbal and Dietary Supplements Flashcards
Definition of herbal supplements
Supplements sold to and consumed by the general population that include plants, plant components,
plant extracts and drinks, tablets, and capsules manufactured from plant sources
What are dietary supplements?
- Intended to supplement dietary intake
- contains one or more of the following: vitamin, mineral, herb botanical or amino acid
Roughly ____% of the general population use an herbal or dietary supplement of some sort
20-50
What is a mistake providers can make regarding supplements?
Many providers forget to ask if a patient is
taking a supplement or herbal medication
T/F Herbal supplements can react with
medications that you will be prescribing
T
1962
Botanicals are not considered drugs
1973
Standard identification of vitamins and minerals only. If the dosing exceeds 150% of recommended daily dosing it is then considered a drug
1977
Prohibiting the FDA from regulating vitamins and minerals as prescription drugs.
1990
Nutrition Labeling and Education Act (NLEA) - Nutrition facts must be on box, declaring all ingredients
1994
Dietary Supplement Health and Education Act (DHSEA) - Senator Orrin Hatch (Utah) & Tom Harkin (Iowa)
- Dietary supplements are food (not medicine - therefore do not need to register with the FDA)
Criticism for the DHSEA of 1994
- Does not require that the supplement demonstrate safety prior to marketing or implementation on the market
- Herbs and supplements do not have to demonstrate efficacy prior to being put on the market
1998
1998 - The Natural Product Association (NPA) good manufacturing practice (GMP) certification program (TruLabel) is formed
- Tests and maintains a minimum standard
2007
- Required manufacturers to evaluate identity, purity, strength and composition.
- Required to submit ALL side effects of the FDA
T/F Research to prove that a supplement is safe
is not required prior to a dietary supplement
being put on the market (unlike drugs)
T
Manufacturers may make three types of claims for their herbal or dietary supplements
1) health claims
2) structure/function claims
3) nutrient content claims.
If the manufacturer does make a claim, it must be followed by the statement:
“This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”
Factors for variability in dietary supplements (3)
- Constituents
- Contamination
- Standardization
Constituents
The parts of the dietary supplement
■ Remember dietary supplements can be a mixture
■ Some ingredients may conflict with others
■ Some ingredients may be synergistic with others
■ Even the way supplements are stored over time
can affect them
Contamination
Supplements can contain contaminants from the
environment, whether known or not known.
■ Heavy metals: lead, mercury
■ Processing and packaging
■ Mixing of other active ingredients
Standardization
Sometimes the active ingredient is unknown.
○ Variable consistency of known active ingredients.
■ Example - Ginseng products contained 10-300% of what was labeled
■ Example - Echinacea showed ≤ 50% of what was labeled.
○ FDA encouraging labeling standards.
In 1998, the NIH established _____ (the National
Center for Complementary and Integrative Medicine)
NCCIM
Due to its many nutrients, which can satisfy almost all needs of the human body, acai is currently
referred to as _____
super food
Acai mechanism of action & suggested use
Antioxidant properties and strong nutritional value
○ Evidence: No well-done scientific studies with significant evidence
○ Often used for anti-inflammatory reasons, fever, pain, flu, etc.
Black cohosh mechanism of action and suggested use
● Proposed Mechanism of Action:
○ Remains unclear; No apparent dietary impact
● Suggested Uses:
○ Breast cancer, infertility, postmenopausal hot flashes (most
popular use), menstrual-related migraines, osteoarthritis,
rheumatoid arthritis
○ Evidence is generally weak. Only short-term use advised
Contraindication: allergy or hypersensitivity interactions, lots of potential drug interactions
Known side effects and adverse reactions of black cohosh
Abdominal pain, bleeding, bradycardia, bruising, constipation, diaphoresis, dizziness, headaches, “heaviness in legs,” increased risk of stroke and hormone-sensitive cancers, hepatotoxicity,
Black cohosh: concerns for drug interactions
Because it is a known CYP450 enzyme player, there are lots of drug interactions possible, most notably with antiseizure medications, analgesics, anesthetics, and anticoagulants.
Uses and indications for calcium
Antacid, bone stress injury prevention, calcium deficiency, cancer, colorectal cancer, growth (low birth weight infants), hyperkalemia, hyperparathyroidism, HTN, lead toxicity (acute
symptom management), magnesium toxicity, rickets, osteoporosis, PMS, preeclampsia
Contraindications for calcium
Ventricular arrhythmias, hypercalcemia, hypophosphatemia, renal stones, sarcoidosis
Vitamin D
● Ergocalciferol (D2), Cholecalciferol (D3).
● Protective of bone health/growth and required to absorb calcium.
○ Often provided together with Calcium in supplement form
Evidence based uses for Vitamin D
Osteoporosis, osteomalacia, hyperparathyroidism, diabetes, depression, psoriasis (topical preparation), acute infection
Known Side Effects and Adverse Reactions of Vitamin D
None unless reach toxic levels. Toxicity occurs at levels > 150 ng/mL - hypercalcemia, nephrocalcinosis, early aging, fatigue, nausea
Echinacea and mechanism of action
- Native American medicinal plant; part of Daisy family
● Proposed Mechanism of Action:
○ No consensus on primary active ingredient or
mechanism of action.
○ Seems to somehow boost immune function, reduce pain and inflammation
Suggested use and contraindications for Echinacea
Suggested Uses:
○ Shorten duration of URI (common cold) and UTI infections, wound healing, yeast infections, immune system support.
○ Evidence: NCCIH-funded studies showed no benefit; Other studies suggest reduction in duration of symptoms
● Contraindications:
○ Not to be used along with Amoxicillin.
○ Contraindicated in ragweed, daisy, or marigold hypersensitivity
Ephedra synthetic version is called
pseudoephedrine
The alkaloid ____ was banned in US in 2004
ephedrine (component from the stem of ephedra)
Ephedra mechanism of action
○ Ephedrine acts as a direct agonist of 𝞪 and 𝞫-adrenergic receptors, stimulating the release of norepinephrine.
○ Acts as an amphetamine-like stimulant
Suggested uses for Ephedra
○ No FDA approved uses!
○ Uses included appetite suppression, weight loss, fatigue treatment, athletic performance, decongestant, asthma, sexual arousal.
○ Evidence: Supports appetite suppression and weight loss effects.
■ However, evidence shows risk outweighs the benefits
Known side effects and adverse reactions of ephedra
Excessive adrenergic stimulation, HTN,
Seizure, Tachycardia, MI, CVA, excessive CNS
stimulation, anxiety, sleeplessness, psychosis
Concern for drug interactions: QT prolonging drugs (risk of ventricular arrythmias)
Fish oil (omega-3)
●Omega-3 fatty acids have been shown to be beneficial for general health and some medical conditions; must be obtained from the diet
● Omega-3 sources: Herring, halibut, salmon, mussels, tilapia, flax, hemp, walnuts, pecans, hazelnuts
Mechanism of action
Mechanism of action for Fish oil
○ Vasodilator and inhibitor of platelet
aggregation.
○ Decreases VLDLs, LDLs, and triglycerides (inhibition of hepatic triglyceride synthesis).
○ Weakly assists chemotaxic (aid in
inflammatory responses)
Suggested use for fish oil
Evidence: CAD, HTN, hyperlipidemia, rheumatoid arthritis (RA), and post-MI
Conraindication for fish oil
Doses > 3g in DM patients (interacts with
medications)
Known side effects and adverse reactions for fish oil
Abdominal pain, bleeding, fishy aftertaste, halitosis, heartburn, hemorrhagic stroke (large doses), gas, loose stools (large dose)
Drug interactions for fish oil?
Anticoagulants/antiplatelet drugs (↑ risk of
bleeding), antidiabetic agents (↑ risk of
hypoglycemia), antihypertensives (↑ risk of
hypotension), contraceptives (altered effect)
Flaxseed is actually a strong source of _____ fatty acids, as well as _____
Omega-3; fiber
The Evidence for flaxseed is most supportive of its use in ______
Diabetes management and treatment of elevated cholesterol
Contraindications for flaxseed
Bowel obstruction, pregnancy & children (insufficient information),
dehydration, immature seeds (toxic)
Side effects and adverse reactions of flaxseed
Diarrhea, abdominal pain, hypoglycemia, hypotension, headaches, possible increased risk of prostate cancer (?), hormone changes (?)
drug interactions with Flaxseed
Is believed to possibly cause decreased absorption of oral medications when given at the same time as the oil
Suggested uses for Garlic
○ Dyslipidemia, antiatherogenic, antibacterial, anti-HTN, anticancer.
○ Evidence: Mild antilipidemic effect, insufficient data on all other
claims. Mayo Clinic gives it a “green light” for evidence and risk
Known side effects and adverse reactions for Garlic
○ Diaphoresis, dizziness, mild abdominal pain
○ Generally well tolerated with low side effect profile
Drug interactions with Garlic
Potentiate other anticoagulants, discontinue before oral or general surgery. Can cause marked reduction in levels of anti-AIDS/HIV medication
Ginger may act as a peripheral _____ agonist, but is mostly unknown
serotonin
Suggested uses for Ginger
○ Antiemetic, nausea reduction,
dysmenorrhea, arthritis.
○ Evidence: Supports pregnancy-induced
nausea, other uses are not supported.
Side effects and adverse reactions for ginger
○ No major side effects reported
○ Like Garlic, Ginger has a Mayo Clinic “green light”
due to fairly strong evidence supporting antiemetic
use and low side effect and contraindication
profile
Antiplatelet activity may potentiate other
anticoagulants and antiplatelet drugs with which supplement
Ginger
Suggested uses for Ginko Baloba
Evidence: Intermittent effects on claudication, mixed support for cognitive impairment. Not a “brain booster” as once thought
○ Commonly used for memory preservation, cognitive impairment,
dementia, Alzheimer’s disease, Cerebrovascular and peripheral
vascular disease, sexual dysfunction, tinnitus
Suggested uses for Ginseng
Evidence: Few studies, most claims are not
supported, possible improved mental function
Known Side Effects and Adverse Reactions for Ginseng
○ Generally well tolerated. May cause headaches,
GI upset, insomnia
○ Gets the Mayo Clinic “green light”
Mechanism of action for Glucosamine-Chondroitin
Believed to be prominent precursors in the biochemical synthesis of the building blocks of joint cartilage
There is some evidence supporting use for severe knee osteoarthritis, but other studies disagree - Which supplement?
Glucosamine-Chondroitin
Which supplement is Contraindicated if allergic to shellfish
Glucosamine-Chondroitin
Which supplement s believed to have a calming effect similar to a benzodiazepine medication?
Kava
Mayo Clinic states it is a “supplement to avoid”
Kava
Suggested uses for Kava
○ Anxiety, sleep disturbances, depression
○ Evidence: Supports anxiolytic effect, comparable to buspirone
Side effects and adverse reactions of Kava
Serious hepatotoxicity, even known to cause death
_____ is Usually supplied by a balanced diet, found abundantly in the body
Magnesium
_____ is a cofactor in more than 300 enzyme systems that regulate diverse biochemical reactions in the body, including protein synthesis,
muscle and nerve function, blood glucose control, and blood pressure regulation.
Magnesium
Suggested uses for Magnesium
○ Several uses: Ventricular arrhythmias (like Torsades), asthma, anxiety,
COPD, CAD, leg cramps, muscle spasm, preterm labor (tocolysis),
preeclampsia, RLS, migraines, HTN, constipation, Mag replacement
○ Evidence: Mild evidence for HTN, preeclampsia, constipation, low Mag
Contraindications for magnesium
Heart block, coma, myocardial damage
Hormone produced in the pineal gland of the brain, synthesized from the amino acid tryptophan
Melatonin
Suggested uses for Melatonin
○ Insomnia, jet lag, other sleep disorders, arthritis, benzodiazepine withdrawal, cancer, headache syndromes, fatigue, stress, dementia, seasonal depression.
○ Evidence: Moderate evidence for insomnia, jet lag, sleep disorders
Mechanism of action for red yeast rice
Red Yeast Rice contains several compounds that seem to lower cholesterol levels. One is monacolin K, which is the same ingredient
found in the cholesterol drug Lovastatin.
Which supplement shows evidence for hypercholesterolemia
Red yeast rice
Which supplement Should not be taken at the same time as Statins?
Red yeast rice
Taking _____ along with other cholesterol-lowering medications increases risks of DDIs significantly, especially Statins.
Red Yeast Rice
Contraindications for Red yeast rice
○ Abnormal LFTs, other liver dysfunction
○ Should not be taken at the same time as Statins
Mechanism of action for St. John’s wart
Inhibition of norepinephrine, dopamine, and serotonin reuptake, possible suppression of ACTH and cortisol secretion
Which supplement is effective in mild to moderate depression
St. John’s wart
Drug interactions for St. John’s wart (There are LOTS)
Most notably antidepressant medications, birth control pills,
anticoagulants, antiseizure medications, some asthma medications,
and all corticosteroids.
This supplement may interact with dihydrotestosterone to inhibit production, inhibit binding, increase clearance
Saw Palmetto
While study results are contradictory, recent meta-analysis suggests that ______ does not have beneficial effects on BPH
saw palmetto
Pregnant women should avoid contact with this supplement
Saw palmetto
Which supplement is Believed to be an antioxidant with anti-inflammatory (COX inhibition)
properties.
Tumeric
Some evidence to suggest _____ can lower cholesterol, decrease joint pain associated with arthritis, and treat dyspepsia
Tumeric
Contraindications for Tumeric
Gastric ulcer, bile duct obstruction
Supplement that is Likely helpful for insomnia, may have slight positive effects on anxiety, menstrual cramps, and menopausal symptoms
Valerian Root
Medscape cites 66 serious interactions, many of them also used for anxiety, sleep, and tremors for this supplement
Valerian Root
