Herbals Flashcards
What should pharmacists do when a patient on warfarin is seeking advice regarding a herbal product?
Look up every agent for warfarin users
Warfarin has many drug interactions, so we should be very cautious
Almost every herbal interacts with warfarin
Is oral cod liver oil great for joints?
Not really, the oil breaks down in the stomach. The oil never reaches the joints
Fairly safe, so don’t fight patients too much on this front
Is dark chocolate effective in reducing CV risk?
Theoretically it does contain antioxidants, but it also comes with a lot of sugar
What is a good resource for herbals?
Natural Medicines database
What condition is glucosamine indicated for?
Used in osteoarthritis
Affects knee, hip, spine
Joint pain relief via preventing cartilage deterioration
What is the difference between rheumatoid and osteoarthritis?
Rheumatoid:
Autoimmune
Less common
Osteoarthritis:
Caused by wear and tear
More common
What is the efficacy of glucosamine/chondroitin in joint conditions ?
Evidence is not very clear
Some professionals think glucosamine doesn’t work, while others disagree
What are some questions pharmacists should ask from someone looking to use glucosamine?
Have you seen an MD for this?
What are you taking it for (get indication)?
How bad is the pain?
Go ahead and add glucosamine as long as the following apply:
Safe to add + minimal side effects
Try for 3-6 months
500mg TID
Should a patient stop using their other drugs when starting glucosamine?
No, glucosamine should be used as an add-on therapy
What is the efficacy of glucosamine and chondroitin at their standard doses?
Not great, but the following doses are given
Glucosamine sulfate 500mg TID
Chondroitin sulfate 400mg TID
What is the potential for side effects and drug interactions for glucosamine or chondroitin?
Both have a great safety record. They also have minimal drug interaction, but like all herbal products be careful when the patient is also on Warfarin
What is SierraSil?
It is indicated for arthritis.
Its contents are essentially soil extract (contains minerals like Ca2+, K+, Na+, etc
Not very effective and not recommended. Don’t fight if someone is adamant (the public doesn’t like them anyways)
What is bromelain (pineapple enzyme)?
It was indicated for a diverse set of indications (this is suspicious)
Not high efficacy
What is the dosing of turmeric/curcumin for arthritis?
30g of turmeric = 2g of curcumin
These doses have shown evidence of helping reduce arthritis pain
What are patients asking pharmacists about omega 3 fish oils?
CV risk reduction
Brain health
What Omega fatty acid is lacking in a Western diet?
Omega 3 is little harder to come by in a standard Western diet
What are the types of omega-3 fatty acids?
ALA: canola, soybeans, walnuts, flaxseed (minimal conversion into EPA and DHA, these omega-3 fatty acids have some CV risk reduction qualities)
EPA and DHA: oily fishes like cod liver, herring, mackerel, salmon, and sardines
EPA and DHA have shown to reduce CV risk
What are the exact benefits of Omega-3 fatty acid sub-types?
ALA: cell membranes + hormones
DHA/EPA: anti-inflammatory and less platelet adhesion
What are the undesirable effects of Omega-6 fatty acids?
Undesirable prostaglandins and subsequent inflammation
What indications are omega-3 fatty acids used for?
CV (primary and secondary MI prevention; high triglycerides)
What is the efficacy of Omega-3 fatty acids?
Studies over the years contradict each other, but they are very safe so use continues
Try to get Omega-3 fatty acids from food, because there is modest or no modest benefit from supplements
Helpful for elevated triglycerides
What is the dose for omega-3 fatty acids?
2 servings/week of specific fish (cod, herring, salmon)
OR
500mg supplement (EPA/DHA) daily
Secondary prevention: 1000mg of fish oil TID
Hypertriglyceremia: 2-4 g of EPA/DHA
What is the utility of flax in terms of reducing CV risk?
Flax contains ALA, only 5% of this is converted into EPA/DHA
Efficacy is even lower
What are some other indications besides Cv risk reduction for Omega-3 fatty acids?
Rheumatoid arthritis (antiinflammatory)
Depression (unclear evidence)
Dry eyes (beneficial)
ADHD (shows promise)
What is the efficacy of herbal alternatives for statins?
Natural products do not show a lot of evidence to reduce LDL
Metamucil (5% reduction, statins can reduce by over 50%)
Omega-3 fatty acids (2-4g EPA/DHA can lower triglycerides alone)
Plant sterols (2g can reduce LDL by 10%)
Soy (25g/day = 5% reduction)
What is ubiquinone (Co Q-10)?
It is a vitamin-like present in all cells. It has antioxidant activitty
It is believed to reduce cancer risk
Statins lower natural ubiquinone, so supplements can be taken to replenish those levels (low evidence that this reduces muscle symptoms)
What are some indications that ubiquinone (Co Q-10) may be effective in treating or preventing?
Congestive Heart Failure (high preload) -treatment
Hypertension - treatment
Heart attack-prevention
Migraine headache-prevention
What is better, ubiquinol or ubiquinone?
It doesn’t really matter, either are fine
What percentage of Canadians have chronic insomnia?
10% of general population experiences chronic insomnia
Are OTC agents effective in insomnia?
Not as good as Rx agents, no real herbal products
What is Cognitive-Behaviour Therapy for insomnia (CBT-I) therapy?
This could be a first thing a practitioner could try initially in a patient reporting insmonia
CBT-I is effectively therapy that tries to calm down insomnia
May need to forward patient to an insomnia therapist
What is the efficacy of chamomile in insomnia?
Chamomile itself is not doing much, perhaps its the ambiance of drinking tea.
Maybe the hot drink makes you drowsy
What is the efficacy of lavender for insomnia?
Low
What is the efficacy of valerian in insomnia?
Not very high
Should pharmacists reccomend homeopathic medicine for insomnia?
Nope, no efficacy at all
What is the efficacy of diphenhydramine in insomnia?
It is the most sedating effects out of all first gen antihistamines
Patients will feel a little sleepy after a dose (won’t knock you out)
Tolerance can develop in long-term use
Is diphenhydramine safe in seniors?
No, they can cause urinary retention
What is the efficacy of Melatonin in insomnia?
It is better vs. the other OTC products for insomnia
New research suggests that it isn’t significantly effetive in improving insomnia
When do natural melatonin levels peak?
Usually peak in the middle of the night (12-4am)
Melatonin production decreases with age
What are some doses for melatonin for insomnia?
Try 1-2mg HS for 2 weeks, then 5mg for 2 weeks, then reassess
Melatonin may not be dose-dependent
No signs of tolerance or negative efffects on sleep
What are some safety concerns with melatonin?
Mild GI
Additive drowsiness if added to other agent that can also cause drowsiness
Safety if used over several years (what is the root cause of insomnia)
What should we ask a patient who has insomnia?
Have you seen an MD?
How long has this been a problem
Any link to an event?
Affect on quality of life?
Is Nytol (diphenhydramine) better for insomnia than melatonin?
No, we should urge patients to shioft from Nytol to melatonin if they have insomnia
Can pharmacists reccomend sleep aids in children?
Need to refer to MD
What are some indications for flaxseed?
Flaxseed contains omega-3 fatty acids (ALA, only 5% is converted into EPA/DHA)
Flaxseeds need to be ground but it is used to help with the following:
CV (low efficacy)
Constipation (source of fibre)
Menopause (low efficacy, maybe)
Should we recommend a flaxseed dose for menopause?
We shouldn’t say any number, the efficacy is really iffy
What is the efficacy of Echinacea?
Low efficacy
What are some indications for garlic?
Antimicrobial or antiviral (low evidence, don’t recommend)
What is the efficacy of ginseng in reducing colds?
Not really effective
What is St. John’s Wort?
It contains Hypericin
It is effective in helping with mild-moderate depression (equivalent efficacy as SSRIs)
Less efficacy for major depression
Is St. John’s Wort a very safe medication?
No, it has a relatively high risk for herbal products
It has lots of CYP 450 related drug interactions (reduces concentration of drugs that are broken down by CYP 450)
Therefore this is under MD care (not even closely within the realm of self-care)
How do SSRIs work?
They prevent the reputable of serotonin, leaving more serotonin in the synapse. This means more receptor stimulation
What is the mechanism of action for St Johns Wort?
Similar to SSRIs
What are some side effects of St John Wort?
It is well tolerated, better adverse effect profile than TCAs and SSRIs
What are some notable drugs that have drug interactions with St John’s Wort?
Birth Control Pills
Warfarin
Both are broken down faster due to St John’s Wort-induced CYP 450 activity
What is serotonin syndrome?
A condition that occurs when there is too much serotonin in the body
Can occur if a patient is on multiple drugs that increase free serotonin (ex. Patient is on SSRIs, St Johns Wort, DM, etc.)
What are some symptoms of severe serotonin syndrome?
Fever (over 38*C)
Confusion/delirium
Sustained clonus/rigidity
Rhabdomyolysis
Death
What is the dosing for St John’s Wort?
300mg TID (0.3% Hypericin —> active ingredient)
Can pharmacists prescribe for UTIs?
Yes
What is the mechanism of action of cranberry juice in UTI?
It can prevent E. coli adhesion onto urinary tract
What is the efficacy of cranberry juice in patients with UTIs?
They can possibly prevent UTIs, no luck for treatment
Low efficacy is due to the active ingredients being digested before they reach the urinary tract
Long-term antibiotics are more effective than cranberry juice for preventing recurrent UTIs
What is the definition of recurrent UTIs
3 or more culture-positive infections in 1 year
May need to be put on prophylaxis
What is the most effective herbal product covered?
St John’s Wort
