Traditional medicines Flashcards
What is Traditional, Complementary & Alternative Medicine (TCAM)?
This encompasses medical and health care therapies outside the territory of conventional medicines, some of which are yet to be validated using scientific methods
3 ways traditional medicines can continue to be sold in the UK:
Achieving traditional herbal medicines registration (THR) via an assessment on application to the MHRA
Being licensed as a medicine under a marketing authorisation
Being prepared for a specific patient by a practitioner following a one to one consultation
what is THR products intended for?
A THR product is only intended for minor health conditions where medical supervision is not required (e.g. cold, cough
what are all the criteria for THR?
A THR product is only intended for minor health conditions where medical supervision is not required (e.g. cold, cough)
If the TCAM claims to treat major health conditions, will then need to apply for a MA
Products not registered under THR can only be sold as a dietary supplement and no health indications are allowed
Claims made for THR products are based on traditional usage and not evidence of the products effectiveness
Guarantee quality and safety (but not efficacy)
What is Ginkgo biloba
what is used for?
cautions
mode of action
dosing
side effects
interactions with other drugs
What is it?
Botanical name: Ginkgo biloba
Leaf is used
what is used for ?
To relieve the symptoms of Raynaud’s syndrome and tinnitus, based on traditional use only
Improved memory
Raynaud’s Syndrome – blood supply to extremities is interrupted temporarily due to change in temperature or stress
Tinnitus – hearing sounds that are not from an outside source
what are the cautions
Active constituents: Ginkgolides (terpenoids)
No strong evidence that the leaf is toxic
Unreliable safety data for pregnancy and breastfeeding, but best avoided
Available in oral solid dosage forms
moa
Mode of action is poorly understood – proposed mechanisms include antioxidant, anti-inflammatory, antiplatelet, anticoagulation and vascular effects
dosage
Dosage varies depending on the indication and typical dose is 80-240 mg of extract per day in divided doses
side effects
Generally well tolerated in typical doses, possible adverse effects
GI disturbances
Headaches and dizziness – due to the change in blood pressure
Palpitations
Bruising, spontaneous bleeding and clotting disorders
Interactions with drugs:
Anticoagulants (warfarin) – good evidence to suggest it would not cause interaction but recommended to monitor early signs of bruising
Antiplatelet (e.g. aspirin, clopidogrel and ticlopidine) – take with caution and monitor bruising
CYP450 substrates (e.g. nifedipine) – may increase the drugs effects – take with caution and monitor side effects
Antiepileptic (valproate and phenytoin) – evidence is limited but it may reduce effects of antiepileptic drugs
Interaction with herbs:
Garlic
Clove
Panax ginseng
what is st johns wort
what is used for?
cautions
mode of action
dosing
side effects
interactions with other drugs
what is it?
Botanical name: Hypericum perforatum L
Main active constituents: hypericin (anthraquinone) and hyperforin (flavonoid)
what is it used for:
For the relief of symptoms of slightly low mood (depression) and mild anxiety
The aerial parts and flowering tops are used
Products may vary in concentration due to various parts of plant used and plant origin
cautions
Caution with certain diseases/health states:
Can induce hypomania or mania when used in patients with bipolar disorder
Can induce hypomania at therapeutic dose in those with major depression
Should be stopped two weeks before elective surgical procedures – may delay prolong general anaesthesia effects
Use should be avoided in pregnancy and lactation due to limited data – but may need to conduct a risk benefit analysis
moa:
Exact mechanism again is not clear: binds GABA receptor, inhibits synaptic reuptake of neurotransmitters and up regulation of serotonin receptors
dose:
Mainly in oral form, but tincture is also available
Dose varies: generally 300 mg of hypericin extract TDS
side effects
Generally well tolerated (as compared to SSRI and tricyclic antidepressants) but can cause:
GI disturbances
Insomnia
Dizziness
Dry mouth
Restlessness, anxiety and agitation
Skin rash and photosensitivity (in high dose for fair skinned people)
interactions
Interaction with drugs:
Anticoagulants (warfarin) – can reduce anticoagulant effects. The UK Committee on Safety of Medicines (UK CSM) advise avoid concomitant use. Or closely monitor INRs at the start
SSRIs – both inhibit serotonin, possibly cause serotonin syndrome, avoid concomitant use if patients are at high risk of increased serotonergic or adverse effects such as confusion
Digoxin – Digoxin is a P-glycoprotein substrate and St Johns wort increases the P-glycoprotein transporter activities, which reduces the absorption of digoxin. Avoid if possible or closely monitor digoxin serum levels and adjust dose.
Oral and emergency hormonal contraceptives – concurrent use with enzyme inducers (e.g. St John’s wort) would reduce contraceptive efficacy and potentially lead to unplanned pregnancy – MHRA advised to avoid
And many more..
what is velerian
what is used for?
cautions
mode of action
dosing
side effects
interactions with other drugs
what
Botanical name: Valeriana officinalis
Active constituents: valerenic acid and valerenol
The root is used.
Mainly used as tablets/capsules, tea or fluid extract (known was tincture)
A pungent odour – smells like ‘old socks’
use
To relieve slightly low mood, mild anxiety and sleep disturbances due to mild anxiety, based on traditional use only.
Regarded as an effective sedative for over 2000 years.
It is often combined with other sedative herbs e.g. passionflower, hops, skullcap and chamomile.
dose:
Studies suggested that 600mg ON for 4-6 weeks to see an effect.
moa:
Again, mode of action is unclear – possibly due to activation of adenosine A1 receptors and GABAA receptors
It inhibits enzyme system that catabolises GABA, increases GABA concentrations and hence decreases CNS activity.
It may also bind directly to GABAA receptors and stimulate the release and reuptake of GABA.
Evidence on its use in anxiety is inconclusive but has been suggested its’ effects on GABAA receptors elicit anxiolytic properties.
cautions:
Advice for customers:
Generally well tolerated when used at the recommended dose
GI disturbances
Headache
Paradoxical restlessness (rare but if occurs, discontinue use)
Vivid dreams (rare)
Occasional dosing may not be effective
Probably need 600 mg for at least 4-6 weeks
To be taken 30 min before sleep
interaction
Avoid use with sedating pain killers (opioids), haloperidol or prior to general anaesthesia
what is devils claw
what is used for?
cautions
mode of action
dosing
side effects
interactions with other drugs
what:
Botanical name: Harpagophytum
Found in Southern Africa
The root is used.
Mainly used as tablets or capsules
use:
For the relief of backache, rheumatic or muscular pains and general aches and pains in the muscles and joints
Active constituent: Harpagoside (iridoid glycosides)
moa:
Suggested mode of action – inhibits lipopolysaccharide-induced inducible nitric oxide (iNOS) and cyclooxygenase-2 (COX-2) – anti-inflammatory and analgesic effects
dose:
Daily doses of 50-100mg harpagoside shows pain relief
To be taken immediately after food
side effect:
Generally well tolerated with few side effects and usually limited to GI upset.
caution
Avoid in duodenal ulcers due to its effect on gastric pH
Contraindicated during pregnancy
interaction
Can increase the activity of warfarin (increased chance of bruising or bleeding
what is milk thistle
what is used for?
cautions
mode of action
dosing
side effects
interactions with other drugs
what
Botanical name: Silybum marianum
The root, leaves and fruits are used
Mainly in oral preparations
used:
To relieve the symptoms associated with occasional over indulgence of food and drink such as indigestion and upset stomach based on traditional use only
Active constituents: flavonoid complex called silymarin (a combination of flavonoids of silibinin, silydianinand silicristin)
moa
Regulates inflammatory mediators e.g. tumor necrosis factor, nitrous oxide and interleukin.
A free radical scavenger with hepatoprotectant effects
dose:
An oral dose of 108mg silymarin up to TDS is used
side effect
Side effects: mild GI symptoms, headache and allergic reactions
tcam food supplements
Also included in the TCAM sector is dietary supplements and diet itself.
These are regulated under food law (different to the THR scheme) but in a similar way it cannot claim or imply that it can treat, prevent or cure and disease.
What types of things might a patient forget to tell you about?
Vitamins
Sports supplements (proteins, creatines)
Diet itself (vegan, vegetarians, juice diets, paleo, intolerances (Lactose, nuts, wheat)
interaction of vit a,b,e,k niacin, calcium and aluminium, calcium, iron, pottasium
Vitamin A – Interaction with retinoids (isotretinoin & acitretin), Vitamin A toxicity
Vitamin B6 – Interaction with phenytoin and levodopa, decreases activity
Vitamin E – Interaction with warfarin, increased risk of bleeding
Vitamin K – Interaction with warfarin, decreases activity
Niacin (vitamin B-complex) – interaction with statins, increased risk of myopathies
Calcium – interaction with tetracyclines and fluoroquinolones, reduced activity
Aluminium and magnesium – binds to tetracyclines, fluoroquinolones and levothyroxine
Calcium – interaction with tetracyclines and fluoroquinolones, reduced activity
Aluminium and magnesium – binds to tetracyclines, fluoroquinolones and levothyroxine
Iron – interacts with tetracyclines, fluoroquinolones, levothyroxine and digoxin, reduces absorption
Potassium – interacts with ACE inhibitors, digoxin, indomethacin, spironolactone, or anything that can cause hyperkalaemia. Increased potassium levels, effects functioning of nerves and muscles.
what is glucosamine
Was previously classified as a food supplement used to treat pain in patients with osteoarthritis or joint pains.
Products that contain dosage levels of base glucosamine >1178mg/day can no longer be sold and is now regarded as a medicine (as has an evidenced pharmacological action at this point)
Lower doses remain unaffected
Shows that investigations into all products is always ongoing and changing
what is glucosamine
Was previously classified as a food supplement used to treat pain in patients with osteoarthritis or joint pains.
Products that contain dosage levels of base glucosamine >1178mg/day can no longer be sold and is now regarded as a medicine (as has an evidenced pharmacological action at this point)
Lower doses remain unaffected
Shows that investigations into all products is always ongoing and changing
pharmacist role - tcam
A responsibility to obtain FULL drug history and current medication including TCAM.
A non-judgmental attitude
Be knowledgeable about and be able to provide the evidence for efficacy and safety of TCAM
Be able to recognise and report adverse effects and interactions
Do not assume – always ask detailed questions on intended use.
