Integrating Herbs with Integrating Herbs with Conventional MedicineConventional Medicine

Linda Diane FeldtLinda Diane FeldtRPP, NCTMBRPP, NCTMB

Holistic Health Practitioner and HerbalistHolistic Health Practitioner and Herbalist

ObjectivesObjectives

Identify the difference between nourishing and Identify the difference between nourishing and medicinal herbsmedicinal herbs

Identify how nourishing herbs are providedIdentify how nourishing herbs are provided Identify how medicinal herbs are providedIdentify how medicinal herbs are provided Know reasons to use nourishing or medicinal herbsKnow reasons to use nourishing or medicinal herbs Learn about 9 popular herbsLearn about 9 popular herbs Learn some of the problems with herbal marketing Learn some of the problems with herbal marketing

and preparationsand preparations Time for questions and individual concernsTime for questions and individual concerns

Nourishing herbsNourishing herbs

Nutrient richNutrient rich Bio-availableBio-available Generally considered safe, side effects uncommonGenerally considered safe, side effects uncommon Dosage and strength less importantDosage and strength less important Tend to be local, whole, and commonTend to be local, whole, and common Large amounts used, in contrast to medicinal plantsLarge amounts used, in contrast to medicinal plants Includes tonicsIncludes tonics Supportive to body systemsSupportive to body systems Long term use is usually beneficialLong term use is usually beneficial

Nourishing Herbs con’t.Nourishing Herbs con’t.

Internal useInternal use InfusionsInfusions

Water basedWater based Vinegar basedVinegar based

Whole plantWhole plant CookedCooked Raw (salad)Raw (salad)

External useExternal use CompressCompress PoulticePoultice SalveSalve

Medicinal HerbsMedicinal Herbs

Dosage and strength important or criticalDosage and strength important or critical Tend to utilize more toxic parts of plantTend to utilize more toxic parts of plant Stimulate or sedateStimulate or sedate More likely to have side effectsMore likely to have side effects Are often plants that are less common, or rareAre often plants that are less common, or rare Long term use is generally discouragedLong term use is generally discouraged More extensive knowledge is needed to use safely More extensive knowledge is needed to use safely

and effectivelyand effectively

Medicinal Herbs con’t.Medicinal Herbs con’t.

Tinctures Tinctures Alcohol basedAlcohol based GlycerinGlycerin

ExtractsExtracts CapsulesCapsules

Case Study: Prophylactic Case Study: Prophylactic Use of Echinacea Use of Echinacea

angustifolia and purpurea angustifolia and purpurea Tincture for Management Tincture for Management

of a Recurrent of a Recurrent Staphylococcus InfectionStaphylococcus Infection

Case Study con’t.Case Study con’t.

46 yo female CHF Heart cath age 53, followed by staph

infection Broad spec. antibiotics no effect Echinacea ang. 30-40 drops every 3 hours Symptom improvement within 2 hours Two days both, stopped Ech. Symptoms

returned within 4 hours Ech and Antibiotic together, no symptoms

Case Study con’t.Case Study con’t.

MD stopped antibiotics, pt. stopped Ech. Symptoms returned

Ech. as before - symptoms gone One day without Ech, some symptoms Ech 10 drops day no symptoms For next 7 years, until death, two

skipped days symptoms return -proven at least five times

Significant pointsSignificant points

Echinacea fought an antibiotic resistant Echinacea fought an antibiotic resistant infectioninfection

Low dose (nourishing) as effective as high Low dose (nourishing) as effective as high dose (stimulating)dose (stimulating)

Low dose safe to use long termLow dose safe to use long term Long term use was necessaryLong term use was necessary Mechanism of action for effect of low dose Mechanism of action for effect of low dose

unknownunknown

Popular HerbsPopular Herbs

The HerbsThe Herbs

Ginkgo biloba Ginkgo biloba

St. John’s wortSt. John’s wort

GarlicGarlic

EchinaceaEchinacea

GoldensealGoldenseal

Saw palmettoSaw palmetto

Milk thistleMilk thistle

Black cohoshBlack cohosh

GingerGinger

Ginkgo bilobaGinkgo biloba

Most ancient tree knownMost ancient tree known Uses: cerebral insufficiency, Alzheimer’s Ds, Uses: cerebral insufficiency, Alzheimer’s Ds,

intermittent claudication, tinnitisintermittent claudication, tinnitis

Powdered Powdered leavesleaves

Tincture or Tincture or infusioninfusion

Ginkgo Ginkgo

Increases vascular flowIncreases vascular flow diabetic peripheral vascular diseasediabetic peripheral vascular disease Raynauds syndromeRaynauds syndrome Other circulatory benefits fro varicose veins, Other circulatory benefits fro varicose veins,

hemorrhoids, eye disordershemorrhoids, eye disorders Affinity for cerebral circulationAffinity for cerebral circulation Inhibits platelet activity factorInhibits platelet activity factor

GinkgoGinkgo

Used to relieve tension, anxiety, elevate moodUsed to relieve tension, anxiety, elevate mood Contains flavanoids, Contains flavanoids, terpene lactones,

ginkgolides A, B, and C, bilobalide, quercetin, and kaempferol.

ginkgolides control allergic inflammation, anaphylactic shock and asthma

antioxidant

What to watch forWhat to watch for

Can increase blood flowCan increase blood flow Discontinue before surgeryDiscontinue before surgery Do not use with menstrual floodingDo not use with menstrual flooding Do not use with other bleeding problems Do not use with other bleeding problems

(ulcer, bruising, etc.)(ulcer, bruising, etc.) Not suggested with blood thinners, aspirin, etc.Not suggested with blood thinners, aspirin, etc.

Gingko biloba & DementiaGingko biloba & Dementia

52 week RCT, double 52 week RCT, double blind, multi-centerblind, multi-center

Outcomes in 309 pts Outcomes in 309 pts (ITT):(ITT): Pt cognition: tx no Pt cognition: tx no

change, placebo worse change, placebo worse (p=0.04)(p=0.04)

Caregiver assess: tx Caregiver assess: tx slight improve, placebo slight improve, placebo worse (p=.004)worse (p=.004)

Dose: 120 mg/d of EGb Dose: 120 mg/d of EGb 761761

Safety: side effects Safety: side effects equalequal

Problems: high dropout Problems: high dropout rate (50% tx, 62% rate (50% tx, 62% placebo)placebo)

Ginkgo & ClaudicationGinkgo & Claudication

Meta-analysis of Egb 761Meta-analysis of Egb 761 5 placebo controlled trials5 placebo controlled trials Moderate to large effect (0.75 Cohen’s Moderate to large effect (0.75 Cohen’s dd) on ) on

pain-free treadmill walking distancepain-free treadmill walking distance

Schneider B. Arzneimforsch 1992;42(4):428-436

Ginkgo - ToxicologyGinkgo - Toxicology

Adverse eventsAdverse events GI complaintsGI complaints bruising & spontaneous bleedingbruising & spontaneous bleeding

Avoid if taking warfarin, heparin, or NSAIDsAvoid if taking warfarin, heparin, or NSAIDs Can increase insulin levelsCan increase insulin levels May increase sedation with trazodone May increase sedation with trazodone

St. John’s Wort St. John’s Wort Hypericum PerforatumHypericum Perforatum

Used as tincture, extract in pill form, Used as tincture, extract in pill form, topically as oil or salvetopically as oil or salve

Popular as anti-depressant.Popular as anti-depressant.

Also used for muscle aches, nerve pain, Also used for muscle aches, nerve pain, nerve regeneration, for herpes nerve regeneration, for herpes outbreaks, bruisingoutbreaks, bruising

St. John’s WortSt. John’s Wort

P450 Cytochrome systemP450 Cytochrome system Can interfere with effectiveness of other Can interfere with effectiveness of other

medicationsmedications Possible rash from exposure to sun (sheep and Possible rash from exposure to sun (sheep and

cows)cows) Use with other mood altering drugs of concernUse with other mood altering drugs of concern Use by people with manic depressive and Use by people with manic depressive and

other psychological conditions of concernother psychological conditions of concern

St. John’s Wort & DepressionSt. John’s Wort & Depression

Meta-analysis: 23 studies, 1757 ptsMeta-analysis: 23 studies, 1757 pts Mild-mod depressionMild-mod depression

Superior to placebo, rrr =2.67 (1.78-4.01)Superior to placebo, rrr =2.67 (1.78-4.01) As effective as TCA’s , rrr=1.10 (0.93-1.31)As effective as TCA’s , rrr=1.10 (0.93-1.31) Fewer side effects than TCA’sFewer side effects than TCA’s Dose: 0.4-2.7 mg Hypericin (standardized extract) Dose: 0.4-2.7 mg Hypericin (standardized extract)

Multi-center trial vs. SSRI’s at DukeMulti-center trial vs. SSRI’s at DukeLinde K, et al. BMJ 1996;313:253-8

St. John’s Wort and ZoloftSt. John’s Wort and Zoloft

Randomized controlled trialRandomized controlled trial St. John’s wort vs. Zoloft vs. placeboSt. John’s wort vs. Zoloft vs. placebo effectseffects Side effectsSide effects

Placebo < SJW < Zoloft (p= 0.000Placebo < SJW < Zoloft (p= 0.000

St. John’s Wort - ToxicologySt. John’s Wort - Toxicology

Side effectsSide effects Theoretical risk - sunburnTheoretical risk - sunburn

Herb-drug interactionsHerb-drug interactions Studies - digoxin, protease inhibitors, TCAsStudies - digoxin, protease inhibitors, TCAs Case reports - cyclosporine, warfarin, oral Case reports - cyclosporine, warfarin, oral

contraceptives, theophylline, SSRIs contraceptives, theophylline, SSRIs Theoretical - ironTheoretical - iron

Facts & Comparisons Review of Natural Products, Dec 2000.

Garlic (Garlic (Allium sativumAllium sativum))

UsesUses Lower cholesterolLower cholesterol anti-thromboticanti-thrombotic lower blood pressurelower blood pressure anti-microbial agentanti-microbial agent Strengthen heart muscleStrengthen heart muscle Reduce platelet clumping Reduce platelet clumping

and clottingand clotting Stabilize blood sugar levelsStabilize blood sugar levels

GarlicGarlic

Some concern about use if bleeding is of Some concern about use if bleeding is of concernconcern

OdorOdor Large amounts can great gasLarge amounts can great gas Potential decreased platelet aggregationPotential decreased platelet aggregation

GarlicGarlic

Contains alliin in intact garlic bulb Contains alliin in intact garlic bulb Alliin Alliin allicin (crushed) allicin (crushed) 600 – 900 mg of dried powder (1.3% allicin)600 – 900 mg of dried powder (1.3% allicin)

Garlic - EvidenceGarlic - Evidence

German Commission E German Commission E elevated blood lipidselevated blood lipids prevention of age-related vascular changesprevention of age-related vascular changes

25 studies between 1979-1998 with 2,920 25 studies between 1979-1998 with 2,920 peoplepeople

Mixed results highly dependent on type of Mixed results highly dependent on type of garlic preparationgarlic preparation

Garlic - EvidenceGarlic - Evidence

2 Meta-analyses 2 Meta-analyses garlic lowered total cholesterol between 9-12%garlic lowered total cholesterol between 9-12%

Meta-analysisMeta-analysis Anti-hypertensive - 10% reductionAnti-hypertensive - 10% reduction

Double blind RCT - 152 subjects for 4 yearsDouble blind RCT - 152 subjects for 4 years garlic reduced development of atherosclerosisgarlic reduced development of atherosclerosis

Echinacea spp.Echinacea spp.

E. pallida purpurea angustifoliaE. pallida purpurea angustifolia Use: prevention and treatment of Use: prevention and treatment of

colds, flucolds, flu One of most popular herbs in USOne of most popular herbs in US German Commission EGerman Commission E

supportive for colds, chronic supportive for colds, chronic URI, UTIURI, UTI

UK - GSLUK - GSL

EchinaceaEchinacea

Stimulating dose not advised with autoimmune Stimulating dose not advised with autoimmune and some systemic diseasesand some systemic diseases

Can interfere with immune suppression during Can interfere with immune suppression during chemotherapy treatmentchemotherapy treatment

Stimulating dose should be short term (3-4 Stimulating dose should be short term (3-4 days) onlydays) only

No known side effectsNo known side effects Concern with steroid treatment - depends on Concern with steroid treatment - depends on

useuse

Echinacea - Human EvidenceEchinacea - Human Evidence

26 controlled trials (many open label)26 controlled trials (many open label) 3 blinded RCT’s on URI3 blinded RCT’s on URI

1 showed dose dependent decrease in symptoms 1 showed dose dependent decrease in symptoms and duration of “flu”and duration of “flu”

2 showed 13-20% relative risk reduction of 2 showed 13-20% relative risk reduction of acquiring URIacquiring URI

Dose: 30-60 gtts 1:5 (g/ml) tincture TIDDose: 30-60 gtts 1:5 (g/ml) tincture TID

Echinacea Systematic ReviewEchinacea Systematic Review

16 randomized or quasi randomized trials16 randomized or quasi randomized trials Echinacea preparation vs. no treatment or Echinacea preparation vs. no treatment or

placeboplacebo 8 trials on prevention, 8 trials on treatment8 trials on prevention, 8 trials on treatment 3396 patients involved3396 patients involved Majority with positive resultsMajority with positive results Cannot say which preparation is bestCannot say which preparation is best

Melchart, D. et al. Cochrane Database Syst Rev 2000;2.

Goldenseal Goldenseal ((Hydrastis Hydrastis

canadensis)canadensis)

Used in Native American medicineUsed in Native American medicine Taken up by European immigrantsTaken up by European immigrants Deep forest dweller, endangered speciesDeep forest dweller, endangered species Part used is the rootPart used is the root Colds, flu, bacterial diarrhea, intestinal Colds, flu, bacterial diarrhea, intestinal

parasites, and ocular trachoma infectionsparasites, and ocular trachoma infections

GoldensealGoldenseal

Endangered herbEndangered herb Internal use has antibiotic effect Internal use has antibiotic effect

concern for contributing to antibiotic resistant concern for contributing to antibiotic resistant bacteriabacteria

Dose, duration, and strength important Dose, duration, and strength important Can be difficult to self-administerCan be difficult to self-administer

Overused and misused by general publicOverused and misused by general public Present in tooth paste, lip balm, herbal mixturesPresent in tooth paste, lip balm, herbal mixtures

Goldenseal - EvidenceGoldenseal - Evidence

Antimicrobial activity vs. bacteria, Antimicrobial activity vs. bacteria, viruses, fungi, protozoans, helminths, viruses, fungi, protozoans, helminths, and chlamydiaand chlamydia

Active components:Active components: berberine (anticholinergic, antisecretory, berberine (anticholinergic, antisecretory,

and antimicrobial) and antimicrobial) beta-hydrastine (astringent) beta-hydrastine (astringent)

In rats, Goldenseal increases IgM antibodiesIn rats, Goldenseal increases IgM antibodies

Saw Palmetto Saw Palmetto (Serenoa repens)(Serenoa repens)

Hexane extract of Hexane extract of dried berriesdried berries

Spasmolytic activitySpasmolytic activity Inhibition of androgenInhibition of androgen Anti-inflammatory Anti-inflammatory Not an inhibitor of 5Not an inhibitor of 5--

reductasereductase Used for benign Used for benign

prostatic hypertrophyprostatic hypertrophy

Saw Palmetto - EvidenceSaw Palmetto - Evidence

18 RCT’s, 16/18 double-blinded18 RCT’s, 16/18 double-blinded 2939 men, duration 4-48 weeks2939 men, duration 4-48 weeks Decreased nocturia, improved symptom scores Decreased nocturia, improved symptom scores

vs. placebovs. placebo Improved symptom score, improved peak Improved symptom score, improved peak

urine flow vs. finasterideurine flow vs. finasteride Dose: 400 mg dry extract BIDDose: 400 mg dry extract BID

Wilt TJ, et al. JAMA 1998; 280:1604-1609.

Saw Palmetto - ToxicologySaw Palmetto - Toxicology

Rats: 80x human dose for 6 monthsRats: 80x human dose for 6 months No negative influencesNo negative influences

Human trials, German Commission EHuman trials, German Commission E GI disturbances, headacheGI disturbances, headache No significant adverse effectsNo significant adverse effects

Drug interactionsDrug interactions Theoretical - Estrogens, oral contraceptives, ironTheoretical - Estrogens, oral contraceptives, iron German Commission E reports noneGerman Commission E reports none

Black Cohosh Black Cohosh (Cimicifuga (Cimicifuga racemosa)racemosa)

Fresh root tincture or Fresh root tincture or dried root infusiondried root infusion

Remifemin, used in Remifemin, used in Germany since 1950’sGermany since 1950’s

Used for hot flashes and Used for hot flashes and night sweatsnight sweats

German Commission E:German Commission E: Premenstrual discomfortPremenstrual discomfort DysmenorrheaDysmenorrhea Menopausal Menopausal

neurovegetative symptomsneurovegetative symptoms

Black Cohosh - Mode of actionBlack Cohosh - Mode of action

Steroidal terpenes? isoflavones? others?Steroidal terpenes? isoflavones? others? Methanol extracts bind estrogen receptorsMethanol extracts bind estrogen receptors Inhibits estrogen dependent breast tumor cell lines Inhibits estrogen dependent breast tumor cell lines

Lowers LH in rats and women, no effect on FSHLowers LH in rats and women, no effect on FSHaa

Stimulatory effect on endometriumStimulatory effect on endometriumb,cb,c

Actein may be beneficial in hypercholesterolemia and Actein may be beneficial in hypercholesterolemia and peripheral arterial disease peripheral arterial disease

a. Duker 1991; b. Stoll 1987; c. Warnecke 1985

Black Cohosh - Clinical TrialsBlack Cohosh - Clinical Trials

5 RCTs in literature5 RCTs in literature Randomized, head to head trialRandomized, head to head trial 60 pts, < 40 yr. old with hysterectomies60 pts, < 40 yr. old with hysterectomies Estriol vs. conjugated estrogens vs. Estriol vs. conjugated estrogens vs.

estrogen-gestegen sequential vs. black estrogen-gestegen sequential vs. black cohosh extractcohosh extract

Outcome: Kupperman’s Menopausal IndexOutcome: Kupperman’s Menopausal Index Black cohosh equal to other treatmentsBlack cohosh equal to other treatments

Lehmann-Willenbrock, et al. Zentralblatt fur Gynakologie 1998;110:611-8similar findings: Warnecke, 1985

Black Cohosh UpdateBlack Cohosh Update

Recent RCTRecent RCT 85 breast cancer survivors85 breast cancer survivors 59 were on tamoxifen59 were on tamoxifen 40 mg/d Remifemin vs. placebo x 2 months40 mg/d Remifemin vs. placebo x 2 months No benefit for hot flashesNo benefit for hot flashes

On-going trial at Columbia UnivOn-going trial at Columbia Univ RCT, 1 year durationRCT, 1 year duration hot flashes, endometrial thickness, bone metab, hot flashes, endometrial thickness, bone metab,

cognitive effectscognitive effects

Jacobson JS, et al. J. Clin. Oncol 2001;19:2739-45.

Black Cohosh - ToxicologyBlack Cohosh - Toxicology

Overdose: nausea, Overdose: nausea, dizziness, nervous system dizziness, nervous system disturbancedisturbance

Mice - Mice - spread of breast spread of breast CACA

Large doses may cause Large doses may cause miscarriage. miscarriage. Contraindicated in Contraindicated in pregnancypregnancy

Long term safety Long term safety unknownunknown

Ginger Ginger Zingiber officinaleZingiber officinale

Used for nauseaUsed for nausea Helpful for colds and Helpful for colds and

fluflu Warming herbWarming herb Many other folkloric Many other folkloric

usesuses

Ginger for Nausea & Ginger for Nausea & Vomiting of PregnancyVomiting of Pregnancy

2 trials show efficacy compared to placebo2 trials show efficacy compared to placebo excess Yang (excess Qi)excess Yang (excess Qi)

N not in AM, N worse p eating, N improves p N not in AM, N worse p eating, N improves p vomitingvomiting

ginger is too “hot”, use peppermint ginger is too “hot”, use peppermint excess Yin (deficient Qi)excess Yin (deficient Qi)

N in AM, N better p eating, N worse p N in AM, N better p eating, N worse p vomitingvomiting

ginger will be helpfulginger will be helpfulTiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196

How to take gingerHow to take ginger

Dose 3-9 grams fresh (or dried) peeled ginger Dose 3-9 grams fresh (or dried) peeled ginger rootroot

Tea made from grated fresh rootTea made from grated fresh root Commercially available capsulesCommercially available capsules NOT ginger biscuits or ginger beerNOT ginger biscuits or ginger beer

Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196

Ginger Root Safety?Ginger Root Safety?

6-gingerol is mutagenic in 6-gingerol is mutagenic in vitro at high dosesvitro at high doses

Other compounds in ginger Other compounds in ginger are anti-mutagenicare anti-mutagenic

Widely used in Traditional Widely used in Traditional Chinese MedicineChinese Medicine

No contraindication in No contraindication in Pharmacopoeia of the Pharmacopoeia of the People’s Republic of China People’s Republic of China (1995)(1995)

May increase miscarriageMay increase miscarriage Contraindicated in Contraindicated in German Commission EGerman Commission E

Milk Thistle Milk Thistle Silybum marianumSilybum marianum

Protects liverProtects liver Promotes hepatic cell Promotes hepatic cell

growthgrowth Supports normal liver Supports normal liver

functionfunction AntioxidantAntioxidant

Milk thistleMilk thistle

Hepatoprotective antioxidant activity 1

toxin blockade at the membrane level 1

enhanced protein synthesis 1

antifibriotic activity 1

possible anti-inflammatory or immunomodulating effects 1

Stimulates action of nucleolar polymerase A causing in ribosomal protein synthesis, stimulating regenerative ability and formation of hepatocytes 2

1 Milk Thistle: Effects on Liver Disease and Cirrhosis and Clinical Adverse Effects Summary, Evidence Report/Technology Assessment: Number 21 Sept. 2000. Agency for Healthcare Research and Quality, Rockville MD

2 German commission E monographs

Milk thistleMilk thistle

German Commission E Monographs reportGerman Commission E Monographs report No contraindicationsNo contraindications No known side effectsNo known side effects No known interactions with other drugsNo known interactions with other drugs

Issues around herbal Issues around herbal preparationspreparations

PreparationsPreparations Capsules and pillsCapsules and pills Tinctures and extractsTinctures and extracts InfusionsInfusions TeasTeas

EffectivenessEffectiveness Herbs in combinationHerbs in combination formulasformulas Locally grown and wild craftingLocally grown and wild crafting

Slide credit # 14-48 based on material prepared Slide credit # 14-48 based on material prepared with with

Sara L. Warber, MDSara L. Warber, MDSuzanne Zick, ND, MPHSuzanne Zick, ND, MPHLeslie Shimp, PharmDLeslie Shimp, PharmD

Contact Information

Linda Diane Feldt P.O. Box 3218

Ann Arbor MI 48106-3218734-662-4902

feldt@holisticwisdom.orgwww.holisticwisdom.orgwww.moonfieldpress.com

Free Herb Class 2nd Monday of each month, sponsored by the People’s Food Co-op,

at Crazy Wisdom Bookstore, Ann ArborOther classes and workshops listed on the web site.