Use of and Familiarity With Dietary Supplement Information References by Practicing PharmacistsMario M. Zeolla, PharmD, BCPS; Jennifer Cerulli, PharmD, BCPS Authors and Disclosures Published: 11/24/2008

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Abstract and IntroductionAbstract Objective: To survey practicing pharmacists regarding their use of and familiarity with six dietary supplement information references. Methods: Pharmacists attending a March 2005 continuing education program at the Albany College of Pharmacy on interactions between drugs and dietary supplements were surveyed about their use of and views on dietary supplement information references. Included in the survey were six references: Physicians Desk Reference (PDR) for Herbal Medicines; Facts and Comparisons: Review of Natural Products; German Commission E Monographs; Natural Medicines Comprehensive Database (online or

textbook format); Micromedex: AltMedDex; and The Natural Therapeutics Pocket Guide. The survey was repeated by mail 1 year after the program. Results: Of the 91 attendees at the program, 58 completed the survey, and 25 individuals returned the 1-year survey. Of those completing the surveys, 80% had more than 10 years in practice, 95% had bachelor's degrees, and most practiced in community or institutional pharmacies. At baseline, fewer than 40% had "heard of" four of the six references. Pharmacists were most familiar with PDR for Herbal Medicines and Factsand Comparisons: Review of Natural Products. Familiarity rates increased at 1 year for five of the six references, though, again, overall rates were low and differences from baseline were not statistically significant for any of the six references. Usage rates increased for two references (Facts and Comparisons: Review of Natural Products and Natural Medicines Comprehensive Database) at 1 year and declined for the remaining four. Conclusion: Experienced pharmacists in both community and institutional settings infrequently use and are unfamiliar with dietary supplement information references, including those found in studies to be of the highest quality. Education on the availability and features of these references could benefit pharmacists and potentially change usage patterns. Introduction The use of dietary supplements in the United States has increased dramatically since the early 1990s. One study found that 73% of Americans reported using a supplement in the previous 12 months.[1] As experts in drug information, pharmacists are often sought by patients and other health care providers to answer questions relating to these agents. Studies suggest that pharmacists perceive a lack of available high-quality dietary supplement information and that some pharmacists may not use or have access to such resources.[2] Many dietary supplement information references are now available in both hard-copy and electronic formats to assist pharmacists in this role. Studies evaluating the quality of these references provide guidance regarding which are most reliable and useful.[3,4] The extent to which pharmacists in diverse practice settings are familiar with or use those references deemed most useful is not fully known.

Use of and Familiarity With Dietary Supplement Information References by Practicing PharmacistsMario M. Zeolla, PharmD, BCPS; Jennifer Cerulli, PharmD, BCPS Authors and Disclosures Published: 11/24/2008

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Abstract and Introduction Objectives and Methods Results Discussion Limitations Conclusion References

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Assess clinically focused product information on Medscape. Click Here for Product Infosites Information from Industry.

Abstract and IntroductionAbstract Objective: To survey practicing pharmacists regarding their use of and familiarity with six dietary supplement information references. Methods: Pharmacists attending a March 2005 continuing education program at the Albany College of Pharmacy on interactions between drugs and dietary supplements were surveyed about their use of and views on dietary supplement information references. Included in the survey were six references: Physicians Desk Reference (PDR) for Herbal Medicines; Facts and Comparisons: Review of Natural Products; German Commission E Monographs; Natural Medicines Comprehensive Database (online or textbook format); Micromedex: AltMedDex; and The Natural Therapeutics Pocket Guide. The survey was repeated by mail 1 year after the program. Results: Of the 91 attendees at the program, 58 completed the survey, and 25 individuals returned the 1-year survey. Of those completing the surveys, 80% had more than 10 years in practice, 95% had bachelor's degrees, and most practiced in community or institutional pharmacies. At baseline, fewer than 40% had "heard of" four of the six references. Pharmacists were most familiar with PDR for Herbal Medicines and Factsand Comparisons: Review of Natural Products. Familiarity rates increased at 1 year for five of the six references, though, again, overall rates were low and differences from baseline were not statistically significant for any of the six references. Usage rates increased for two references (Facts and Comparisons: Review of Natural Products and Natural Medicines Comprehensive Database) at 1 year and declined for the remaining four. Conclusion: Experienced pharmacists in both community and institutional settings infrequently use and are unfamiliar with dietary supplement information references,

including those found in studies to be of the highest quality. Education on the availability and features of these references could benefit pharmacists and potentially change usage patterns. Introduction The use of dietary supplements in the United States has increased dramatically since the early 1990s. One study found that 73% of Americans reported using a supplement in the previous 12 months.[1] As experts in drug information, pharmacists are often sought by patients and other health care providers to answer questions relating to these agents. Studies suggest that pharmacists perceive a lack of available high-quality dietary supplement information and that some pharmacists may not use or have access to such resources.[2] Many dietary supplement information references are now available in both hard-copy and electronic formats to assist pharmacists in this role. Studies evaluating the quality of these references provide guidance regarding which are most reliable and useful.[3,4] The extent to which pharmacists in diverse practice settings are familiar with or use those references deemed most useful is not fully known.

Beware of scams and health fraudScammers have perfected ways to convince you that their alternative medicine products are the best. These opportunists often target people who are overweight or who have medical conditions for which there is no cure, such as multiple sclerosis, diabetes, Alzheimer's disease, cancer, HIV/AIDS and arthritis. Remember if it sounds too good to be true, it probably is. Be alert for these red flags:

Big promises. Advertisements call the product a "miracle cure" or "revolutionary discovery." If that were true, it would be widely reported in the media and your doctor would recommend it. Pseudomedical jargon. Although terms such as "purify," "detoxify" and "energize" may sound impressive and may even have an element of truth, they're generally used to cover up a lack of scientific proof. Cure-alls. The manufacturer claims that the product can treat a wide range of symptoms, or cure or prevent a number of diseases. No single product can do all this. Testimonials. Anecdotes from individuals who have used the product are no substitute for scientific proof. If the product's claims were backed up with hard evidence, the manufacturer would say so. Guarantees and limited offers. These pitches are intended to get you to buy before you can evaluate the product's claims.

Choose practitioners wiselyTake care when choosing an alternative medicine practitioner. Picking a name out of the phone book isn't the safest way to select a practitioner. Instead, try these tips from the National Center for Complementary and Alternative Medicine (NCCAM):

Talk with your doctor. Ask your conventional doctor for recommendations. He or she can also be a source of advice about any recommendations you get from an alternative medicine practitioner. Contact a local hospital or medical school. They often keep lists of area CAM practitioners. Some have their own CAM practitioners on staff. Check the national association. Alternative medicine associations will often provide a list of certified practitioners in your area. To find the addresses and phone numbers of these associations, check the Directory of Health Organizations online compiled by the National Library of Medicine. Call your local health department. Ask if they know of state or local certifying, licensing or accreditation bodies for the alternative medicine practice you're considering. Ask questions. Ask CAM practitioners about their education, training, licenses and certifications. Ask if they specialize in particular diseases or health conditions and whether they frequently treat people with problems similar to yours. Also ask what treatments cost and find out if your health insurance covers them.

CAM starts with complementaryIdeally the various forms of treatments you select should work together with the care of your conventional doctor. You may find that certain alternative treatments help you maintain your health and relieve some of your symptoms. But continue to rely on conventional medicine to diagnose a problem and treat diseases. Don't change your conventional treatment such as your dose of prescribed medication without talking to your doctor first. For your safety, tell your doctor about all alternative treatments you use. Different standards for reporting ADRs to herbal remedies and conventional OTC medicines: face-to-face interviews with 515 users of herbal remedies Joanne Barnes,1 Simon Y Mills, Neil C Abbot,2 Martin Willoughby,2 and Edzard Ernst1 1 Department of Complementary Medicine, Postgraduate Medical School, University of Exeter, 25 Victoria Park Road, Exeter EX2 4NT, UK 2 Centre for Complementary Health Studies, Amory Building, University of Exeter, Exeter EX4 4RJ, UK Correspondence: Joanne Barnes, Department of Complementary Medicine, Postgraduate Medical School, University of Exeter, 25 Victoria Park Road, Exeter EX2 4NT. Received September 19, 1997; Accepted January 6, 1998. This article has been cited by other articles in PMC.

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Abstract Aims To determine whether adverse drug reactions (ADRs) to herbal remedies would be reported differently from similar ADRs to conventional over-the-counter (OTC) medicines by herbal-remedy users. Methods Face-to-face interviews (using a structured questionnaire) with 515 users of herbal remedies were conducted in six pharmacy stores and six healthfood stores in the UK. The questionnaire focused on the likely course of action taken by herbal-remedy users after experiencing an ADR associated with a conventional OTC medicine and a herbal remedy. Results Following a serious suspected ADR, 156 respondents (30.3%) would consult their GP irrespective of whether the ADR was associated with the use of a herbal remedy or a conventional OTC medicine, whereas 221 respondents (42.9%) would not consult their GP for a serious ADR associated with either type of preparation. One hundred and thirtyfour respondents (26.0%) would consult their GP for a serious ADR to a conventional OTC medicine, but not for a similar ADR to a herbal remedy, whereas four respondents (0.8%) would consult their GP for a serious ADR to a herbal remedy, but not for a similar ADR to a conventional OTC medicine. Similar differences were found in attitudes towards reporting minor suspected ADRs. Conclusions Consumers of herbal remedies would act differently with regard to reporting an ADR (serious or minor) to their GP depending on whether it was associated with a herbal remedy or a conventional OTC medicine. This has implications for herbal pharmacovigilance, particularly given the increasing use of OTC herbal remedies. The finding that a high proportion of respondents would not consult their GP or pharmacist following ADRs to conventional OTC medicines is also of concern. Keywords: herbal medicines, drugs, nonprescription, drug monitoring, adverse drug reaction reporting systems, alternative medicine

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Introduction In the UK, herbal remedies (or phytomedicines) are increasingly being used by the general public on a self-selection basis to replace or complement conventional medicines [1]. The use of herbal remedies is widespread across Europein 1991, the total over-thecounter (OTC) market for herbal remedies was 1.45 billion [2]. Another source

estimated that, in 1992, the herbal market of the European Community was worth US$2.4 billion [3]. More recently, the market for licensed herbal medicines in the UK was estimated to be worth 38 million in 1996, representing over half of the total market for complementary remedies [4]. One of the reasons for the popularity of herbal remedies is the belief among many users and suppliers of herbal remedies that these preparations are natural and therefore safe [1]. This, however, is a misconceptionherbal remedies can produce adverse drug reactions (ADRs) [5, 6], some of which can be serious and even fatal [7, 8]. However, because users believe that such remedies are safe, individuals experiencing ADRs may not associate these with their use of herbal remedies [7]. A further complication is that, in the UK, the majority of herbal remedies are self-prescribed [1], and many individuals may be reluctant to tell their general practitioner (GP) that they are using them [7]. Even if ADRs are reported by patients, their GPs may not be fully briefed about the use and effects (adverse or otherwise) of herbal remedies. The European Union (EU) has commissioned research into this problem through its BIOMED (Biomedical and Health Research) programme. As part of that programme, this study was designed to determine whether ADRs to herbal remedies would be reported differently from similar ADRs to conventional OTC medicines, and to identify experiences of ADRs to herbal remedies and how they are perceived by consumers.

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Methods Customer interview Experienced interviewers, recruited and trained for this task by a market research company, were provided with study questionnaires, photographs and lists of examples of herbal remedies, other complementary remedies and conventional OTC medicines, and a list of examples of ADRs. These materials were used to assist interviewers and interviewees in identifying what was and what was not a herbal remedy. The list of ADRs was used as a prompt if consumers were unsure what was meant by a side-effect, or if they answered that they had never experienced any side-effects to herbal remedies. Interviewers were instructed to position themselves at an appropriate distance from the herbal remedies counter in the respective stores, and to approach customers who had purchased herbal remedies or those who had browsed the herbal remedies section. Customers were asked if they would be willing to be interviewed as part of a study on herbal remedies. Those agreeing to be interviewed were asked if they ever use herbal remedies; if they answered, No the interview was terminated. If a customer answered, Yes, the interviewer continued with the questionnaire (written consent was not obtained); interviews took around 8 min. All questionnaires were analysed at the University of Exeter.

Two types of outletBoots the Chemists Ltd (BTC) and Holland & Barrett (H & B), representing a pharmacy setting and healthfood store setting, respectivelywere chosen. Interviews were conducted in six BTC stores with a high turnover of herbal remedies (Manchester, Leeds, Newcastle, Milton Keynes, London, Cardiff) and in six H & B stores near the selected BTC stores (Manchester, Leeds, Newcastle, Milton Keynes, London, Swansea). The study was conducted in September, 1996. An interviewer was present in the selected stores on 2 consecutive days for 8h per day in BTC stores, and 4h per day in H & B stores. The study was weighted more towards BTC customers than H & B customers to reflect market share [4]. Data collected A structured questionnaire for customer interviews was designed and developed for this survey by researchers at the University of Exeter. Copies of the questionnaire are available on request. Respondents were asked what herbal remedies they used, how often, and for what condition. The same questions were asked for conventional OTC medicines. Respondents were also asked if they ever used vitamins, minerals or dietary supplements, or other natural health remedies (e.g. homoeopathic medicines, aromatherapy oils). Data on how respondents choose their herbal remedies and from where they obtain them, were also collected. In addition, respondents were asked if they had ever experienced any sideeffects after taking herbal remedies and, if so, were asked to provide the following details: name of herbal remedy; associated side-effect; severity (mild, moderate or severe); if they reported the side-effect and to whom; if they stopped taking the remedy because of the side-effect. Respondents were also asked for demographic information (gender, age, occupation); social grade and ethnic group were assessed by the interviewer. The key part of the interview sought to obtain information on what action respondents would take if they experienced (a) a serious side-effect (for the purposes of this survey, this was defined as symptom(s) that were worrying or alarming), and (b) a minor sideeffect (defined as symptom(s) that caused some discomfort, but were not alarming) to a conventional OTC medicine and to a herbal remedy. Respondents were allowed to select one or more of the following responses: continue taking [the preparation] and see if symptom(s) resolved; stop taking immediately; consult your doctor; consult your pharmacist; consult another health care practitioner; other action. Prior to conducting the full survey, a pilot survey was conducted. Thirty-two herbal remedy users were interviewed by one interviewer in the BTC store in Leeds. Following the pilot study, a minor alteration was made to the questionnaire (the order of the two questions on the action respondents would take following a serious and a minor ADR was reversed). Data from the full survey were entered via a semiautomated Foxbase application into a spreadsheet for analysis. The data from the pilot study were not included in the final analysis.

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Results Six hundred and ninety individuals agreed to be interviewed. Of these, 175 (25.4%) stated that they did not use herbal remedies and therefore these interviews were terminated. Five hundred and fifteen face-to-face interviews with users of herbal remedies were conducted: 336 in BTC stores and 179 in H & B stores. Females predominated (82% overall). The ethnic origin of respondents was predominantly Caucasian (91%); Afro-Caribbean (2%), Indian/Pakistani (2%) and Chinese/Japanese (1%) ethnic groups were also represented. The age distribution of respondents was: