3Objectives of This Workshop – Learn About Pharmacological mechanism of actionTraditional evidence and clinical evidence supporting the use of herbs in the treatment of inflammation and pain.Dose levels and additive effects.Importance of pharmacokinetics on clinical outcome:Duration of responseMinimal effective doseDose level and dosing interval
4Guy Chamberland, M.Sc., Ph.D., Master Herbalist B.Sc. In Agricultural Chemistry, McGill University.M.Sc., Ph.D. in toxicology (Biomedical sciences), University of Montreal.Natural Health Practitioner & Bioenergetics Practitioner diploma (Oriental medicine), Alternative Medicine College of Canada.Proficiency in Herbal Prescription, Australian College of Phytotherapy.Chartered & Master Herbalist, Dominion College of Canada.
5Guy Chamberland, M.Sc., Ph.D., Master Herbalist Over 16 years developing new drugs in pharmaceutical industry (Canada & USA).Drug safety & Drug development.Research in herbal anxiety, sleep, pain/inflammation & wound treatments.Since 2007.Preclinical & clinical research: inflammation/pain; wound healing.2 herb-based patents (pending): inflammation/pain; wound healing.Clinical research treatment anxiety, sleep and pain/inflammation.
7PAIN medication Worried about addiction. Do not tolerate the pain meds PAIN medication Worried about addiction? Do not tolerate the pain meds? Pain meds are contraindicated? Concerned about long-term safety? Patient wants a natural treatment.
8True or false?Botanical medicines are as efficacious as prescription drugs in the management of inflammation & pain
11Summary – Botanical Medicines As efficacious as a drug in the treatment of pain.Disadvantage: bioavailability of some herbs.Advantages: Safety.Good tolerance-safety.No negative effect on cognition or motor coordination.No addiction.No rebound.
12Botanical Medicines In many cases, should be used as a First Line : When NSAID contraindicated!Night pain.Keep in mind delay to onset when treating acute pain!
13Botanical Medicines – Treating Pain Need to set realistic expectations:Even with drugs, after many years of adjusting drug therapy, patient may still have pain.Define short-term pain relief goals for patient.1st target main area of pain to bring some relief to patient.Expand to other areas of body as progress is made.Focus on sleep early on.Use complementary strategies in severe cases.
14Review of the importance of pharmacokinetics on clinical outcome.
25Are there herbs that allow us to develop a botanical medicine that is similar in potency to a prescription drug?
26Herbs – Anti-Inflammatory - Analgesic Many clinical trials.Main problems:Bioavailability & standardization.Not a drug development concept.Dose & frequency is critical for efficacy.Herbs used according to their pharmacology:mu1, COX-2, serotonine.Activity = ‘atypical’eg., mu1 + 5-HT1 / 5-HT7
27Herbs – Anti-inflammatory or Analgesic Boswellia (Boswellia sacra)Salix (Salix alba)Devil’s claw (Harpagophytum procumbens)California poppy (Eschscholzia californica)NSAIDAtypical opioidUse cautiously in patients taking drugs metabolized by liver cytochrome P450 enzymes.Boswellia (Boswellia serrata)Salix (Salix alba)Devil’s claw (Harpagophytum procumbens)California poppy (Eschscholzia californica)Interaction with anticoagulants (heparin, coumarin derivatives) is of therapeutic importance.
29Should your practice consider sleep quality Pain interferes with sleep.50% - 88% patients treated for chronic pain (nonmalignant) reported sleep impairment.Patients with high pain intensity had less sleep time, more delayed sleep onset, and more nighttime wakening than patients with low pain intensity.Disturbed sleep lowers pain threshold.Whether sleep disturbance precedes or follows pain onset is unclear.
30Should your practice consider sleep quality Chronic pain:Pain initiates and exacerbates sleep disturbance.Disturbed sleep maintains and exacerbates chronic pain and related dysfunction.Sleep disruption, fragmentation, or restriction produces hyperalgesia (increased sensitivity to pain) and can interfere with analgesic treatments involving opiodergic and serotonergic mechanisms of action.
32Association of Sleep & Pain versus NSAID Treatment with NSAIDOA show significantly greater objective sleep disturbance.NSAID:Inhibition of prostaglandin synthesis during nighttime hours induces change in sleep patterns due to a decrease in synthesis of prostaglandin D2.Suppression of normal nocturnal surge in melatonin synthesis.Suppression by 75% within 75 minutes after single dose of NSAID.Melatonin surge important to induce sleep.Aspirin and Ibuprofen (significant versus placebo); acetaminophen not significant.
33Should your practice consider sleep quality REM sleep deprivation results in hyperalgesia during the subsequent awake period.Nonrestorative sleep occurs in 73% to 76% of fibromyalgia patients.Presence of restorative sleep in patients with fibromyalgia predicted resolution of pain at 15 months.
34Recommended & Current Uses California poppy Night Pain:1 or 2 capsules at night.Analgesic & Hypnotic.Better sleep quality.Reduced doses of morphine at night.Co-analgesic (Adjuvant):1 capsule bid (off-label use by physicians).Patients intolerant to meds such as Lyrica and/or Cymbalta.Reduce doses of other pain meds.Insomnia:1 or 2 capsules 30 minutes before bedtime.Sedative & Hypnotic.*1 capsule = mg extract (standardized)
35California poppy (Eschscholzia californica) Historical Use:Relaxing nervine in anxiety and nervousnessSedative in insomniaAnodyne in pain.A more recent usage is in the treatment of heroin addiction and withdrawal.Although remedies such as Opium Poppy are of great use as an anodyne and analgesic, Felter and Lloyd considered Eschscholzia to be an “…analgesic and soporific without the dangers attending opiates, quieting pain and producing (a) calm sleep” (1893).
36Analgesia with Sedation Opioid ReceptorsMorphineXXXCalifornia poppyXAnalgesia with SedationXXXX
45Summary – California poppy Induces sleep & analgesia at correct dosage.Clinical evidence effective treatment night pain.No impact on cognition.No impact on motor incoordination.No addiction.No rebound.
46Recommended & Current Uses California poppy (Eschscholzia californica) Night Pain:1 or 2 capsules at night.Analgesic & Hypnotic.Better sleep quality.Reduced doses of morphine at night.Co-analgesic (Adjuvant):1 capsule bid (off-label use by physicians).Patients intolerant to meds such as Lyrica and/or Cymbalta.Reduce doses of other pain meds.Insomnia:1 or 2 capsules 30 minutes before bedtime.Sedative & Hypnotic.*1 capsule = mg extract (standardized)
48NSAID vs Botanical Drug NSAIDs used for:OA of knee, hip, and spine & NSLBP associated with pain, stiffness, limitation of function, and diminished quality of life.Superior to acetaminophen in majority of trials!
49NSAID vs BOTANICAL DRUG Treatment guidelines recommend simple analgesics as first-line drugs.Because of superior efficacy, NSAIDs are preferred despite the lower safety-margin and the higher cost.A critical part of an effectivepain management strategy.
50NSAID vs BOTANICAL DRUG Consider alternatives to NSAID therapy:High incidence of NSAID related adverse events.GIT complicationsRisks associated with cardiovascular systemsEspecially in the elderlyHigh costs related to adverse events:gastrointestinal bleeding or perforation.additional medical attendances, diagnostic procedures, treatments and admissions to hospital.
51We need a natural NSAID! Which herb is an effective & safe choice?
52Selection of an NSAIDHerbs with Clinical Evidence for Osteoarthritis, Rheumatoid Arthritis, Low Back Pain (LBP):BoswelliaWillow barkDevil’s clawLBP:Equivalence trial vs 12.5 mg rofecoxibEquivalence trial vs 12.5mg rofecoxib
53X Willow Bark Drug interactions: Assessment of EMA limited to documented interactions. Not theoretical.EMA concluded: Interaction with oral anticoagulants (heparin, coumarine derivatives) is plausible and of therapeutic importance.Clinical trials demonstrated:Willow bark significantly AA- and ADP-induced aggregation but to a significantly lesser extent than acetylsalicylate did.Statistically significant associations between the use of willow bark and bleeding events were identified......EMA recommends: The combined use of Willow bark with acetylsalicylic acid/other NSAIDS is not recommended.
54Boswellia vs Devil’s claw Pharmacokinetics:Poor bioavailability of boswellic acids.Food alters the pharmaco-kinetic profile.Meals high in fat increased the concentration in plasma.Mean elimination half-life: 5.97 hours.Time to Peak (Tmax): 4.5 ± 0.55 hours.Pharmacokinetics:Degradation of harpagosides in stomach.Food alters absorption.Mean elimination half-life: 5.6 hours.Time to Peak (Tmax): 1.3 to 2.5 hours.
55Boswellia vs Devil’s claw Pharmacokinetics:Moderate-to-potent inhibitors of CYP enzymes, with equal potency for inhibiting the major drug metabolizing enzymes 1A2, 2C8, 2C9, 2C19, 2D6, and 3A4.Use cautiously in patients taking agents metabolized by the liver's cytochrome P450 enzymes.Pharmacokinetics:No cytochrome P450 induction or inhibition.No caution statements.X
56Devil’s Claw Devil’s claw known safety profile Anticoagulants and antiplatelets:One case of purpura reported in a patient taking warfarin (Coumadin®) with devil's claw.Evidence is inconclusive. Could be simply due to drug.European Medical Agency (EMA) approved Devil’s claw as a medicinal herb.Detailed assessment of the safety information to issue warnings. EMA concluded: could not find any study or reported cases suggesting an interaction with oral anticoagulants, or sulfonylureas.EMA stated: no signal, even weak, has emerged from the literature to date.Conclusion: Even if evidence is weak, be cautious when using Devil’s claw on a patient taking an AC or AP.
62Data shows need 50-100 mg per day. Ideal is 20 mg tid. More than 23 clinical trials in patient populations of: osteoarthritis, rheumatoid arthritis, low back pain.‘Double-blind’- RCT with placebo: 13 studies.Studies that showed equivalence to an active control:Osteoarthritis – knee and hip:57 mg harpagoside/day vs 100 mg DiacerheinLBP:60 mg harpagoside/day vs 12.5 mg VioxxRheumatoid arthritis:60 mg harpagoside/day vs Phenybutazone (300mg/day D1-4; 200mg/day D5-28)Data shows need mg per day.Ideal is 20 mg tid.Consistent with animal data – 20 mg effective after single dose.*Gibofsky A et al. Comparing the efficacy of cyclooxygenase 2-specific inhibitors in treating osteoarthritis. Arthritis & Rheumatism 2003; 48(11):*Laudahn D et Walper A. Efficacy and tolerance of Harpagophytum extract LI 174 in patients with chronic non-radicular back pain. Phytother. Res. 2001; 15:
64Study Design:Double-blind, RandomizedDouble-blind, Randomized, MulticentreMulticentre, Postmarketing SurveillanceSubjects:88 patients with acutely exacerbated low back pain;Rx 6 weeks. DC versus 12.5 mg/day Vioxx122 patients suffering from osteoarthritis of the knee and hip.DC versus diacerhein 100 mg/day; 4 months treatment75 patients with osteoarthritis of the hip or knee.12 weeksDevil’s claw (DC):800 mg extract (20 mg harpagoside) tid870 mg extract (19 mg harpagoside) tidMethod:400 mg/day Tramadol rescue allowed.Arhus LBP Index & Health Assessment Questionnaire.Pain & functional disability on VAS;Severity of osteoarthritis using Lequesne's index (LI).WOMAC indexVAS pain scaleResults:Number of pain-free patients: DC 22%,Rofecoxib 11% NS;Percentage change Arhus component pain: DC30%, Rofecoxib 29% (intention-to-treat analysis)Spontaneous pain: significant improvement during study; no difference in the efficacy.A progressive & significant reduction in LI & no statistical difference was found between treatments.At end of study: DC were using significantly less NSAIDs and antalgic drugs.Frequency of AE events was significantly lower in DC.Improvement in WOMAC subscale : 23.8% pain, 22.2% stiffness , 23.1% physical function.WOMAC total score 22.9%.VAS: 25.8% actual pain, 25.2% average pain, 22.6% worst pain , 24.5% total pain score.Physicians reported a continuous improvement in typical clinical findings such as 45.5% for pain on palpation, 35% for limitation of mobility and 25.4% for joint crepitus.Reference:Chrubasik S et al.. Rheumatology 2003;42:Chantre P et al. Phytomedicine Jun;7(3):177-83Wegner et Lupke. Phytother Res Dec;17(10):
654-weeks, Equivalence study Study Design:8-week4-weeks, Equivalence study4-week, Randomized, Double-blind, Placebo controlledSubjects:675 patients with painful osteoarthritis, spondylarthropathies or fibromyalgic complaintsbid197 patients, tid65 received 200 mg tablets66 received 400 mg tablets66 placebo118 patients acute low back pain (non-specific; pain for at least 6mnths).2 tablets TidDevil’s claw (DC):480 mg extract4500 and 9000 mg/day, (50 and 100 mg harpagoside per day)4500 mg/day, (50 mg harpagoside per day)Method:CGI scoreReduction in symptom severity scoreUse of NSAIDs or corticosteroidsPain-free without NSAIDs for 5 days at end of study.Arhus low back pain index.Use of rescue meds (Tramadol).Need to use supplementary analgesic (Tramadol) during final 3 weeks.Number of patients pain-free at end.Results:CGI scores rated good or very good in 82% of cases.Symptom score for painful motion decreased by 53% from 2.23 (indicating moderate pain) to 1.04 (indicating slight pain) after eight weeks.Co-medication doses were reduced or discontinued in 60% of the 464 patients taking NSAIDs and 56% of the 50 patients taking corticosteroids.Pain-free patients : 9% DC1; 15% DC2; 5% PL (p=0.027).Overall median Arhus index scores: 55% at baseline to 20% by week 4, but no statistically significant difference between both treatment groups & PL.Greater effectiveness of DC2 seen only in subgroups with more severe pain radiating to the leg, the smaller dose did not seem to have much effect on them.Non-radiating pain, DC2 was more effective.DC group tended to use fewer analgesics (p=0.44).A non-significant improvement in median Arhus low back pain index scores was seen (20% vs. 8%; p<0.059).Significantly more pain-free patients at the end of the trial (9/51 vs. 1/54; p=0.008).Percentage change Arhus component pain: DC 34%, PL 6% (p=0.016)Reference:Ribbat NaturaMed 2001;16:23-30Chrubasik et al. Eur.J Anaesthesiol. 1999;16(2):Chrubasik et al. Phytomedicine 1996;3(1):1-10.
66Study Design: Subjects: Devil’s claw (DC): Method: Results: Reference: 20-week, Randomized, Placebo controlled trial4-month, Randomized, Double-blind, Parallel-group study8-weeks, Multicentre, Postmarketing studySubjects:46 patients with osteoarthritis of the hipRx DC vs PL (placebo); bid122 patients with hip and knee osteoarthritisRx DC vs 100 mg Diacerhein104 patients with low back pain, 85 patients with arthritic knee pain, and 61 patients with arthritic hip painDevil’s claw (DC):4500 mg/day, (< 30 mg harpagoside per dayDC 2610 mg (57mg of harpagoside)/day800 mg extract (20 mg harpagoside) tidMethod:Efficacy using WOMAC.Stepwise-reduced daily doses of ibuprofen: 800mg daily for the first eight weeks, 400mg daily for a further eight weeks, and none during theSpontaneous pain using VASLequesne Index, functional disability of movement assessed on a VAS, amount of taken rescue medication (acetaminophen-caffeine with or without diclofenac).Arhus low back pain index.WOMAC index.HAQUnvalidated measures (total pain index, three score index, the patient's global assessment of the effectiveness of treatment.Results:WOMAC scores both groups despite the reduced dose of ibuprofen.Stiffness, pain & dysfunction both groups.Ibuprofen-free period, 20% or less in the pain score considered clinically relevant response rate: 71% DC vs 41% PL met criteria (p=0.04).52% DC vs 36% PL completed without using rescue during Ibuprofen-free period..65.3% DC & 60% Diacerhein had considerable improvements in OA symptoms both groups.No significant differences for pain, functional disability, or Lequesne score.DC found to be using statistically significantly less analgesic medications (p=0.01).Adverse effects (mainly diarrhea) that were considered to be due to treatment were reported in 8.1% and 26.7% of Harpadol®and Diacerhein patients, respectively (p=0.017).Improvement tended to be more when the initial pain and disability score was more: older patients tended to improve less than younger, the hip group tended to improve convincingly more than the back group, whereas the improvement in the knee group was less readily differentiated from that in the back group. The subgroup of patients with back pain who required NSAIDs during the eight weeks used significantly more per patient than patients in the other two groups, but that requirement also declined more with time. About 10% of the patients suffered from minor adverse events that could possibly have been attributable to Doloteffin. Between 50% and 70% of the patients benefitted from Doloteffin with few adverse effects (primarily gastrointestinal).Reference:Frerick et al. Stufenschema bei Coxarthrose. Der Kassenarzt 2001;5(34):41.Chantre et al. Phytomedicine 2000;7(3):Chrubasik et al. Phytomedicine 2002;9(3):
67Devil’s claw (Harpagophytum procumbens) According to UpToDate (www.uptodate.com):"Devil's claw reportedly improves joint mobility and reduces pain and swelling in arthritis.""It may be more effective for osteoarthritis as compared to rheumatoid arthritis.""It may be more effective for chronic, rather than acute, arthritis symptoms."*UpToDate® is an evidence-based clinical decision support system authored by physicians
68Devil’s claw (Harpagophytum procumbens) "There is a growing body of scientific evidence suggesting that devil's claw is safe and beneficial in the short-term management of pain related to degenerative joint disease or osteoarthritis. It may be equally effective as drug therapies, such as non-steroidal anti inflammatory drugs (or may allow for dose reductions or cessation of these drugs in some patients).“ – Natural Standard database**Natural Standard is impartial; not supported by any interest group, professional organization or product manufacturer.
69Devil’s claw (Harpagophytum procumbens) Enteric coating required:Studies demonstrated loss of anti-inflammatory effects by oral administrationDose-dependent effects observed with intraperitoneal and intraduodenal administrationEnteric coating - protection of efficacy demonstratedImportance of enteric coated formulations…
70Devil’s claw (Harpagophytum procumbens) The iridoid glycoside, harpagoside, linked to its anti-inflammatory and analgesic benefits.PD & PK - 3 studies in human volunteers*:Relation between serum harpagoside levels and the inhibition of leukotriene biosynthesis.Maximum levels of plasma harpagoside reached after 1.3 to 2.5 hours.Harpagoside elimination half-life has been reported as 5.6 hours.*Clin Pharmacol Ther May;69(5):
71Devil’s claw (Harpagophytum procumbens) Inhibition of Cyclo Oxygenase 2Assists the extracellular matrixconstruction (synthesis of GAGs)Synthesis of hyaluronic acid(human chondrocytes)Iridoids (harpagosides) interact with Arachidonic Acid metabolism pathways:• Action on eicosanoids synthesis• Action on cyclo-oxygenase, lipoxygenase and NO synthetase• Action on TNFa liberation• Action on Cys-LT synthetis• Action on enzymes responsible for collagen degradationPharmacological mode of action:COX-2 inhibitionOther pathways targetedExplanation for absence of renal & cardiovascular toxicity: Potent cytokine release inhibitor & weak inhibitor of COX-2 mediated prostaglandin E2 biosynthesis.
72Systematic Review - Conclusions No efficacy when less than <30 mg harpagoside per day in the treatment of knee and hip osteoarthritis.Moderate evidence when 60 mg harpagoside per day in the treatment of osteoarthritis of the spine, hip and knee.Moderate evidence (57 mg harpagoside per day) for non-inferiority to diacerhein (inhibitor of IL-1) in treatment of acute exacerbations of osteoarthritis in the hip and knee.Important to give mg harpagosides per day.Joel J Gagnier et al. Harpgophytum procumbens for osteoarthritis and low back pain: A systematic review. BMC Complementary and Alternative Medicine 2004, 4:13.
73Systematic Review - Conclusions Moderate evidence for a daily dose of 100 mg harpagoside in the treatment of acute exacerbations of chronic non-specific low back pain.subgroup with neurological deficits (e.g. radiation into the leg) responded well.60 mg harpagoside being non-inferior to 12.5 mg rofecoxib (VIOXX) per day for chronic non-specific low back pain (NSLBP) in the short term.Strong evidence for 50 mg harpagoside in the treatment of acute exacerbations of chronic NSLBP.Important to give mg harpagosides per day.Joel J Gagnier et al. Harpgophytum procumbens for osteoarthritis and low back pain: A systematic review. BMC Complementary and Alternative Medicine 2004, 4:13.
74Laudahn D and Walper A. Efficacy and Tolerance of Harpagophytum Extract LI 174 in Patients with Chronic Non-radicular Back Pain. Phytother. Res. 15, 621–624 (2001)
75Laudahn D and Walper A. Efficacy and Tolerance of Harpagophytum Extract LI 174 in Patients with Chronic Non-radicular Back Pain. Phytother. Res. 15, 621–624 (2001)
76Using Schober’s sign, a significant improvement in the evaluation of mobility of the spinal column. Laudahn D and Walper A. Efficacy and Tolerance of Harpagophytum Extract LI 174 in Patients with Chronic Non-radicular Back Pain. Phytother. Res. 15, 621–624 (2001)
77The mobility of the spinal column increased significantly during treatment. There was a significant reduction (p ) in the average finger–floor distance (FFD) from 15.1 cm initially to 10.2 cm at the end of treatment (Fig. 4).Laudahn D and Walper A. Efficacy and Tolerance of Harpagophytum Extract LI 174 in Patients with Chronic Non-radicular Back Pain. Phytother. Res. 15, 621–624 (2001)
78A question of dose. Consider a loading dose! Study - ConclusionsThe drug was slow in taking effect (about 14 days)."Does not seem to have immediate analgesic potency. More a question of a myotonolytic effect which may be combined with an antiinflammatory effect as a result of an increased blood supply to the affected regions".Patient should be told about the slow onset of action so that treatment is not stopped prematurely.A question of dose. Consider a loading dose!Laudahn D and Walper A. Efficacy and Tolerance of Harpagophytum Extract LI 174 in Patients with Chronic Non-radicular Back Pain. Phytother. Res. 15, 621–624 (2001)
79Study - Conclusions Treatment costs: no need for gastric protection treatment or secondary treatment for gastrointestinal ulcers.Can be used in patients with known sensitivity to NSAIDshigh-dose Harpagophytum extract.Laudahn D and Walper A. Efficacy and Tolerance of Harpagophytum Extract LI 174 in Patients with Chronic Non-radicular Back Pain. Phytother. Res. 15, 621–624 (2001)
80Recommended & Current Uses Devil’s claw (Harpagophytum procumbens) Chronic Pain:1 tablet bid or tid.Half-life 5.6 hours; 4-6 hrs prn.Fibromyalgia:1 tablet tid.Acute Pain (sporadic):2 tablets single dose.No contraindications:Hypertension, cardiovascular risk, no risk of GI bleeds.*1 tablet = 23.4 mg harpagoside (3.74 g dried secondary root)
82Skullcap (Scutellaria lateriflora) (also known as Virginia Skullcap) Used as a nerve tonic, sedative and nervous conditions.Used as antispasmodic medicine in the early 1900’s and the Manual of Materia Medica lists the following pain associated conditions where it was used: spasms, muscular twitching, and neuralgia.Today it is widely used for treating tension, anxiety and insomnia as well as a visceral relaxant / antispasmodic for muscular cramps.
83Skullcap (Scutellaria lateriflora) (also known as Virginia Skullcap) Scutellarin:Shown protective effect for cerebral injury via regulating expression of NOS isoforms & angiogenic molecules (Hu XM et al)Protection against ConA-induced immunological liver injury in mice; mechanism: effect on pro-inflammatory cytokines (inhibition NF-kappaB-TNF-alpha-iNOS transduction pathway) (Tan ZH et al)Study showed neuroprotective effects on brain ischemic injury-iinhibition of the apoptosis-inducing factor pathway in rats (Zhang HF et al)Anti-inflammatory activity in microglial cell (Wang S et al)
84Skullcap (Scutellaria lateriflora) Bioenergetic uses of Scullcap are:Relaxes constraint. Tonifies the Yin, clears empty heat.Relieves Heart Qi constraint (Liver-Yang rising) or Kidney/adrenal Qi constraint).Treats conditions of heart and kidney Yin deficiency:- insomnia, anxiety.Treats conditions of stomach or kidney Qi stagnation:nervousness, stress.Treats conditions of kidney /adrenal Qi constraint:- mental/nervous tension from chronic stress or pain or mental/physical exhaustion, unrest, stress-related conditions, anxiety, panic attacks.- tension headache, neuralgia, neuritis, uterine pain, muscle spasms/cramps (e.g.,lower leg, back).Should be used to treat conditions with patterns of constrained Qi arising from deficiency; empty tense conditions. Not for conditions arising from excess. Indicated for chronic and not acute stages.Recognized as a nervine tonic.Considered to have trophorestorative effect on nerves.Systemic relaxant: very effective for spasms-cramps.
85Muscle Relaxants Clinical trials: Insufficient evidence to determine whether skeletal musclerelaxants are effective for subacute or chronic LBP.No difference in short-term reduction of muscle spasmbetween cyclobenzaprine and placebo.Benzodiazepines:Used as skeletal muscle relaxants.Two trials: more effective than placebo for short-termpain intensity and overall improvement.One trial: no difference between diazepam and placebofor muscle spasm.Short term use to avoid addiction.
91Can we effectively reduce moderate-severe pain with a combination of Devil’s claw, California poppy and Skullcap?
92Pain Medications – Visual Analog Scale The clinical goal in the treatment of pain is to suppress the feeling of pain until it is tolerable (or gone) by the patient.One of the primary endpoints is the measure of the sensation of pain by the patient using a Visual Analog Scale (VAS).An effective dose of an analgesic must lower VAS by 2.0 or more.
93Pain Medications – Visual Analog Scale The clinical goal in the treatment of pain is to suppress the feeling of pain until it is tolerable (or gone) by the patient.One of the primary endpoints is the measure of the sensation of pain by the patient using a Visual Analog Scale (VAS).The patient scores the level of the feeling of pain using a 0 to 10 scale. For example, a patient taking acetaminophen + ibuprofen that is in chronic severe pain has a VAS of 9. The physician will begin by adding 2 mg of hydromorphone. This can reduce the feeling of pain by 30% (VAS = 6). The physician will then increase the dosage of hydromorphone to 4 mg which is still clinically acceptable. If the VAS does not decrease to a level that is tolerable for the patient, the physician will then begin adding or analgesics and or switching to stronger narcotics.
94INDEPENDENT CLINICAL DATA – Acute Pain Protocol Analgesic:California poppy – single dose (2 grams Dried Herb Equivalent (DHE) per day) at night.Anti-inflammatory:Devil’s claw – 2 tablets twice (4 grams DHE bid) a day.Anti-Spasmodic:Scullcap – 2 tablets three times (4 grams DHE tid) a dayTopical gel:3 – 4 times a day on affected area
95INDEPENDENT CLINICAL DATA – Chronic Pain Protocol Anti-Inflammatory:2 capsules TID; each equivalent to 1000 mg. Daily dose = 6000 mg DHE.Analgesic-Anti-Inflammatory:1 capsule of 2500 mg dried herb top California poppy at night mg Devil’s claw.Topical gel:3 to 4 times a day on affected
105Case Study – Low Back Pain 50 year old male with history of chronic back pain due to lumbar disc hernia. Complains of low back and limb muscle spasms. Patient refuses to take narcotics because of negative impact on his ability to concentrate and opioids make him aggressive. Epidural injections of steroids and anesthetic do not provide adequate benefit and patient has severe hypertension due to steroids.Initial intervention:- 2 tablets (enteric coated) of 23.4 mg harpagoside three times a day for first 48-hours. Reduced to 1 tablet three times a day for 2 weeks (next visit).- 1 tablet (2 g DHE; enteric coated) of Scullcap three times a day for first week. Reduced to 1 tablet p.r.n. every 4-6 hours as needed for spasms.Second intervention:- Maintain 1 tablet 23.4 mg harpagoside three times a day for one month. Explained increase to 2 tablets three times a day for 24 hours when flare-up due to false movement or exertion.- 1 tablet of Scullcap p.r.n. every 4-6 hours as needed for spasms.- Night pain: 1 tablet Devil’s claw & 3 tablets Scullcap 30 minutes before bedtime.
106Case Study– Low Back Pain 50 year old male with history of chronic back pain due to lumbar disc hernia. Complains of low back and limb muscle spasms. Patient refuses to take narcotics because of negative impact on his ability to concentrate and opioids make him aggressive. Epidural injections of steroids and anesthetic do not provide adequate benefit and patient has severe hypertension due to steroids.Initial intervention:- 2 tablets of 23.4 mg harpagoside three times a day for first 48-hours. Reduced to 1 tablet three times a day for 2 weeks (next visit).- 1 tablet of Scullcap three times a day for first week. Reduced to 1 tablet p.r.n. every 4-6 hours as needed for spasms.Devil’s claw – standardized harpagoside:Acute pain: use three times a day for first 48-hours.Do not exceed 48-hours.TID important based on half-life.2) Reduce to 1 tablet three times a day for 2 weeks.3) Reduce to 1 tablet twice a day for longer.RAPID PAIN REDUCTION: LOADING DOSE FOLLOWED BY OPTIMIZED DOSE FREQUENCY.
107Case Study – Low Back Pain Initial intervention:- 2 tablets of 23.4 mg harpagoside three times a day for first 48-hours. Reduced to 1 tablet three times a day for 2 weeks (next visit).- 1 tablet (2 g DHE) of Scullcap three times a day for first week. Reduced to 1 tablet p.r.n. every 4-6 hours as needed for spasms.Enteric coated Scullcap:Spasms-cramps:Depending on severity, 1 tablet every 4-6 hours as needed.Beware of tranquilizing effect - drowsiness.2) Maintain lower dose during day.3) If no sleep aid, use 2-3 tablets at bedtime.BALANCE SPASM/CRAMP REDUCTION VERSUS TRANQUILIZING EFFECT DURING DAYTIME!.
108Case Study – Low Back Pain Second intervention:Maintain 1 tablet 23.4 mgharpagoside three times a dayfor one month. Explainedincrease to 2 tablets three times aday for 24 hours when flare-updue to false movement orexertion.1 tablet of (2g DHE) Scullcap p.r.n. every 4-6 hours as needed for spasms.Night pain: 1 tablet Devil’s claw & 3 tablets Scullcap 30 minutes before bedtime.Devil’s claw :Flare-ups: important to rapidly reduce sudden increase in pain.Do not exceed 48-hours.TID important based on half-life.2) Reduce to maintenance dosing or stopif no longer taking.
109Case Study – Low Back Pain Second intervention:Maintain 1 tablet 23.4 mgharpagoside three times a dayfor one month. Explainedincrease to 2 tablets threetimes a day for 24 hours whenflare-up due to falsemovement or exertion.1 tablet (2 g DHE) of Scullcap p.r.n. every 4-6 hours as needed for spasms.Night pain: 1 tablet Devil’sclaw & 3 tablets Scullcap 30minutes before bedtime.Night Pain:Important to add sedative-hypnotic PLUS anti-inflammatory-analgesic.2) Skullcap is good choice because ofantispasmodic effect. Lemon balm-Passion flower can also be used fornight pain in combinations with naturalNSAID.