1. Herbal Medications in College Health: Considerations & Evidence Cheryl Flynn*, MD, MS, MA Syracuse University Health Services caflynn@syr.edu *No conflicts of interest

2. Disclosures What I am not… n Not an herbalist n Not a naturopath n Do not practice Eastern medicine What I am… n Family Physician n Allopathic trained n Do my best to practice evidence-based medicine n In college health 2.5 years

3. What we won’t be talking about… n Medical marijuana ä (Nor non-medical uses of marijuana for that matter)

4. …and what we will (aka Objectives) 1. Herbals as supplements ä FDA regulations differ from medications ä Specific issues of safety 2. Herbal medication uses in college health ä Key conditions for which herbals may be used ä Summarize evidence re: efficacy for selected topics ä Highlight any concerning safety issues 3. Sources of valid information regarding herbal medications

5. Going green w/ your meds? n Herbal supplements are derived from plants, used for therapeutic purposes n Assumption: natural = safe ä Herbal supplements are still chemical ä Can have own list of adverse effects ä Can interact with other medications

6. Herbals & the FDA n Herbals considered “supplements” n Subjected to food regulations, not drug regulations 1. Less standardization of content 2. No pre-requisite for safety or efficacy prior to being marketed –FDA MedWatch program to monitor –Limits claims that can be made

8. The FDA disclaimer n The products and the claims made about specific products on or through this site have not been evaluated by the Bayside Laboratories or the United States Food and Drug Administration and are not approved to diagnose, treat, cure or prevent disease.United States Food and Drug Administration n The information provided on this site is for informational purposes only and is not intended as a substitute for advice from your physician or other health care professional or any information contained on or in any product label or packaging. n You should not use the information on this site for diagnosis or treatment of any health problem or for prescription of any medication or other treatment. n You should consult with a healthcare professional before starting any diet, exercise or supplementation program, before taking any medication, or if you have or suspect you might have a health problem. Acaiberrysite.com is owned and operated by Alive by Nature Inc.

9. What’s a clinician to do? n Ask students specifically about use of herbal meds n Offer info about limitations of FDA regulations n Know the evidence… ä Check valid info sources for efficacy and give recommendations ä Watch for warnings ä Educate that hype and advertising are not the same as sound medical research

10. Cheryl’s Approach n Does this product work for the reason the student is seeking? ä B grade with RCT data n If so, is it safe? n If not, is it safe? n Pot’l harms: adverse effects—real or theoretical? n Pot’l harm: wasted $

11. Balancing benefits & risks Examples: n Kava for anxiety n Melatonin for sleep disturbances n High dose riboflavin for migraine prevention

12. A comment about evidence… Validity for treatment n Meta-analysis of RCTs n Double blind RCT n Controlled trial n Cohort n Case control Relevance n Human > animal n Patient-oriented > disease oriented

13. 3. Information sites about Herbals n NIH drug information ä http://www.nlm.nih.gov/medlineplus/druginformation.html http://www.nlm.nih.gov/medlineplus/druginformation.html n Nat’l Center for Complementary & Alternative Medicine ä http://nccam.nih.gov/health/herbsataglance.htm http://nccam.nih.gov/health/herbsataglance.htm ä Can register for updates CF Commentary ä Useful for clinicians, educators, patients ä Information on efficacy (grade) and safety ä Focus on validity, not necessarily relevance ä Sometimes grade does not fully correlate w/ levels of evidence

14. Other evidence sources: original data n Cochrane Database ä Systematic reviews of RCTs on a wide variety of topics ä Group within focuses on alternative meds ä Worthwhile first look for any Q about treatment n PubMed Clinical Queries ä Therapy, systematic reviews ä Adds validity filters to your search to help retreive better info

15. 2. Audience query… What herbals/alternative meds are you being asked about? What conditions do you see students taking herbal meds for?

16. Why might college students use herbals? n To prevent an illness ä UTI, URI, heart disease n To treat a condition ä depression, sleep problems, infections, ADHD n For enhancement of some sort ä Improved memory, sexual performance, muscle building, weight loss, “general health”

17. Selected topics to be covered n Handout covers broader range ä More still likely to be encountered n Selected handful of topics based on internal survey of frequency ä URI prevention/treatment ä Depression ä UTIs ä Body enhancement

18. Upper Respiratory Infections

19. Case 1: URI n 19 y/o presents for ankle injury n No PMHx, but taking vit C every day to prevent illness to limit illness, esp during midterms n What do you tell him about herbals and preventing or treating URIs?

20. URIs & Echinacea n Echinacea is the most commonly used herbal prep n Touted to boost immune system n Pot’l to prevent and treat common cold

21. Echinacea & Preventing URIs: The Evidence n Cochrane review, updated 2007 ä 3 RCTs—none found any benefit over placebo n 2008 RCT, double blinded ä 90 healthy adults treated bid x 8 wk ä No difference in # sick days/person ä No difference in adverse effects C NIH  B based on NCCAM inoculation study

22. Echinacea & Treating URIs: The Evidence n Cochrane review, updated 2007 ä 16 RCTs echinacea vs placebo –Heterogeneity of preps –Benefit in 9, trend in 1, no difference in 6 –Pooled data shows statistical benefit B Dose: 500-1000mg QD

23. Echinacea & Safety n Safe and well tolerated in RCTs ä Adverse effects minor, and not increased in echinacea group except rashes in one study of children n No significant drug interactions

24. URIs & Vitamin C n 1971 Linus Pauling n Antioxidant, promotes well being and immune function n Debate about accuracy of research, low dose vs high dose, dietary consumption vs supplemental n Though vit C found in plants, mostly chemically made so technically not an herbal

25. Vitamin C & Preventing URIs: The Evidence n Cochrane review, updated 2007 ä 30 RCTs using doses of >200mg/day involving 11,350 people ä No benefit in prevention (RR 0.96) –Subset of high exercise, exposure to Arctic temps had RR 0.50 ä Modest statistical but not clinical reduction in duration of symptoms (8%) n No newer RCTs D

26. Vitamin C & Treating URIs: The Evidence n Cochrane review, updated 2006 ä 7 RCTs with 3294 subjects ä No benefit to duration or severity of URI sx D

27. Vitamin C & Safety n Generally well tolerated in RCTs n High doses (>2g/day) less tolerated ä GI upset, flushing ä Incr risk kidney stones ä Abrupt discontinuation may lead to VitC def, so tapering rec’d

28. Garlic & URI prevention n Cochrane review, updated 2009 ä Only 1 dbl blind RCT ä 146 adults took garlic daily vs placebo x 3 months ä Fewer total URIs, no difference in duration of illness if sick n Safety ä Safe, well tolerated –Pot’l for halitosis! ä Avoid before surgery given pot’l bleeding risk ä Not proven to affect glucose C

29. Pelargonium Sidoides & URI tx n 2008 Cochrane review ä Significant heterogeneity but some benefit for treating acute bronchitis in adults ä 1 unpublished study found benefit to adults in acute sinusitis n 2 subsequent RCTs ä 2009 adults w/ URIs found lower sx scores, fewer days off work ä 2010 children/adol w/ bronchitis found overall lower sx scores Safety  Well tolerated and safe as noted within existing RCTs  Not yet listed in NCCAM or NIH sites C +

30. Zinc & URIs Prevention n Systematic review ä 2 RCTs for innoculated colds find no preventive benefit ä 1 placebo controlled RCT of Zn supplementation in children found cold rate decreased from 1.7 to 1.2 over 7 month period Treatment n Cochrane review, updated 1999 ä 8 RCTs; 4 finding no benefit, 4 improperly blinded did find modest benefit n Pubmed search ä Multiple RCTs w/ conflicting results; those finding benefit often w/ design limitations C C

31. Zn & Safety n Less tolerated than placebo in RCTs ä Mild, but lead to stopping med ä Bad taste, nasal irritation ä Concern of long term taste/smell distortion n Case reports ä Erosion of mucosal surfaces, hepatitis n Avoid if kidney disease (renal excretion)

32. & how about… n “Airborne contains a special blend of 17 vitamins, minerals and herbs, including Zinc, Ginger, Echinacea and a blast of Vitamin C! “ n NO STUDIES H

33. Depression

34. Case 2: depression n 26 y/o graduate student with mod depression, already in therapy. Family has had bad reactions to anti-depressants, so she’s fearful of trying. Would prefer something natural. n PMHx benign; routine GYN care, on OCPs for contraception n How would you advise this patient?

35. Depression & St Johns Wort n Also known as Hypericum perforatum n Widely used as treatment for depression, esp in Europe n Large RCT by NCCAM division of NIH

36. SJW & Depression: The Evidence n Cochrane review, updated 2008 ä 18 RCTs SJW vs placebo in pts with major depression ä Heterogeneity of results, beneficial effect –Large studies RR for response: 1.28 –Smaller studies RR 1.87 ä (also 17 RCTs vs other anti-depressants finding equivalency in efficacy but more side effects/withdrawals in Rx group) n 2010 RCT adults w/ depression & atypical features ä Benefit in validated depression sx scores vs placebo B Dose: 300mg tid

37. SJW & safety n Well tolerated in the research studies ä Typical mild serotonin side effects: GI upset, sexual dysfunction, though better tolerated than Rx anti- depressants (TCAs and SSRIs) n Possible serotonin syndrome if combined w/ other serotonin meds ä Not to be combined w/ other SSRIs ä Be aware of triptans, dextromethorphan also! n Affects cytochrome P450, so caution advised when taking concurrent meds ä Anti-epileptics, cyclcosporin, HIV meds may be lowered; Specific FDA warning re: lowered efficacy of indinavir

38. SJW & OCPs: a special consideration in college population n Theoretical impact via Cyt P450 ä Advise back-up for of contraception ä 1 study showing incr break through bleeding; case reports of unwanted pregnancy n 1 small RCT lower hormone levels, “possible incr ovulation n 2 larger RCTs no such effect; one measured ovulation n Efficacy studies not finding any increased pregnancy rates reported.

39. Depression & Fish Oil n AKA omega-3; Polyunsaturated fatty acids ä EPA & DHA are specific types n Not an herbal, but a supplement n Observational association between low dietary intake of omega-3 PUFAs & depression

40. Omega-3 & Depression: The Evidence n No Cochrane reviews n Pubmed search id’d a 2010 meta-analysis ä Included 35 RCTs ä Pooled data demo’d benefit for those w/ depression dx ä (No benefit if nondepressed pts) ä Concerns: heterogeneous, probable publication bias n 3 RCTs ä varying pop: childhood bipolar, women w/ psych distress, preventing peri-partum depression ä Mixed results C +

41. Omega-3s & Safety n Generally safe in doses up to 3g/day ä No significant harms id’d in literature ä Theoretical harm of very high dosing increasing bleeding risk ä Greater concern of contaminants if consumed in fish products (mercury poisoning etc) n Tolerability ä Fish burps! Can be managed by freezing capsules

42. UTIs

43. Case 3: UTI n 19 y/o sophomore presents with dysuria & frequency. She comes to clinic Monday uncomfortable, having tried cranberry juice all weekend. n ROS—no vaginal sx n PMHx—only 2 UTIs in the past, one responded to cranberry juice; no h/o pyelo; no h/o STDs n SHx—not currently sexually active; 1 lifetime partner n How would you counsel her about cranberry juice?

44. Cranberries & UTIs n Acidify urine? n Reduce bacterial adhesion to bladder wall n Touted as prevention and treatment of UTIs

45. Cranberries and UTI prevention: The Evidence n Cochrane review, updated 2008 ä 10 RCTs, 1049 patients ä Significant reduction in UTIs, RR 0.65 ä Specifically effective in women w/ recurrent UTIs n 3 further placebo controlled RCTs for prevention ä Children, spinal cord injury, older women ä All showed benefit B- Dose: 3-16 oz cranberry juice cocktail bid

46. Cranberries and UTI treatment: The Evidence n Cochrane review, updated 2008 ä NO RCTs exist addressing cranberry products as treatment for UTI C

47. Cranberry & Safety n Generally safe; no harms id’d in studies ä Pot’l for GI upset/diarrhea w/ large quantity consumption ä Pot’l for kidney stones related to oxalate n Do NOT use as substitute for eval/antibiotics for suspected bladder infection

48. Weight Loss

49. Case 4: weight loss n 18 y/o 1 st year from the midwest presents wanting to lose weight. Has been on many diets w/ minimal success, always gained weight back. Is considering buying Hoodia over the internet as her friends said that worked well. n PE: BMI 25 n What do you tell her?

50. Bitter Orange & Weight loss n Citrus aurantium ä synephrine n Chemical composition similar to ephedra/phenylephrine n Extracts now used in place of ephedra in weight loss supplements since ephedra off the market

51. Bitter Orange & Weight Loss: The Evidence n No Cochrane Reviews n A 2004 meta-analysis ä 1 study of 20 people x 6 wks, no benefit ä did not address safety n Additional RCT of 8 people ä No benefit C

52. Bitter Orange & Safety n Limited data on safety ä Existing small studies find no adverse effects but not powered enough to find them ä Physical effects of appetite suppression also pot’l to incr HR, BP ä Theoretical dangers similar to ephedra –Though the NCCAM working group’s report noted possible harm and insufficient data ä Caution use if known CV disease or on other meds affecting CV system

53. Acai Berry & Weight Loss No clinical trials id’d H

54. Hoodia & Weight Loss n Also NO clinical trials for weight loss id’d H

55. Muscle Building

56. Case 5: muscle building n 22 y/o senior presents for STD screening. On PMHx exploration you discover he is taking 5g creatine supplement per day as part of his weight lifting routine. n How do you counsel him about the supplement?

57. Creatine & Muscle building n Supplement, not actually an herbal n Touted as building muscles, increasing strength n Anecdotally, used by many male college students, esp those who lift weights

58. Creatine & Muscle Building: The evidence n No cochrane reviews or meta-analyses n Multiple RCTs ä Heterogeneous populations, dosing, duration, outcome measurements ä Gestalt: the majority--but not consistently-- show some favorable outcomes A- A

59. Creatine & Safety n Concern re: pot’l harm to kidney ä Those w/ renal disease advised to not use this supplement ä Actual harm not born out in literature ä Encourage good hydration if using n Large quantities over long-term use  formaldehyde ä Short term eval not finding incr’d levels

61. Case 6: cyclical breast pain n 21 y/o for acute care visit. Med lists id’s vit E supplementation as routine. You inquire about this use. She reports her GYN advised it for “general health.” GYN tells you it was recommended for managing breast tenderness before pt’s periods. n How do you address this?

62. Case 7: managing blood sugar n Your uncle has type 2 diabetes and heard on the radio that cinnamon helps manage blood sugar. n How do you respond?