Disease management
Are your chronically ill patients turning to herbal treatments?
Some cause potentially dangerous interactions
Many chronically ill patients become disenchanted with Western medicine and turn to alternative therapies, including herbal remedies and supplements. "When Western medicine doesn’t offer patients an acceptable solution, many start looking for anything that will help them," says Doug Murray, PharmD, director of pharmacy and clinical services at Kershaw County Medical Center in Camden, SC, and an adjunct professor at the University of South Carolina College of Pharmacy in Columbia.
American medical journals are taking notice of the trend, Murray notes. American Health Consultants, for instance, publisher of Case Management Advisor, publishes a newsletter, Alternative Medicine Alert, devoted to herbs and other alternative remedies. Archives of Internal Medicine had a review article on herbs as medicine in its Nov. 9, 1998, issue. Articles on herbal supplements also have appeared in recent issues of the peer-reviewed journal American Journal of Health Services Pharmacy. "Look for information in peer-reviewed scientific journals. More information is coming out, and I find most of the information I use in current journals," says Murray, who has prepared lectures for pharmacy students on herbal remedies. (For other sources of information on herbal supplements, see box, p. 71.)
A great deal of research is available on herbal remedies because they have been prescribed by physicians and covered by insurance companies in Germany for years. "The Germans are the backbones of this," Murray notes. "They’ve done the research, and it’s been published. The Germans also have a lot of standard review textbooks that are accepted now in the United States."
Congress paved the way to ensure herbal supplements don’t have to go through the expensive and rigorous drug-testing process in the United States through passage of the Dietary Supplement and Health Information Act of 1994. While concerned consumer advocates, pharmaceutical representatives, nutritional supplement manufacturers, and health care professionals debated whether herbs were drugs or dietary supplements, the non-drug advocates won. As a result, herbs are not regulated by the government, which means anyone with a garden can grow and sell their own.
The recent surge in the popularity of herbal supplements has caused concern among physicians and other health care providers because patients may experience dangerous side effects by combining herbs with their prescription medications.
What else are you taking?’
"We found that a lot of patients’ doctors were not even aware that their patients were using herbs," says Kathleen Hughes, RN, director of home care for Kershaw County Medical Center Home Health Care in Camden, SC. "We have seen such an increase on medication sheets of people taking herbs," Hughes says, explaining that the agency’s nurses record herbs along with prescribed drugs on patients’ medication sheets.
"Our concern was how these herbs might be interacting with the patient’s other medication," she says. "And how could we teach patients what’s going on with their medicines?"
Murray also has seen an increase in use and interest in herbal medicines. "I see a steady increase in questions from physicians who have patients taking herbs. They want to know about possible interactions with drugs their patients are taking."
The real risk comes when patients don’t inform their physicians about their herb use, he notes. "Many patients are reluctant to talk to their physicians, case managers, and care providers about taking herbs. They often feel as if they are doing something their health care providers might not approve of. Patients have this guilt about herb use. They also often don’t feel that herbs are medicine. They think of herb use as something natural that they are doing for their health."
Murray says his hospital now formally asks every patient on admission for a complete medication history that includes over-the-counter products, vitamins, and herbal products. He says it’s important for case managers to do the same and to consider the possibility of herbal supplements when patients report new or unexpected changes in their health status.
"There are some developments that should tip you off or at least cause you to question the possibility of herbal use; for example, if a patient is doing well for several months on blood pressure medication, and then suddenly their medication no longer controls their hypertension. You have to start asking questions. It’s like being a detective," he says.
Of course, in addition to possible herbal use, the patient may have stopped taking an old prescription or started a new one, he says. Questions he suggests case managers ask include the following:
• Have you stopped taking any medications or added any new medications since you have experienced these symptoms?
• Have you started taking any new vitamins or herbal supplements or stopped taking any vitamins or herbal supplements since you have experienced these symptoms?
• Have you recently tried a new over-the-counter medication?
Cause for concern
Murray has educated himself on herbal remedies, their side effects, and how they interact with prescription medications. He suggests case managers learn about these basic herbal remedies and how they might adversely affect patients’ health:
o Feverfew: This herb is used for prophylactic treatment of migraine headaches. Pregnant women should avoid it, and it can increase a person’s heart rate slightly, Murray says. Because of this potential side effect, medical experts now think people should avoid using feverfew if they are taking any of these medications:
• calcium channel blockers;
• Ticlid, an anti-platelet drug;
• Coumadin.
"With these drugs, you could have a potentiation of the effects, so it’s something to be careful about," Murray says.
o Garlic: Garlic pills, touted as a great cholesterol reducer in radio and television advertisements, also can decrease blood pressure, as well as cholesterol. "There are some warnings that people who take anticoagulants like Coumadin while taking garlic may increase their chance of bleeding," Murray says.
o Ginkgo biloba: This herb has received a lot of news coverage recently about its ability to increase circulation to the brain and extremities. Some researchers claim it might be a good antioxidant, and they’re studying it for use with Alzheimer’s disease patients as a way to improve short-term memory. It’s also thought to help with ringing in the ears. Less well known are its adverse side effects, which include restlessness, insomnia, nausea, and vomiting, Murray notes. "In the literature, there are three cases of spontaneous bleeding from people taking it, and because of this, some literature is saying you shouldn’t take this with heparin or Coumadin."
In addition, people who have hemophilia or von Willebrand’s disease should avoid ginkgo because of the bleeding potential. Experts also warn people on nitrate drugs and antidepressants to avoid the herb.
o Asian ginseng: "Asian ginseng is a real popular drug that is thought to increase energy, improve mood, and improve resistance to infection," Murray says. "It’s the top-selling herb in the U.S., with $78 million in sales annually."
The herb has been studied for use by postmenopausal women and Alzheimer’s disease patients. There are some potential adverse side effects, such as insomnia, nervousness, and irritability. Pregnant women should avoid this herb, he says. "They think people with coronary artery disease, hypertension, or arrhythmia should be cautious in taking it also."
Research shows that Asian ginseng might interact with digoxin and increase the levels of digoxin in the blood. This could be a serious problem because digoxin is a dangerous drug that has a narrow therapeutic window, meaning that the amount of digoxin in your body that is thought to be effective is not too far away from the amount of digoxin that could cause toxicity, Murray explains.
Medical experts also are concerned about people taking this herb while they are on Coumadin because it also has a narrow therapeutic window.
o St. John’s wort: This herb also has been widely publicized. Research shows it helps alleviate depression and anxiety. Its side effects may include restlessness and fatigue. "They say until more is known, you probably shouldn’t take St. John’s wort with prescription antidepressants," Murray says. This is because selective serotonin re-uptake inhibit ors such as Prozac form a powerful chemical class of antidepressants that is fairly new. "If you take those types of antidepressants, then you should stop three weeks before taking St. John’s wort."
o Valerian root: People often take this herb as a sleep aid for nervousness. Although it appears to be safe as far as adverse side effects are concerned, medical experts advise people to take it for only one week at a time, Murray says. "If you get it really concentrated, when you make your own teas, for example, it can actually decrease your blood pressure a little."
It also may cause orthostatic hypotension, the dizziness that occurs when a person who is sitting or lying down stands up quickly and loses his or her balance. For this reason, people who are taking blood pressure medications should take precautions when using valerian root.
Like benzodiazepines, Valerian root has a sedative effect. Therefore, people taking the herb should be cautious when driving.
o Chamomile tea: People sometimes drink chamomile tea to help settle an upset stomach or relieve tension. The medical literature warns people who have ragweed allergies to be cautious because they also might be allergic to chamomile.
o Purple cone flower: Also called Echinacea, this is used to improve the healing process or boost the immune system. Current medical literature suggests the herb does have some properties that might improve an individual’s immune system temporarily. "Some authors are thinking the effect decreases after eight weeks, so it’s better to take it intermittently," Murray says.
Caution: Avoid at all costs
Some herbs should be avoided altogether because they are unsafe, Murray cautions. Some stores may sell these herbs, or people may find them in the wild:
o Blue cohosh: The black cohosh is safe, but the blue cohosh is believed to increase a person’s blood pressure and provoke angina.
o Chaparral: Believed to have blood-cleansing and cancer-fighting properties, chaparral is carcinogenic and toxic.
o Comfrey: This damages the liver and is carcinogenic when taken internally. People sometimes use it to promote bone healing, he notes.
Murray says he also worries about people buying herbs from questionable sources, such as small fly-by-night manufacturers, because the quality and even the ingredients may not be inspected. (A list of herbal use guidelines case managers may want to share with patients appears in the box, above left.)
A worst-case scenario occurred in 1989 when an outbreak of eosinophilia-myalgia syndrome (EMS) in the United States was associated with L-tryptophan, an over-the-counter dietary supplement used for weight loss. There were more than 1,500 cases of EMS, including 38 deaths, reported to the Centers for Disease Control and Prevention in Atlanta, according to the U.S. Food and Drug Administration (FDA) in Washington, DC. Some people with EMS experience severe pain and bleeding.
More than 95% of those cases were traced to L-tryptophan supplied by Showa Denka K.K. of Japan. Researchers found some trace-level impurities, suggesting a contaminated batch contributed to the outbreak. The FDA limited the availability of L-tryptophan supplements and enforced an import alert because of the outbreak.
While this type of danger rarely occurs with food supplements and herbal remedies, health care professionals still advise people to avoid purchasing these products from unfamiliar manufacturers. Recently, several major drug manufacturers started producing herbal remedies, so consumers now have choices that include manufacturers with proven track records, Murray adds.
[Editor’s note: The preceding information on herbal supplements was provided at the request of a Case Manage ment Advisor reader. If you have a topic you would like us to research, please contact: Lauren Hoffmann, editor, Case Management Advisor, P.O. Box 740056, Atlanta, GA 30374. Phone: (770) 955-9252.]
Web sites offer herb info
Case managers who want to learn more about herbal remedies should consider starting on line. Doug Murray, PharmD, director of pharmacy and clinical services at Kershaw County Medical Center in Camden, SC, and an adjunct professor at the University of South Carolina College of Pharmacy in Columbia, says the Internet has several useful sites, including these:
• www.egregore.com: This site, Medicinal Herbs Online, lists more than 100 diseases and 125 herbs, including extensive descriptions of each.
• altmed.od.nih.gov/oam: This is the site for the Office of Alternative Medicine at the National Institutes of Health in Bethesda, MD. For other resources available from this government office, contact OAM, 9000 Rockville Pike, Building 31, Room 5B-38, Bethesda, MD 20892. Phone: (800) 531-1794 or (301) 402-2466. Fax: (301) 402-4741.
Scientific and technical journals
In addition to Web sites, several scientific and technical journals regularly publish information on herbal remedies. The 1996 American Botanical Council translation of the German Commission E Monographs, for instance, is the scientific gold standard for information on herbal supplements, Murray says. "This is a source many pharmacists, myself included, keep on hand and refer to." Other journals include the following:
• Chemical Pharmaceutical Bulletin
• International Journal of Pharmacognosy
• Journal of Ethnopharmacology
• Planta Medica
• Professional Journal of Botanical Medicine
• The British Journal of Phytotherapy
• Alternative Therapies in Health & Medicine
• Herbs for Health
• Nutrition Forum
• Nutrition Science News
• The Journal of Alternative and Complementary Medicine
Share this with patients
The rapid rise in the popularity and use of herbal supplements in the past few years has sparked a great deal of concern in the health care community. At a recent professional meeting of hospital pharmacists in South Carolina, Doug Murray, PharmD, director of pharmacy and clinical services at Kershaw County Medical Center in Camden, SC, and an adjunct professor at the University of South Carolina College of Pharmacy in Columbia, received these guidelines on herbal use. He suggests case managers share them with patients:
1. Do not take herbal supplements if you are pregnant or trying to conceive.
2. Do not take herbal supplements if you are lactating.
3. Do not give herbal supplements to infants and young children.
4. Maintain realistic expectations about the benefits of herbal supplements. They are not miracle drugs.
5. Use standardized products when available. Products should have the scientific name and quantity of the botanical clearly identified on the label. The name and address of the manufacturer, the lot numbers, and expiration date also should be marked clearly on the label.
6. Stop taking a product immediately if adverse effects occur.
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