The Pros and Cons of Herbal Use:
A Discussion for the Healthcare Professional
Presented byYvette P. Ladd, RPh, ACE-CPT, RYT-200
www.wellness-pursuits.com
Staff pharmacist-Outpatient Pharmacy
August Health, Fishersville, VA
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Objectives:
Explore the prevalence of herbal supplement use
List and discuss the pros and cons of herbal supplement
use
List commonly used herbal supplements and potential
drug interactions
Identify the healthcare professional’s role in gathering
information and making decisions about herbal
supplement use among patients
Provide resources for learning about herbal
supplements and their regulation
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Herbal History
Herbal or Botanical:
A plant or part of a plant used for its flavor, scent, or potential
therapeutic properties. Includes flowers, leaves, bark, fruit, seeds,
stems, and roots.
Herbal medicines reflect some of the first attempts to improve
the human condition. The personal effects of the mummified
prehistoric “ice man” found in the Italian Alps in 1991 included
medicinal herbs. By the Middle Ages, thousands of botanical
products had been inventoried for their medicinal effects.
-http://nccam.nih.gov/health/whatiscam
In some Asian and African countries, 80% of the population
depends on traditional medicine for primary health care.
Herbal medicines are the most lucrative form of traditional
medicine, generating billions of dollars in revenue.
More than 100 countries have regulations for herbal medicines.
-http://www.who.int/mediacentre/factsheets/fs134/en/
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The Prevalence of Herbal Use:
Herbs fall under the category of dietary supplements.
The most commonly used dietary supplement is a
multivitamin/mineral complex
Approximately 30 to 40% of US adults have used an herbal
supplement. Roughly, 72% of those are using herbals in
conjunction with prescription medications.
FACTORS ASSOCIATED WITH HERBAL THERAPY USE BY ADULTS IN THE UNITED
STATES • Paula Gardiner, MD; Robert Graham MD, MPH; Anna T.R. Legedza, ScD; Andrew
C. Ahn, MD, MPH; David M. Eisenberg, MD; Russell S. Phillips, MD
Herbal supplement sales in the U.S. increased 3.3% in 2010,
reaching a total estimated figure of 5.2 billion dollars.
HerbalGram. 2011; American Botanical Council; Herb Sales Continue Growth – Up 3.3% in
2010; by Mark Blumenthal; Ashley Lindstrom; Mary Ellen Lynch; Patrick Rea
According to the market report the top 10 best selling herbs in 2011 were, in rank
order:
1. Cranberry
2. Saw palmetto
3. Soy
4. Garlic
5. Gingko
6. Echinacea
7. Milk thistle
8. Black cohosh
9. St. John's Wort
10. Ginseng
http://takingcharge.csh.umn.edu/explore-healing-practices/botanical-medicine/10-top-bestselling-botanicals-what-they-do
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The Cons:
Herbs are assumed safe
because they are ‘natural’- ‘a
plant or a food’
-potential drug interactions exist
-patient age health can compromise
metabolism
Use and adverse events are
under-reported
-Forty-one percent (41%) of patients do
not disclose herbal supplementation to
their health providers
-uncertainty exists as to what causes and
adverse event due to polypharmacy
and/or polyherbacy
Dosing of herbs can be difficult
-standardization vs. whole plant
-different dosage forms
Lack of knowledge of health
care professionals
-they don’t know where to look for
information
-patients expect their doctors to be
informed
Lack of Regulation
Lack of science-based
research
Lack of Quality Control (QC)
–contamination and adulteration
The Pros:
Herbs are affordable and
accessible
-lack of health insurance, limited
income
-there is a trend of mistrust of the
medical establishment
-patients want to be in control of health
and medical needs. Herbal
supplementation is consistent with the
current paradigm shift in making
lifestyle modifications to improve health
and a desire to take a more ‘natural’
approach toward medical care. Lifestyle
makes a difference in how a patient will
respond to treatment.
Herbs aid bodily functions
and help to normalize
imbalances, thus enhancing the
body’s ability to heal itself
-herbs have a long history of use
-herbs typically have few side effects
-very few drug interactions have been
documented
DSHEA(1994) gives the FDA
authority to regulate herbs
-cGMP instituted in 2010-requiring
phytoequivalence within a dosage form
and also addressing cultivation methods
-the SIDI protocol
-in 2006 adverse event reporting by
manufacturers and distributors became
mandatory
Research is growing
-Natural Medicines Comprehensive
Database: the number of scientific
publications on this subject has
increased over 140 times from the
1980’s-2007.
Consumer Demand will
result in an increase in
Quality Control measures
-manufacturers who want to stay in
business will create and follow QC
standards
-USP, NSF, NPA
-Certificate of Analysis
-3rd party certification programs
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Commonly use Herbs and Potential Drug
Interactions: (this is not a comprehensive list)
Gingko and Garlic - increased risk of bleeding when used with
antiplatelet, anticoagulant or antithrombotic agents (Coumadin,
Plavix, Lovenox, nsaids)
St. John’s Wort – induces cytochrome P450- an enzyme involved
in the metabolism of more than 50% of all prescription medications;
may also have a synergistic effect with SSRI’s and other drugs that
influence serotonin levels
Saw Palmetto – inhibits cyclo-oxygenase (COX) and increases the
antiplatelet effects of warfarin; may have anti-estrogenic effects
Green Tea - caffeine content can pose problems with various drugs
– i.e. with amphetamines or decongestants may increase risk of CNS
side effects
Echinacea – inhibits certain CYP enzymes- increased potential for
hepatotoxic effects of other medications due to elevated serum drug
levels; also a potential to interfere with immunosuppressant drugs
(cyclosporine, Cellcept, Prograf, corticosteroids)
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The Medical Assistant's role in herbal
use among patients:
Take a thorough history from the patient
 update EMR (software may have capability of being
customized for this purpose)
 have receptionist ask for updates to medications and
supplements as they as for other information
Encourage patients:
 to communicate all supplement use and why
 to purchase products with a solid reputation for quality
 to report suspected adverse events or drug interactions to
the manufacturer
Educate yourself
 Continuing education
 Self-education
 Herbal workshops
 Resources (final pages of this presentation)
 Reach out to local Naturopathic doctors, Master
Herbalists, local health food stores (verify education
of staff) - (invite them in for in-services- great way
to support one another)
 Talk to specific manufacturers
 Understand the basics of DSHEA (Herbalgram
February 2012 and CRNUSA website noted in
resources section)
 ingredients in existence prior to DSHEA
to not have to be prove safety or
effectiveness, new ingredients DO!
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The Medical Assistant's role in herbal use among patients:
(continued)
Educate yourself (continued)
 Self-education (continued)
 be aware of health claims- allowed:
addresses a specific nutritional
deficiency; supports health; is linked to
a particular function (digestive,
immunity)- claims must be followed by
disclaimer:
 once on market FDA monitors safety
and associated product information (in
conjunction w/FTC)
 Serious adverse reactions MUST be
reported to FDA via MEDWATCH
 Stay abreast of current research and quality control
standards(resources)
 the more research available the more
sales and use of herbal products. This
industry isn't going away!
Educate your patients- Provide evidence-based educational
material and a list of other resources.
Communicate & Educate!
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Web resources for herbal research:
Research:
National Institutes of Health: National Center for Complimentary and Alternative
Medicine
http://nccam.nih.gov
Integrative Medicine Research- science based research
http://www.naturalstandard.com
The Cochrane Collaboration- science based research
http://www.cochrane.org
US Pharmacopeial- standardization/certification of botanicals, science based research, the
‘white paper’
http://www.usp.org/dietary-supplements/overview
Natural Medicines Comprehensive Database- complete herb information; science based
research; drug interaction checker; rating for significance of potential drug
interactions; patient handouts
http://www.naturaldatabase.therapeuticresearch.com
Product Integrity:
Consumer Lab.com- Independent Testing/Reporting; current news
http://www.consumerlab.com
Emerson Ecologics- an example of quality control
http://www.emersonecologics.com/Quality/EmersonQualityProgramPartnerStandards
General Herbal information:
Herb Research Foundation- comprehensive information about botanicals
http://www.herbs.org/herbnews
American Botanical Council- the HerbalGram; monographs (patient handouts);
research; international regulatory status
http://abc.herbalgram.org
Herb Pharm- brand of tinctures; but also offer educational material
http://herb-pharm.com/education.html
Herb Society of America- herbal history, use and more!
http://www.herbsociety.org
American Herbal Products Association- representing the companies behind the products;
current news, research, resource for NDIs.
http://www.ahpa.org
Regulation:
Center for Responsible Nutrition- Representing manufacturers and suppliers
A great place to learn about DSHEA.
http://www.crnusa.org
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Other Resources:
Books/Journals:
The ABC Clinical Guide to Herbs (free with membership to American
Botanical Society)
A-Z Guide to Drug-Herb-Vitamin Interactions
Nutritional Healing (Balch)- great overall reference
Women’s Encyclopedia of Natural Medicine (Hudson)
Rosemary Gladstar's Medicinal Herbs: A Beginner's Guide: 33
Healing Herbs to Know, Grow, and Use
Complimentary Therapies in Medicine (journal)
German Commision E Monographs (also available from American
Botanical Society)
2012 USP Dietary Supplements Compendium (DSC)
Manufacturers of Products:
Review if available or ask about Quality Control policies and procedures.
Companies that care about quality should not be afraid to share
information with you. Many of them also conduct their own research.
ExamplesEmerson Ecologics
Pure Encapsulations
Metagenics
NOW
Gaia