Pharmacy: Evidence-Based Approach to NHPs

Evidence-based Approach to NHPs

• The role of the pharmacist is to foster open communication and create a non-threatening environment where patients can disclose CAM/NHP use and ask questions.
• Pharmacists should include in their medication review: "What else are you doing/taking to take care of your health?"

Role of the Pharmacist

• Help patients make informed choices about NHPs by providing evidence-based NHP information.
• Standards of evidence for NHPs are the same as for conventional treatments, but few NHPs have enough evidence to be routinely recommended.

Echinacea (Echinacea purpurea; Echinacea angustifolia; Echinacea pallida)

• Pharmacology: Echinacea appears to target both nonspecific and specific immune function, with 4 groups of compounds contributing to immunomodulatory activity: alkamides, glycoproteins, polysaccharides, and caffeic acid derivatives.
• Alkamides have anti-inflammatory properties and are found in roots of E. angustifolia and the roots + aerial parts of E. purpurea, while glycoproteins, polysaccharides, and caffeic acid derivatives have been shown to activate macrophages and NK cells, and have anti-viral activity.

Efficacy for the Common Cold

• 24 RCTs including 33 comparisons of echinacea with a control group (n= 4631) have been conducted to study the treatment and/or prevention of the common cold.
• Cochrane review (2014): Echinacea products have not been shown to provide benefits for treating colds, although there is possible weak benefit from some Echinacea products.

Treatment of Colds

• Cochrane review (2014): Only one of the seven treatment trials reporting data on the duration of colds showed a significant effect of Echinacea over placebo.

Prevention of Colds

• Cochrane review (2014): None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference.
• However, a post hoc pooling of results suggests a relative risk reduction of 10% to 20%.

Echinacea: Cautions

• Generally well-tolerated with few AEs reported, but theoretical caution is needed in cases of chronic immune dysfunction and autoimmune conditions.
• Adverse reactions: uncommon, but include allergic reactions which vary from mild to anaphylactic.
• Drug Interactions: theoretically may interfere with immunosuppressant therapy (e.g., cyclosporin, prednisone); reports of changes in CYP enzymes (likely not clinically significant).

Echinacea: Dose

• Depends on the dosage form and standardization, with a wide range of doses tested in studies, including:
  • Capsules (of powdered herb): 500-1000mg three times daily, for five to seven days.
  • Expressed juice: 6-9mL daily in divided doses, for five to seven days.
  • Tincture (1:5): 0.75 to 1.5mL, gargled then swallowed, 2-5 times per day, for five to seven days.
  • Tea: 2 tsp. (4g of Echinacea) of coarsely powdered herb simmered in 1 cup of boiling water for 10 minutes, daily for 5-7 days.

Evidence-based Approach to NHPs

• The role of the pharmacist is to foster open communication and create a non-threatening environment where patients can disclose CAM/NHP use and ask questions.
• Pharmacists should include in their medication review: "What else are you doing/taking to take care of your health?"

Role of the Pharmacist

• Help patients make informed choices about NHPs by providing evidence-based NHP information.
• Standards of evidence for NHPs are the same as for conventional treatments, but few NHPs have enough evidence to be routinely recommended.

Echinacea (Echinacea purpurea; Echinacea angustifolia; Echinacea pallida)

• Pharmacology: Echinacea appears to target both nonspecific and specific immune function, with 4 groups of compounds contributing to immunomodulatory activity: alkamides, glycoproteins, polysaccharides, and caffeic acid derivatives.
• Alkamides have anti-inflammatory properties and are found in roots of E. angustifolia and the roots + aerial parts of E. purpurea, while glycoproteins, polysaccharides, and caffeic acid derivatives have been shown to activate macrophages and NK cells, and have anti-viral activity.

Efficacy for the Common Cold

• 24 RCTs including 33 comparisons of echinacea with a control group (n= 4631) have been conducted to study the treatment and/or prevention of the common cold.
• Cochrane review (2014): Echinacea products have not been shown to provide benefits for treating colds, although there is possible weak benefit from some Echinacea products.

Treatment of Colds

• Cochrane review (2014): Only one of the seven treatment trials reporting data on the duration of colds showed a significant effect of Echinacea over placebo.

Prevention of Colds

• Cochrane review (2014): None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference.
• However, a post hoc pooling of results suggests a relative risk reduction of 10% to 20%.

Echinacea: Cautions

• Generally well-tolerated with few AEs reported, but theoretical caution is needed in cases of chronic immune dysfunction and autoimmune conditions.
• Adverse reactions: uncommon, but include allergic reactions which vary from mild to anaphylactic.
• Drug Interactions: theoretically may interfere with immunosuppressant therapy (e.g., cyclosporin, prednisone); reports of changes in CYP enzymes (likely not clinically significant).

Echinacea: Dose

• Depends on the dosage form and standardization, with a wide range of doses tested in studies, including:
  • Capsules (of powdered herb): 500-1000mg three times daily, for five to seven days.
  • Expressed juice: 6-9mL daily in divided doses, for five to seven days.
  • Tincture (1:5): 0.75 to 1.5mL, gargled then swallowed, 2-5 times per day, for five to seven days.
  • Tea: 2 tsp. (4g of Echinacea) of coarsely powdered herb simmered in 1 cup of boiling water for 10 minutes, daily for 5-7 days.

Evidence-based Approach to NHPs

• The role of the pharmacist is to foster open communication and create a non-threatening environment where patients can disclose CAM/NHP use and ask questions.
• Pharmacists should include in their medication review: "What else are you doing/taking to take care of your health?"

Role of the Pharmacist

• Help patients make informed choices about NHPs by providing evidence-based NHP information.
• Standards of evidence for NHPs are the same as for conventional treatments, but few NHPs have enough evidence to be routinely recommended.

Echinacea (Echinacea purpurea; Echinacea angustifolia; Echinacea pallida)

• Pharmacology: Echinacea appears to target both nonspecific and specific immune function, with 4 groups of compounds contributing to immunomodulatory activity: alkamides, glycoproteins, polysaccharides, and caffeic acid derivatives.
• Alkamides have anti-inflammatory properties and are found in roots of E. angustifolia and the roots + aerial parts of E. purpurea, while glycoproteins, polysaccharides, and caffeic acid derivatives have been shown to activate macrophages and NK cells, and have anti-viral activity.

Efficacy for the Common Cold

• 24 RCTs including 33 comparisons of echinacea with a control group (n= 4631) have been conducted to study the treatment and/or prevention of the common cold.
• Cochrane review (2014): Echinacea products have not been shown to provide benefits for treating colds, although there is possible weak benefit from some Echinacea products.

Treatment of Colds

• Cochrane review (2014): Only one of the seven treatment trials reporting data on the duration of colds showed a significant effect of Echinacea over placebo.

Prevention of Colds

• Cochrane review (2014): None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference.
• However, a post hoc pooling of results suggests a relative risk reduction of 10% to 20%.

Echinacea: Cautions

• Generally well-tolerated with few AEs reported, but theoretical caution is needed in cases of chronic immune dysfunction and autoimmune conditions.
• Adverse reactions: uncommon, but include allergic reactions which vary from mild to anaphylactic.
• Drug Interactions: theoretically may interfere with immunosuppressant therapy (e.g., cyclosporin, prednisone); reports of changes in CYP enzymes (likely not clinically significant).

Echinacea: Dose

• Depends on the dosage form and standardization, with a wide range of doses tested in studies, including:
  • Capsules (of powdered herb): 500-1000mg three times daily, for five to seven days.
  • Expressed juice: 6-9mL daily in divided doses, for five to seven days.
  • Tincture (1:5): 0.75 to 1.5mL, gargled then swallowed, 2-5 times per day, for five to seven days.
  • Tea: 2 tsp. (4g of Echinacea) of coarsely powdered herb simmered in 1 cup of boiling water for 10 minutes, daily for 5-7 days.