Understanding Phytotherapy & Herbal Supplementation

Phytotherapy (Herbs)

• The science of using plant-derived substances to treat and prevent illness, including leaves, flowers, or roots
• Herbs and botanicals are terms often used to describe these substances

Herbal Supplementation Facts

• Used for thousands of years
• Available without a prescription and may carry function claims
• Function claims describe the role of a nutrient or dietary ingredient intended to affect the normal structure or function of the human body
• No data suggests herbs are more beneficial than conventional drugs for treating illnesses
• "Natural" products are not always safe and can have drug-like effects
• Herbal supplements are not required to undergo the same strict testing as OTC and prescribed medicine
• Not regulated as closely by the FDA
• The active ingredients and the mode of action have been defined for many botanical products
• Others are still being researched
• Botanical medicine can be investigated with the same scientific tools as prescription drugs (double-blind, placebo-controlled clinical trials)

Botanical Formulations

• Available in many forms including: bulk herbs, beverages, extracts, and pills
• Topical application of botanicals and/or nutrients in the form of creams or essential oils are not classified as dietary supplements under the current regulations

Regulation of Herbs and Botanicals

• Herbs and botanicals are sold as dietary supplements and regulated differently than pharmaceutical drugs.
• The FDA does not test herbs for safety or efficacy
• The Dietary Supplement Health and Education Act of 1994 (DSHEA) clarifies marketing regulations for botanicals and reclassifies them as dietary supplements, distinct from food or drugs
• No claims about the prevention or cure of specific conditions can be made, for example, a product manufacturer cannot claim that a dietary supplement “prevents heart disease”; however, it can be said that a product “helps to increase blood flow to the heart.”

Disclaimers and Global Regulations

• All products must display the following disclaimer: “This statement has not been evaluated by the food and drug administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”
• In the USA it is the consumers’ responsibility to educate themselves
• In the European market, especially in Germany, botanicals are considered drugs and are prescribed by physicians and dispensed by pharmacists

Reported Problems Since DSHEA

• Misrepresentation of product contents
• Different recommended dosages among products
• Inadequate information about how a company’s herbs are grown and processed
• Poor standards of quality product safety, or activity of ingredients
• Governments and industries are working to develop high-quality manufacturing guidelines Good Manufacturing Practices (GMP) for all dietary supplements, including botanical products.

Classification of Herbs

• A helpful safety rating classification has been developed by the American Herbal Products Association

Most Commonly Used Herbs

• Echinacea
• Garlic
• Ginger
• Ginkgo
• Ginseng
• Hawthorn
• Milk Thistle
• Saw Palmetto
• St. John's Wort
• Valerian

Echinacea

• Source: Purple flower
• Indication: prevent or moderate the symptoms of colds and flu and chronic infection of the upper respiratory tract
• Action: Immune-stimulating activity including high and low molecular weight flavonoids and caffeic acid derivatives (not single compound)
• Cautions: avoid if immunosuppressive drugs taken and do not use frequently
• Class 1 botanical
• Thought to be a stimulant to the immune system, making it a low risk and effective alternative to some cold medicines
• Studies that have proven this to be true, tested Echinacea concentrate, not Echinacea sold in stores
• Echinacea sold in stores may not be potent enough, and it is possible that additional substances are in Echinacea supplements
• It is important to find out about the product manufacturer's reputation.
• Contains a complex mix of active substances, (antimicrobial, human immune system)
• Contains phenols, which control the activity of a range of enzymes and cell receptors, and protect the plant from infections and ultraviolet (UV) radiation damage and have antioxidant properties
• Contains alkyl-amides which have an effect on the immune system

Garlic

• Source: Garlic plant, belongs to the genus Allium and is closely related to the onion
• Indication: hyperlipidemia, hypertension, useful against bacterial, fungal, and viral infections
• Action: Chewing or crushing activates sulfur-containing compounds, moderate reductions in blood pressure, modest reductions in blood cholesterol levels, inhibition of blood clot formation, and relaxing the smooth muscle of blood vessels
• Cautions: more than five cloves produce heartburn, mild allergic reactions, and GI symptoms, interaction when using aspirin or other anticoagulant drugs such as warfarin, antiplatelet aggregation drugs, omega-3 fatty acid
• Class 2c botanical
• Alliin is a sulfoxide that is a natural constituent of fresh garlic
• It is a derivative of the amino acid cysteine
• When fresh garlic is chopped or crushed, the enzyme alliinase converts alliin into allicin, which is responsible for the aroma of fresh garlic
• Has antioxidant and hydroxyl radical-scavenging properties, it is presumed owing to the alliin contained within
• Alliin has also been found to affect immune responses in blood
• Alliin was the first natural product found to have both carbon- and sulfur-centered stereochemistry
• Short-term heating reduces the anti-inflammatory effects of fresh raw garlic extracts

Ginger

• Source: Ginger plant, family (Zingiberaceae)
• Part used: the tuberous rhizome (rootstock) is used, the adherent thread like roots are cut off, the rhizome should be cleaned and freed from the outer layer of cork, then dried in the sun
• Contains an aromatic-smelling essential oil and non-volatile pungent substances (gingerols and shogaol)
• Class 1 botanical
• Cautions: increase the risk of bleeding when combined with blood thinning agents and may interfere with blood pressure and blood sugar regulating medication
• Benefits: the phenolic compounds in ginger are known to help relieve gastrointestinal (GI) irritation, stimulate saliva and bile production, and suppress gastric contractions as food and fluids move through the GI tract
• Has beneficial effects on the enzymes trypsin and pancreatic lipase, and to increase motility through the digestive tract; this suggests ginger could help prevent colon cancer and constipation
• Chewing raw ginger or drinking ginger tea is a common home remedy for nausea during cancer treatment
• Taking ginger for motion sickness seems to reduce feelings of nausea, but it does not appear to prevent vomiting
• Ginger is safe to use during pregnancy, to relieve nausea and is available in the form of ginger lozenges or candies
• Pain reduction: reduced muscle pain, to reduce the symptoms of dysmenorrhea
• Inflammation: been found to be "modestly efficacious and reasonably safe" for treating inflammation associated with osteoarthritis
• Improves cardiovascular health

Ginkgo

• Source: Ginkgo tree - Ginkgo biloba L.
• Part used: The dried leaves are used
• Ginkgo leaves contain flavonoids, diterpenlactone (ginkgolides) and bilobalide ginkgolic
• Indication: treat age-related decline in mental (short-term memory loss, poor concentration) and Alzheimer’s type may also be improved by the use of the extract
• Action: antioxidant activity, protects cells against free radical damage, particularly damage to the lipid layer of the cell membrane, increasing blood flow and enhancing circulation
• Cautions: should not be combined with blood thinning medications (aspirin) and should not be combined with blood thinning supplementations ( omega-3 fatty acids, ginger, garlic) and interferes with diabetes medication
• During pregnancy and breast-feeding ginkgo should not be used without consulting the doctor, because as yet there is no experience on its harmlessness

Ginseng

• Source: Slow growing plant that takes at least 6 years
• Indication: helps the body cope with stress, improves energy levels, increases circulation, and treats fatigue
• Action: effect on blood pressure; mild action on the central nervous system
• Cautions: do not take with caffeine; may cause overstimulation and gastrointestinal distress; affects blood sugar or blood pressure and interferes with blood coagulation or affects the heart rate
• Class 2d botanical

Hawthorn

• Source: Hawthorn tree (leaves, berries, and blossoms).
• Indication: Improves blood flow in circulatory disorders such as heart failure and improves heartbeat
• Action: dilates the coronary vessels to lower blood pressure, improves the metabolic processes of the heart, and increases nerve conductivity and heart muscle contractibility
• Cautions: side effects are rare; however, a person with heart disease should consult a health care provider, no adverse reactions with medication, caution when combining with cardio active drugs or with blood pressure lowering medication or supplementation
• Class 1 botanical

Milk Thistle

• Source: Tall plant with prickly leaves and milky sap
• Indication: To treat mild to moderate liver disease, hypolipidemic, and lower fat deposit in the liver
• Action: protects hepatocytes from toxins and increases the ability of liver cells to regenerate by stimulating protein synthesis
• Cautions: mild laxative effect in the first few days and may reduce the activity of drug-metabolizing enzymes in the intestine and liver
• Class 1 botanical

Turmeric

• Botanical name: Curcuma longa L.
• Part used: The dried rhizomes
• Ingredients: The rhizomes of Curcuma rhizomes contain spicy curcuminoids (Dicinnamoyl methane derivate), curcumin (yellow pigments), essential oils
• Indication: Liver disorder and inflammatory condition
• Action: Anti-inflammatory, free radical scavenger activity, cyclooxygenase inhibition
• Cautions: if there is bile occlusion or inflammation of a bile, gall stones or gall bladder and liver disease, Curcuma may not be taken and there are still no studies on the safety during pregnancy and breastfeeding as well as for use in children and adolescents under 18 years old

Willow Bark

• Name: Willow - Salix L.
• Part used: The dried bark of young branches is used in the second or third year
• Ingredients: Willow bark contains salicylic acid derivatives (salicylates), caffeic acid derivatives, and flavonoids
• Indication: chronic forms of muscle pain, rheumatoid fever, and headache
• Action: Due to the content of phenolic glycoside (Salicin)
• Cautions: people with hypersensitivity to salicylates (e.g. aspirin) and other anti-inflammatory drugs as well as those who are prone to allergies should not take willow bark, patients with asthma, gastrointestinal ulcers and renal or liver function should only use it after consulting a doctor, it is not recommended to use Willow bark during pregnancy and breast-feeding because salicylates penetrate the placenta and enter the breast milk, and a doctor should be consulted for use in children and adolescents under 18 years old

Saw Palmetto

• Source: Saw palmetto palm tree
• Indication: reduces the incidence of benign prostatic hyperplasia
• Action: the extract inhibit 5-a-reductase (the enzyme which catalyzes the conversion of testosterone to dihydrotestosterone )
• Cautions: contains phytoestrogens that mimic the effects of the animal hormone estrogen and potentially could interfere with estrogen therapy, progesterone therapy, and oral contraceptives
• Class 1 botanical

St. John’s Wort

• Source: Small yellow flowers.
• Indication: Mild to moderate depression.
• Ingredients: hyperforin and hypericin and pseudo hypericin
• Action: inhabitation of the reuptake of the neurotransmitters serotonin, norepinephrine
• Cautions: oral contraceptives and LDL cholesterol (rosuvastatin)
• Class 2d botanical
• Has been proven to treat mild to moderate depression by alleviating some symptoms, including lack of activity, tiredness, fatigue, and disturbed sleep
• Has been associated with negative side effects, like gastrointestinal irritations, allergic reactions, and restlessness, another problem is it has not been tested for it’s long term safety
• Interaction with oral contraceptives: effects on the pharmacokinetics of norethindrone and ethinyl estradiol, ovarian activity and breakthrough bleeding
• Women using OCs should be cautioned that it might interfere with contraceptive effectiveness
• Reduces efficacy of rosuvastatin to the list of drugs whose efficacy can be diminished by St. John’s wort

Valerian

• Source: White and red flowers.
• Indication: Sleep aid, anxiety, and insomnia.
• Action: Binds to receptor sites to depress central nervous system activity.
• Cautions: No side effect if used at the recommendations level.
• Class 1 botanical

Discontinuation of Use

• Health care professionals should also be aware that people typically do not inform their health care practitioners of their use of botanicals or other dietary supplements
• It is particularly important that dietary supplement use be discussed before surgery
• Table below lists recommended discontinuation time before surgery for eight common botanicals chart lists discontinuation time before surgery for 8 common botanicals

FDA Warnings

• The FDA warns against the following herbs which are considered toxic, and given their side effects, should be avoided:
  • Chapparal: irreversible liver damage
  • Comfrey: liver toxicity, carcinogenic effects, and damage to fetus if used during pregnancy
  • Ephedra: hypertension, myocardial infarction (MI), seizure, stroke, psychosis, 155 deaths and over 16,000 side effects
  • Germander: liver damage and death
  • Kava: liver damage, especially risky for those with liver problems
  • Lobelia: breathing problems, rapid heartbeat, low blood pressure, coma, or death
  • Willow bark: Reye’s syndrome in children, and allergic reaction in adults
  • Wormwood: seizures, numbness of legs and arms, delirium, and kidney failure
  • Yohimbe: hypotension (low blood pressure), heart conduction disorders, kidney disorders, nervous system disorders, death