Musculoskeletal Herbs Lecture 3 PDF

Phytotherapy (PG-906 clinical, PG-907 General) Herbal therapy for musculoskeletal disorders. root Pharm D ninth semester students By: Dr/Shimaa Abdelgawad Lecturer of Pharmacognosy,...

Phytotherapy (PG-906 clinical, PG-907 General) Herbal therapy for musculoskeletal disorders. root Pharm D ninth semester students By: Dr/Shimaa Abdelgawad Lecturer of Pharmacognosy, Faculty of Pharmacy, Fayoum University Definition of musculoskeletal system: Musculoskeletal health refers to the performance of the locomotor system, comprising intact muscles, bones, joints and adjacent connective tissues. Symptoms of musculoskeletal disorders: Musculoskeletal conditions are typically characterized by: ✓ Pain (often persistent). ✓ Limitations in mobility and dexterity. Reducing people’s ability to work and participate in society. Pain experienced in musculoskeletal structures is the most common form of non-cancer pain. Types of musculoskeletal disorders: Joints such as osteoarthritis, rheumatoid arthritis, psoriatic arthritis, gout, spondylarthritis. Bones such as osteoporosis, osteopenia and associated fragility fractures, traumatic fractures. Muscles such as sarcopenia Multiple body areas - Regional (e.g. back and neck pain). - Widespread (e.g. fibromyalgia) - Inflammatory diseases such as connective tissue diseases, vasculitis, systemic lupus erythematosus, or amputation as a result of disease or trauma. Treatment of musculoskeletal disorders: Treatment plan will depend on the underlying cause of your musculoskeletal pain. Common treatments include: Acupuncture. Therapeutic massage Treatment of musculoskeletal disorders: Treatment plan will depend on the underlying cause of your musculoskeletal pain. Common treatments include: Chiropractic adjustment. Occupational therapy. Treatment of musculoskeletal disorders: Treatment plan will depend on the underlying cause of your musculoskeletal pain. Common treatments include: Splints Steroid injections Treatment of musculoskeletal disorders: Treatment plan will depend on the underlying cause of your musculoskeletal pain. Common treatments include: Pain relievers Herbal medicines Arthritis Definition of Arthritis Arthritis is a joint(s) inflammation Types of Arthritis Osteoarthritis Rheumatoid arthritis Gouty arthritis 1- Osteoarthritis Degenerative arthritis occurs when the protective cartilage on the ends of bones wears down over a period of time. It occurs most often in knees, hips, lower back and neck, small joints of fingers and the bases of the thumb and big toe. 1- Osteoarthritis Symptoms: ✓Severe sharp and burning pain increases with movement. ✓Light pressure applied on joints lead to pain ✓Stiffness with first motion in the morning, also occurs after a period of rest. 2- Rheumatoid arthritis Chronic inflammatory disorder that can affect joints as well as other areas of the body. It occurs when immunity system mistakenly attacks body tissues. Affects commonly joints of the hands, feet, wrists, elbows, knees and ankles. 3- Gouty arthritis Causes: inflammatory reaction that arises in response to the deposition of monosodium urate crystals into the joints of patients with hyperuricemia. Uric acid is a waste product made by the body when it digests certain foods. Affecting mainly fingers, knee, ankle and big toes joints.  Drug Management of Arthritis Pharmacologic interventions: 1. Analgesics: Begin treatment with acetaminophen for mild or moderate osteoarthritic pain without apparent inflammation. If the clinical response to acetaminophen is not satisfactory or if the clinical presentation of osteoarthritis is inflammatory, consider using a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen, ibuprofen, and diclofenac or Celecoxib (nonselective NSAIDs). 2. Hydroxychloroquine, which is approved for use in rheumatoid arthritis.  Drug Management of Arthritis Pharmacologic interventions: 3. Duloxetine: The selective serotonin-norepinephrine reuptake inhibitor duloxetine. 4. Corticosteroids: specially in rheumatoid arthritis. 5. Platelet-rich plasma 6. Sodium hyaluronate: Intra-articular injection of sodium hyaluronate, also referred to as visco-supplementation, has been shown to be safe and possibly effective for symptomatic relief of knee osteoarthritis. 7. Glucosamine and chondroitin sulfate 8. Herbal supplements such as: avocado, feverfew, devil’s claw, olibanum, white willow, arnica, turmeric, ginger, butterbur, colchicine, gamma- linolenic acid (GLA). Natural herbal remedies for arthritis: 1. Avocado 2. Feverfew 3. Devil’s claw ❑ Botanical origin 4. Olibanum ❑ Active constituent 5. White willow ❑ Mechanism of action 6. Arnica ❑ Dosage 7. Turmeric ❑ Side effects 8. Ginger ❑ Contraindications 9. Butterbur ❑ Drug interactions 10.Colchicine 11. Gamma- linolenic acid (GLA) 1-Avocado ‫أفوكادو‬ Fruits  1- Avocado Botanical origin Fruits of Persea americana Family: Lauraceae. Active constituents Phytosterols (β-sitosterol, campesterol and stigmasterol).  1- Avocado Mechanism of action Anticatabolic properties: prevent cartilage degradation by inhibiting the release and activity of matrix metalloproteinases inhibits these catabolic enzymes. Anabolic properties: promote cartilage repair by stimulating collagen and aggrecan synthesis. Anti-inflammatory: inhibits production of cytokines such as IL-1, IL- 6, IL-8, TNF, prostaglandin E2. Chondroprotective: by correcting growth factor abnormalities, increasing TGF-β, and decreasing vascular endothelial growth factor (VEGF) in synovial fluid.  1- Avocado Dosage: Adverse reaction: Fruits: Safe when the fruit 0.5-2 fruits daily. is eaten in food Extract or oil: 300 mg daily. amounts or in Indications: medicinal doses for For osteoarthritis: 300 mg up to 2 years. daily of an extract made from Avocado has a lot the oils of avocado and of calories because soybeans "unsaponifiables." of its fat content.  1- Avocado Contraindications: Drug interactions: Pregnancy and breast-feeding. Warfarin (Coumadin): Avocado decreases the Latex allergy: People who are effectiveness of warfarin sensitive to latex can have an → increase the risk of allergic reaction to avocado. clotting. 2-Devil’s claw ‫مخلب الشيطان‬ Root tuber  2-Devil’s claw Botanical origin Roots of Harpagophytum procumbens Family: Pedaliaceae. Active constituents Iridoid glycosides: harpagoside and harpagide.  2-Devil’s claw Mechanism of action Anti-inflammatory: Inhibits production of: - Cytokines such as IL-6, TNF. - Lipoxygenase enzyme. - Leukotriene. Analgesic: highly selective COX-2 inhibitors.  2-Devil’s claw Dosage: Root tuber: up to 9 g. Extract: 1 to 3 g Adverse reaction: Rare, generally Harpagoside: 50 to 100 mg. consisting of Indications: headache, tinnitus, or devil's claw for 8 to 12 weeks anorexia. A case of can reduce pain and improve devil’s claw-induced physical functioning in hypertension has people with osteoarthritis. been documented.  2-Devil’s claw Contraindications: Drug interactions: Gastric or duodenal ulcers as ✓Should not be used with it increases gastric secretions. antiarrhythmic, Pregnancy/Lactation: chronotropic, or inotropic oxytocic. medicines.  ‫‪3- Feverfew‬‬ ‫االقحوان أو بابونج بري‬ ‫‪Leaves‬‬  3- Feverfew Botanical origin Leaves of Tanacetum parthenium Family: Asteraceae. Active constituents Sesquiterpene lactones: mainly Parthenolide  3- Feverfew Mechanism of action Analgesic & anti-inflammatory effects: Parthenolide inhibit enzymes of: ❑ Phospholipase. ❑ Lipoxygenase. ❑ Cyclooxygenase. → inhibit the biosynthesis of prostaglandins, leukotrienes and Thromboxanes.  3- Feverfew Dosage: Adverse reaction: Extract: 50 to 150 "post-feverfew syndrome." mg/day. allergic contact dermatitis. Swelling of the lips, tongue, and oral mucosa, in addition Indications: to mouth ulceration. Relief pain in GI effects, such as abdominal rheumatoid arthritis. pain, nausea, vomiting, Analgesic in diarrhea, indigestion, and migraine. flatulence, may also occur.  3- Feverfew Contraindications: Drug interactions: Allergy to other members of the Anticoagulant/antiplatelets Asteraceae family, such as aster, drugs. chamomile, chrysanthemum, Nonsteroidal anti- ragweed, sunflower. inflammatory agents, Blood clotting disorders and before salicylates, or thrombolytic surgery due to its antiplatelet effect. agents. Pregnancy/Lactation  4- Olibanum or Boswellia ‫اللبان الدكار‬ Dried gum resin  4- Olibanum Botanical origin Dried gum resin Boswellia serrata Family: Burseraceae. Active constituents Boswellic acid (triterpene). Essential oil.  4- Olibanum Mechanism of action Inhibit 5-lipoxygenase → inhibit biosynthesis of leukotrienes. Anti-inflammatory: reduce production of cytokines such as interleukin-6 (IL-6), nitric oxide (NO) metabolites, malondialdehyde (MDA).  4- Olibanum Dosage: Extract: 300-400 mg (containing 60% boswellic acids) 3 times daily. Essential oil: Dilute every 1 drop of essential oil with 1 ounce of a carrier oil Adverse before applying to the skin. reaction: Indications: Diarrhea. Abdominal pain. Anti inflammatory, improve symptoms Nausea. in patients with osteoarthritis, and rheumatoid arthritis.  4- Olibanum Drug interactions: Contraindications: Medications metabolized by Substrates of cytochrome Hypersensitivity to P450 (CYP-450) enzymes. olibanum. Warfarin: → increase risk Pregnancy and lactation. of bleeding due to ↓ metabolism of warfarin. 5- White willow ‫الصفصاف األبيض‬ Bark  5- White willow Botanical origin Bark of Salix alba Family: Salicaceae Active constituents Salicin.  5- White willow Mechanism of action Anti-inflammatory/analgesic: Inhibits the activity of cyclooxygenase (COX-1) and thereby inhibiting the synthesis of prostaglandins.  5- White willow Dosage: A daily dose of 120 - 240 mg of salicin. Indications: For pain and mild rheumatic Adverse reaction: conditions. Stomach upsets Increased blood pressure Allergic reactions.  5- White willow Contraindications: Impaired thrombocyte function Drug interactions: (bleeding disorders). Gastrointestinal and liver ❑ Anticoagulants. problems. ❑ Acetazolamide. Diabetes. ❑ Antihypertensives. Gout, kidney disorders. ❑ Anti-inflammatory Peptic ulcer. drugs. Pregnancy and lactation. 6-Arnica Flower  6-Arnica Botanical origin Flowers of Arnica montana Family: Asteraceae. Active constituents Sesquiterpene lactones: helenalin, helenalin acetate and 11 α, 13 dihydro-helenalin Helenalin  6-Arnica Mechanism of action Anti-inflammatory: suppress the activity of prostaglandin synthetase. Reduce production of inflammatory cytokines such as TNF-α  6-Arnica Dosage: Adverse reaction: Arnica products are 5C-30C Dermatitis: usually dilutions. The "C" means that the active following prolonged, ingredient was initially diluted by 100- external application of fold. The "5" or "30" means that the tincture. resulting dilution is then diluted again by 100-fold, 5 or 30 more times. Ingestion: may result in gastroenteritis, Indications: muscle paralysis Used as a topical gel for treatment of (Voluntary and muscular aches, joint pain, and arthritis cardiac), heart (toxic orally). palpitations, shortness of breath and death.  6-Arnica Contraindications: Pregnancy and lactation. Arnica should never be applied to Drug interactions: broken skin. Allergy or hypersensitivity to arnica. Anticoagulants. long period usage of arnica can cause skin irritation, eczema, peeling of the skin, or blisters. 7-Turmeric ‫الكركم‬ Roots  7-Turmeric Botanical origin Rhizome of Curcuma longa Family: Zingiberaceae. Active constituents 1- Curcuminoids: The chief constituent of the coloring matter is curcumin I (60%). 2- Volatile oil: zingiberene, curcumene α and β turmerone. Curcumin I  7-Turmeric Mechanism of action Anti-inflammatory Inhibition of the trypsin and hyaluronidase enzymes. Antioxidant scavenge oxygen radicals which have been implicated in the inflammation process.  7-Turmeric Dosage: Dry powder: up to 1.5 grams daily. Standardized curcuminoid: 200 mg/day to 6 g/day Adverse (treatment durations of up to 8 reaction: months). Stomach upset Indications: Nausea Usually extracts or Improve morning stiffness, curcuminoids mixed with Dizziness walking time and joint swelling. piperine to increases its Diarrhea. bioavailability.  7-Turmeric Contraindications: Drug interactions: Gallstones and bile duct Anticoagulant. obstruction Antidiabetic drug. Bleeding problems Turmeric may decrease the Hormone-sensitive condition absorption and effects of such as breast cancer some drugs such as: Infertility Talinolol, anticancer drugs Pregnancy and breast feeding. (eg. Tamoxifen). 8- Ginger ‫الزنجبيل‬ rhizome  8- Ginger Botanical origin Rhizomes of Zingiber officinale family: Zingiberaceae. Active constituents Oleoresin: (volatile oil+resin) Including Gingerols (6-gingerol). Shagols.  8- Ginger Mechanism of action Ginger inhibits the activities of cyclooxygenase and lipoxygenase, decrease in the formation of prostaglandins and leukotrienes. Inhibits thromboxane synthase (thromboxane is vasoconstrictor and inducer of platelet aggregation).  8- Ginger Dosage: Dried plant: 0.5 - 3 g daily up to 12 weeks. Dried extract: 250-500 mg 3 times Adverse daily. reaction: Indications: Heartburn. Diarrhea. Anti-inflammatory agent: for treatment of rheumatic and muscular Burping. disorders. 6-gingerol decrease Stomach inflammation, swelling, and pain. discomfort  8- Ginger Drug interactions: Contraindications: Anticoagulant: bleeding. Bleeding disorders. Antidiabetics: hypoglycemia. Gallstones. Anti-hypertensives: hypotension. Pregnancy: ginger Cyclosporine, Metronidazole shouldn’t exceed 2g (Flagyl): Ginger increases the absorption and side effects of these drugs. 9- Butterbur (petasites) ‫قبعية‬ Leaves and roots  9- Butterbur Botanical origin Leaves and roots of Petasites hybridus. Family: Asteraceae Active constituents 1- sesquiterpenes (petasin and isopetasin). 2-Volatile oil. 3-pyrrolizidine alkaloids (senecionine and integerrimine)  9- Butterbur Mechanism of action Petasin → inhibit lipoxygenase enzyme → inhibit leukotriene synthesis.  9- Butterbur Dosage: 50-150 mg daily. Adverse reaction: Indications: Belching, Analgesic relief rheumatic pain. headache, itchy eyes, diarrhea, upset stomach, and drowsiness. Liver and lungs damage or cancers.  9- Butterbur Contraindications: Drug interactions: Pregnancy and lactation. Allergy to ragweed and related ✓Medications plants. metabolized by Liver diseases. cytochrome P450 (CYP- Children 450) enzymes. 10- Colchicine Alkaloid  10- Colchicine Botanical origin Alkaloid from seeds and corms of Colchicum autumnale Family: Liliaceae. Active constituents Proto-alkaloid or biological amine contain tropolone nucleus  10- Colchicine ❑ The affected synovium of patients with acute gouty arthritis is infiltrated with neutrophils, mononuclear phagocytes, and lymphocytes, resulting in marked swelling of the tissues and vascular injury. ❑ Microtubule polymerization can control numerous cellular functions, including secretion of cytokines and chemokines Mechanism of action Colchicine → anti-Inflammatory effect → : ✓ Inhibits neutrophil motility and activity. ✓ Inhibits microtubule-based inflammatory cell chemotaxis. ✓ Inhibits generation of leukotrienes and cytokines, and phagocytosis.  10- Colchicine Dosage: 0.6-1.2 mg twice daily. Indications: Adverse reaction: Prophylaxis and GI effects (eg, treatment of gout diarrhea, nausea, flares in adults. cramping, abdominal pain, vomiting). Fatigue.  10- Colchicine Drug interactions: ✓ CYP3A4 and P-gp substrate and Contraindications: ✓ Inhibitors. Patients with both renal and hepatic ✓ HMG-CoA reductase impairment. inhibitors. ✓ Digoxin: increase the risk of rhabdomyolysis. ✓ Oral contraceptives.  11- Gamma linolenic acid (GLA)  11- Gamma linolenic acid (GLA) Botanical origin Borage oil. ‫زيت لسان الثور‬ Blackcurrant oil. ‫زيت الكشمش األسود‬ Evening primrose oil. ‫زيت زهرة الربيع‬ ‫المسائية‬ Active constituents GLA is all-cis-6,9,12 octadecatrienoic acid  11- Gamma linolenic acid (GLA) Mechanism of action Reduce inflammation via competitive inhibition of leukotrienes and 2-series prostaglandins. Restores balance to the system of inflammatory cytokines. Like PGE3, PGE1 is an antiinflammatory that inhibits TNF-α, IL-1β, and IL-6.  11- Gamma linolenic acid (GLA) Dosage: 320-480 mg by mouth daily. Indications: Reduce pain, swelling, and morning stiffness in rheumatoid Adverse reaction: arthritis patients. Soft stools, diarrhea, belching, and gas.  11- Gamma linolenic acid (GLA) Contraindications: Pregnancy and breast-feeding. Drug interactions: Bleeding disorders. ✓Anticoagulants Surgery. Thank you