By Teresa Bruce, Pharmacist, St. Joseph’s Care Group Is “Natural” Better? The expanded use of herbal medications/nutritional supplements by an increasing number of consumers in North America raises questions about their appropriate therapeutic uses. There is a general belief held by most consumers of alternative therapies that these products are safer than pharmaceuticals because they come from "natural sources". Although many physicians and pharmacists have begun to recognize the relative safety and efficacy of at least some of the more well researched herbs on the market, many have raised concerns about contraindications, potential adverse reactions and possible herb-drug interactions. Safety becomes an issue given limited scientific information and the fact that most companies do not standardize their products or perform extensive testing for quality control. Standardization alone, however, will not ensure safe products.
This article is intended to provide some information about the kinds of herbal supplements/remedies that people assume will help with various mood-related and cognitive functions such as improved concentration, treatment of anxiety, of depression, of insomnia, etc. This article will also try to list some of the precautions that people should exercise in taking these alternative therapies. Weight Loss Products promoted as weight loss agents to increase metabolism often contain stimulants like ephedrine. Other names of ephedrine in herbal supplements include "Chinese ephedra, ma huang extract, or Sida cordfolia. These stimulants can increase blood pressure and heart rate. They can also increase anxiety and lead to seizures. Health Canada is requesting a recall from the market of certain products containing ephedra/ephedrine (January 2002). Sexual Performance Health Canada is also warning consumers not to use Hau Fo tablets, an unapproved herbal product that claims to enhance sexual function. Health Canada analyzed samples of Hau Fo tablets and found that they contained sildenafil. Sildenafil is a drug approved as prescription only and sold under the brand name Viagra. Use of sildenafil without medical supervision could cause severe adverse reactions (February 15, 2002). Sildenafil should not be used by individuals who are taking any nitrate medication sold by prescription or over the counter. Nitrate medications are commonly used for angina. Concurrent use could result in the development of potentially life-threatening low blood pressure. Stress & Anxiety Reduction Kava, also known as Awa or Intoxicating Pepper has been popularized as an effective agent to reduce anxiety or stress. People who consume kava at normal doses may experience gastrointestinal complaints, headache, dizziness, drowsiness, and impairment of motor reflexes. However, the adverse effect that is becoming the greatest concern is liver toxicity. Health Canada is advising consumers not to use kava (kava-kava) products (January 16, 2002) until a safety assessment can be completed. Brain Functions Gingko Biloba (gingko leaf extract) is used for several types of dementia, including Alzheimer's and vascular dementia. People use ginkgo for conditions that include memory loss, headache, tinnitus, and difficulty concentrating. Ginkgo biloba leaf extracts cause vasodilation and increases peripheral blood flow in a number of vascular disorders. Ginkgo may decrease the ability of blood to clot, therefore can increase the risk of bleeding with anticoagulant drugs (warfarin) or antiplatelet agents. Typical of herbal medications, it lacks standardized trials using rigorous methodology; some studies show a positive effect while others do not. Energy Claims for ginseng include improved concentration, increased stamina, improved erectile functions, cardiovascular protection, decreased blood pressure, anti-stress activity, and better athletic performance. There are three types of ginseng: American, Asian (Chinese and Korean) and Siberian. Siberian ginseng is from a different species of ginseng and may have different effects. Because of the different types and grades of ginseng which vary widely in quality, and the addition of ephedrine and caffeine in some of the products, it is important to read product labeling carefully. Ginseng has
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no effect on mood in healthy young adults. Hypertension is noted as a side effect of ginseng. Headache, nervousness,
agitation and trouble sleeping may occur if using ginseng. Ginseng may lower blood sugar levels. Diabetic patients must monitor blood sugar levels carefully if using this product. Most claims of improved athletic performance are not supported by scientific evidence. Mood Problems St. John's Wort is used for depressed mood, anxiety and secondary symptoms associated with depression such as fatigue, lack of drive, loss of appetite and sleep disturbances. Natural Medicines Comprehensive Database lists St. John's Wort as likely effective (when a standardized product is used) for treating mild to moderate depression. St. John's Wort taken orally can cause gastrointestinal symptoms (stomach upset-nausea, vomiting, diarrhea) and fatigue. St. John's Wort is involved in several drug interactions. Of note, there are multiple reports of breakthrough bleeding and irregular menstrual bleeding in women taking birth control pills and St. John's Wort. In other words, the effectiveness of oral contraceptives may be decreased. There are reports of acute cardiac transplant rejection because levels of the anti- rejection drug Cyclosporine were decreased when St. John's Wort was started. It appears from the limited human data available that St. John's Wort may cause photosensitivity (severe sunburn from normal sun exposure). Patients should be cautioned to avoid bright light exposure while taking St. John's Wort, especially those with fair skin. If considerable light exposure is unavoidable, patients should cover exposed skin, using long sleeve shirts, pants, wide-brimmed hats, and wraparound sunglasses. Tanning beds should be avoided. Sleep Valerian is a popular herbal sleep remedy. It is probably the most studied of the herbal sleep supplements. Long term use of valerian has been associated with a benzodiazepine-like (Valium, Ativan) withdrawal syndrome. Valerian use appears to be well tolerated with few reports of residual morning sleepiness.
People also use german chamomile, lavender, lemon balm, and passionflower to induce sleep. There are very few studies that have examined the sedative effects of these herbal supplements. Reported side effects of these minor sleep herbals are rare. Chamomile has been known to cause allergic reactions (contact dermatitis, severe hypersensitivity reactions, and anaphylaxis). Chamomile is related to ragweed. Patients sensitive to ragweed should avoid chamomile. Be Careful The recent popularity of herbal remedies is often associated with high hopes and expectations by consumers. These expectations can be fueled by unrealistic claims and advertisements from the herbal manufacturers. A potential danger arises from self-diagnosis and treatment since herbal preparations are readily available. Hopefully there will be more reliable studies carried out on the effectiveness and safety of these natural health products in the near future as Health Canada is developing the Natural Health Product Regulations. These regulations are intended to provide Canadians with ready access to natural health products that are safe, effective and of high quality, while respecting freedom of choice and philosophical and cultural diversity.
It became apparent that on preparation of this article that there are not many reliable reference sources for this information. The information presented here has been obtained from sources such as The Natural Medicines Comprehensive Database, The Pharmacist's Letter, The US pharmacist, and various internet sites providing drug information.
Teresa Bruce, PharmacistSt. Joseph's Care Group
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By Teresa Bruce, Pharmacist, St. Joseph’s Care Group