adams ch10 lecture

PHARMACOLOGY FOR NURSESPHARMACOLOGY FOR NURSESA Pathophysiological ApproachA Pathophysiological Approach

FOURTH EDITIONFOURTH EDITION

Copyright © 2014, © 2011, © 2008 by Pearson Education, Inc.All Rights Reserved

CHAPTER

Herbal and Alternative Therapies

10

Pharmacology for Nursing: A Pathophysiology Approach, Fourth EditionMichael Patrick Adams | Leland N. Holland | Carol Urban

Complementary and Alternative Complementary and Alternative Medicine (CAM)Medicine (CAM)

• Considered outside mainstream health care

• Very diverse set of therapies and healing systems


Major Characteristics of CAMMajor Characteristics of CAM

• Treat each person as individual• Consider health care of whole person• Emphasize integration of mind and

body• Promote disease prevention, self-care,

self-healing• Recognize role of spirituality


ResearchResearch

• Rigorous research lacking, though underway for many therapies

• Seeks effectiveness or lack of effectiveness


Nurses and CAMNurses and CAM

• Have long known of healing benefits• Can reduce reliance on some

medications, which reduces adverse effects

• Can bring greater compliance• Advantages and limitations should be

presented to patients.


CAM Healing MethodsCAM Healing Methods

• Ingested therapies– Herbal therapies, nutritional

supplements, special diets



• Alternate health care systems– Naturotherapy, homeopathy,

chiropractic– Native American medicine (sweat

lodges, medicine wheels)– Chinese traditional medicine

(acupuncture, Chinese herbals)



• Manual healing– Massage, pressure-point therapies,

hand-medicated biofield therapies• Mind-body interventions

– Yoga, meditation, hypnotherapy – Guided imagery, biofeedback– Movement-oriented therapies (music

and dance)



• Spiritual– Shamans, faith, prayer

• Other therapies• Bioelectromagnetics, detoxifying

therapies• Animal-assisted therapy


Table 10.1 Complementary and Alternative Therapies

continued on next slide


Table 10.1 (continued) Complementary and Alternative Therapies


HerbsHerbs

• Technically a botanical without any woody tissue such as stems or bark

• Meaning has changed to refer to any plant product with some useful application either as a food enhancer or a medicine.

• Documented use for thousands of years


Table 10.2 Top-Selling Herbal Supplements



Table 10.2 (continued) Top-Selling Herbal Supplements


Dietary and Herbal SupplementsDietary and Herbal Supplements

• Use waned with rise of pharmacology.• Marketing, increased awareness, and

availability brought resurgence in 1970s.

• Majority of adult Americans take or have taken botanicals on a regular basis.


Aging PopulationAging Population

• Pain• Arthritis• Hormone-replacement therapy• Prostate difficulty


High Cost of Prescription High Cost of Prescription MedicationsMedications

• Leads patients to seek CAM therapies


Examples of Herbal Examples of Herbal SupplementsSupplements

• Garlic• Soy• St. John's wort• Cranberry • Ginseng• Bilberry


Active Ingredient(s) in HerbsActive Ingredient(s) in Herbs

• Usually found only in specific part of the plant

• May have multiple active ingredients, unlike most modern drugs

• Potency can depend on where herb was grown or how it was grown or harvested.


Active Chemicals in HerbsActive Chemicals in Herbs

• Work synergistically• May not have same activity if isolated


Herbal FormulationsHerbal Formulations

• Two basic formulations: solid and liquid


Solid Formulations of HerbsSolid Formulations of Herbs

• Pills • Tablets• Capsules• Salves • Ointments


Liquid Formulations of HerbsLiquid Formulations of Herbs

• Tea • Infusion• Decoction• Tincture• Extract


Figure 10.2 Three different ginkgo formulations: tablets, tea bags, and liquid extract


Table 10.4 Diseases for Which Medical Consensus Exists That Herbal Therapies May Be Useful


Dietary Supplement Health and Dietary Supplement Health and Education Act of 1994 (DSHEA)Education Act of 1994 (DSHEA)• Regulatory act for dietary supplements• Less rigid than the Food, Drug, and

Cosmetic Act (FDA)• Dietary supplements are exempted

from FDA standards.• Gives FDA power to remove products

considered harmful.


Food, Drug, and Cosmetic Act Food, Drug, and Cosmetic Act Definition of Dietary SupplementsDefinition of Dietary Supplements• Products intended to enhance or

supplement the diet:– Botanicals– Vitamins– Minerals– Metabolites


DSHEA WeaknessesDSHEA Weaknesses

• Not necessary to demonstrate effectiveness prior to marketing

• Manufacturer not required to prove efficacy or safety

• Labels not monitored for accuracy in product amounts or claims of benefits of product


Figure 10.3a Labeling of black cohosh: front label with general health claim



Figure 10.3b Labeling of black cohosh: back label with more health claims and FDA disclaimer


Dietary Supplement and Nonprescription Dietary Supplement and Nonprescription Drug Consumer Protection Act (2007)Drug Consumer Protection Act (2007)

• Companies must– Include contact information on product

labels for reporting adverse events– Notify the FDA of any serious adverse

event reports within 15 days of receiving such reports

– Keep extensive records on reports


Further FDA RulesFurther FDA Rules

• Manufacturers of dietary supplements required to evaluate the identity, purity, potency, and composition of their products and report on label


““NaturalNatural”” Does Not Always Does Not Always Mean SaferMean Safer

• Some active chemicals are the same as in prescription and OTC medications.

• Patient substituting alternative therapy for established medical treatment may prolong condition.


Nurse ResponsibilityNurse Responsibility

• Watch for herbal products with ingredients that interact with prescription drugs

• Ask questions and obtain medical histories

• Pregnant/lactating women need approval from health care provider.


Allergic ReactionsAllergic Reactions

• Natural products may contain several chemicals or ingredients.

• Safer to begin with smaller doses


Seek Latest Medical Information Seek Latest Medical Information on CAM on CAM

• Keep current with updated information


Educate PatientsEducate Patients

• Strengths and weaknesses of CAM• Encourage patients to seek information

from reputable sources• Pregnant/lactating women should never

take supplements without approval from health care provider.


Avoid False Hope of CureAvoid False Hope of Cure

• Ensure patients' understanding of uses and limitations of CAM

• Encourage skepticism of claims on manufacturer labels

• Never condemn a patient's desire to use alternative therapies


Patient Health HistoryPatient Health History

• Aids in avoiding adverse reactions• Aids in identifying drug interactions


Common Drug–Herb InteractionsCommon Drug–Herb Interactions

• Obtain patient's health history to prevent drug–herb interactions


Table 10.5 Documented Herb–Drug Interactions



Table 10.5 (continued) Documented Herb–Drug Interactions


Echinacea Traits (partial) Echinacea Traits (partial)

• Interacts with amiodarone and anabolic steroids

• Results in possible increased hepatotoxicity


Interactions with Feverfew, Interactions with Feverfew, Ginger, and Ginkgo (partial)Ginger, and Ginkgo (partial)

• Aspirin• Heparin• NSAIDs• Warfarin• Results in possible increased bleeding

potential


Interactions with Garlic and Interactions with Garlic and Ginseng (partial) Ginseng (partial)

• Insulin• Oral hypoglycemic agents• Results in increased hypoglycemic

effects


Interaction with Ginkgo (partial) Interaction with Ginkgo (partial)

• Anticonvulsants—decreased effectiveness

• Tricyclic antidepressants—decreased seizure threshold


Interactions with CNS Depressants Interactions with CNS Depressants

• St. John's wort• Ginseng• Valerian• Results in increased sedative effect


Specialty SupplementsSpecialty Supplements

• Nonherbal dietary products are used to enhance a wide variety of body functions.

• Occur naturally in the body• Excessive amounts may have harmful

effects.• Example—chondroitin and glucosamine• Link with benefits is unclear.


Table 10.6 Selected Specialty Supplements


Standardizing Herbal Products Standardizing Herbal Products

• Attempts have been made to standardize measurement of active ingredient, but with no comprehensive success yet.

• Uses marker substance such as percent flavones in ginkgo

• Until science is better, it is best to conceptualize the active ingredient of an herb as being the entire herb itself.


Table 10.3 Standardization of Selected Herb Extracts


Figure 10.1a Two ginkgo biloba labels: note the lack of standardization in 60 mg of extract, 24% ginkgo flavone glycosides and 6% terpenes



Figure 10.1b Two ginkgo biloba labels: note the lack of standardization in 50:1 ginkgo leaf extract, 24% ginkgo flavone glycosides