tre principi fitoterapici echinacea, zenzero, cranberry · effectiveness of an herbal preparation...
TRANSCRIPT
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Dr . Sandro Valentini
Pediatra di famiglia
Docente Fitoterapia Ped. Master II liv. Univ. di Siena
Tre principi fitoterapici –
echinacea, zenzero, cranberry
Firenze - 24 novembre 2018
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Echinacea Angustifolia
Echinacea Purpurea Pallida
Zingiber officinale
Vaccinium macrocarpon
e
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Echinacea Angustifolia
Echinacea Purpurea Pallida
Zingiber officinale
Vaccinium macrocarpon
e
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“ Evidence Based phytotherapy “
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FARMACOPEE
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Echinacea Angustifolia
Echinacea Purpurea Pallidae
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Echinacea Angustifolia
Echinacea Purpurea
Parte usata: Tutta la parte aerea e le radici
Pallida
e
Origine :
Famiglia:
America del Nord e
Messico
Asteracee
e
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Echinacea Angustifolia
Echinacea Purpurea
Preparazione farmaceutica consigliata :
Estr.secco ( echinacoside min
0.6%: farmacopea fr. ) –
In commercio anche:
echinacoside 4%, polisaccaridi 16%
Pallida
e
Posologia :
12 – 13 mg/ Kg / die in 2
somm.
lontano dai pasti
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Echinacee
Az. Battericida e
fungistatica
Az.Immunostimolante
Az.cicatrizzante
Fitocomplesso
Ac.caffeico-clorogenico-dicafeilchinici
cicorico -ferulico
cinarina verbascoside
echinacoside
Polisaccaridi complessi
(arabinogalactani..)
Poliine
Quercetina
Kempferolo
vanillina
oli essenziali ( cariofillene ,limonene.. )
Melanina
Az.antiflogistica
Proprietà Terapeutiche :
Az. antiossidante
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Az.ImmunostimolanteFarmacologia sperimentale
AUMENTO
Fagocitosi
Es. etanolico 90% +23%
“ “ fraz. Cloroformica +39%
“ “ fraz. Idrosolubile +14%
indice fagocitosi
granulociti umani
Test clerence
carbone in topi
+2,2 volte
+2,6
volte+1,3volte
fagocitosi
e
anticorpi
Echinacee
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Az.Immunostimolante
numero e attività macrofagi
immunoglob. M
produzione interferone alfa e beta
interlukine ( IL1-IL6 ) e TNFalfa
+NO
Farmacologia sperimentale
AUMENTO
Fraz. Polisaccaridica e
Glicoproteica
nel topo
Echinacee
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Az.cicatrizzante
Az.antiflogistica
Per inibizione ialuronidasi
Stabilizzzione Ac. ialuronici cutanei Protezione dei
tessuti
ACTH Aumento produzione glicocrticoidi
Alchilamidi Inibiz. Ciclossigenasi e Lipossigenasi
Farmacologia sperimentale
Echinacee
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Az. Battericida - antivirale - fungistatica
Echinacoside Poliine
Az. Batteriostatica e fungistatica diretta:
Staph. A. -E.coli- Ps Aeruginosa- Ephydermophiton
interdigitale ( 50 mcg/ml dopo 4 gg di terapia e perdura
per 7 gg )
In vitro:
ostacola penetrazione intracellulare Virus H. Simplex 1 e
influenzale A 2
Farmacologia sperimentale
Echinacee
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Ac.caffeico-clorogenico-dicafeilchinici
cicorico -ferulico
cinarina verbascoside
echinacoside
Polisaccaridi complessi
(arabinogalactani..)
Poliine
Quercetina
Kempferolo
vanillina
oli essenziali ( cariofillene ,limonene.. )
Melatonina
Fitocomplesso
Az.Immunostimolante
Az.ImmunostimolanteAz. Battericida - antivirale -
fungistatica
Melanina
Az. Battericida - antivirale -
fungistatica
Az.Immunostimolante
Echinacee
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Studi clinici
Prevenzione infez alte vv. respiratorie
Trattamento infez alte vv respiratorie
Trattamento del raffreddore
Trattamento dell’influenza
Utilizzo come cicatrizzante (etnobot.)
centinaia trials
clinici !?!?
Echinacee
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Az.Immunostimolante
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Echinacee
Studi clinici
Arch Pediatr Adolesc Med. 2004 Mar;158(3):217-21.
Effectiveness of an herbal preparation containing echinacea, propolis, and
vitamin C in preventing respiratory tract infections in children
A randomized, double-blind, placebo-controlled, multicenter study.
Cohen HA, Varsano I, Kahan E, Sarrell EM, Uziel Y.
Pediatric and Adolescent Ambulatory Community Clinic, Petach Tikva, Israel.
328 bambini : 160 gruppo trattamento , 168 gruppo placebo
5 ml/die da 1 a 3 anni 7,5 ml/die da 4 a 5 anni.
Dosi aumentate nella fasi acute di malattia respiratoria
Indici primari di valutazioneNumero totale infez. Vv. resp.
Numero tot. Giorni malattia
Indici secondari di valutazioneNumero tot. Giorni con febbre, tosse,
rinite
Durata assunzione antipiretico o
antibioticoFollow up a 4 – 8 – 12 settimane
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Ecinacee
Studi clinici
Arch Pediatr Adolesc Med. 2004 Mar;158(3):217-21.
Effectiveness of an herbal preparation containing echinacea, propolis, and
vitamin C in preventing respiratory tract infections in children
A randomized, double-blind, placebo-controlled, multicenter study.
Cohen HA, Varsano I, Kahan E, Sarrell EM, Uziel Y.
Pediatric and Adolescent Ambulatory Community Clinic, Petach Tikva, Israel.
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Echinacee
Studi clinici
Arch Pediatr Adolesc Med. 2004 Mar;158(3):217-21.
Effectiveness of an herbal preparation containing echinacea, propolis, and
vitamin C in preventing respiratory tract infections in children A randomized, double-blind, placebo-controlled, multicenter study. Cohen HA, Varsano I, Kahan E, Sarrell EM, Uziel Y.
Pediatric and Adolescent Ambulatory Community Clinic, Petach Tikva, Israel.
Forte riduzione nel gruppo “trattato” di:
N. Di casi di malattia
N. Medio di episodi per paziente
Giorni di malattia del bambino
Durata degli episodi individuali
O.M.A
Polmoniti
Faringotonsilliti
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Echinacee
Studi clinici
Arch Pediatr Adolesc Med. 2004 Mar;158(3):217-21.
Effectiveness of an herbal preparation containing echinacea, propolis, and
vitamin C in preventing respiratory tract infections in children A randomized, double-blind, placebo-controlled, multicenter study. Cohen HA, Varsano I, Kahan E, Sarrell EM, Uziel Y.
Pediatric and Adolescent Ambulatory Community Clinic, Petach Tikva, Israel.
Forte riduzione nel gruppo “trattato” di:
N. Giorni con febbre
N.Giorni di assunzione antipiretico
N.Giorni di utilizzo di antibiotico
Visite mediche per infez. Resp.
Giorni di assenza scolastica e cure domiciliari
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Echinacee
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Echinacee
Studi clinici
L’Echinacea ha diminuito:
il rischio di sviluppare un common cold del
58%
la durata degli episodi di 1.4 giorni
Lancet Infect Dis. 2007 Jul;7(7):473-80
Evaluation of echinacea for the prevention and treatment
of the common cold: a meta-analysis.
Shah SA, Sander S, White CM, Rinaldi M, Coleman CI.
University of Connecticut School of Pharmacy, Storrs, CT, USA.
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……In general, trials investigating Echinacea for preventing colds
did not show statistically significant reductions in illness occurrence.
However, nearly all prevention trials pointed in the direction of small
preventive effects. The number of patients dropping out or
reporting adverse effects did not differ significantly between treatment
and control groups in prevention and treatement trials …..
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…. Gli studi individuali di profilassi non mostrano alcuna associazione con la prevenzione del comune raffreddore, ma la
meta-analisi esplorativa suggerisce che i prodotti a base di Echinacea possono essere associati a una piccola riduzione
dell'incidenza delle malattie da freddo. Nelle prove di trattamento, non vi era alcuna associazione
di prodotti Echinacea con una durata più breve di raffreddori….
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J Matern Fetal Neonatal Med. 2011 Sep 16. Efficacy of Arnica Echinacea Powder in umbilical cord care in a large cohort study.Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Italy.
Az.cicatrizzante Echinacee
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Echinacee
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J Matern Fetal Neonatal Med. 2011 Sep 16. Efficacy of Arnica Echinacea Powder in umbilical cord care in a large cohort study.Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Italy.
6200 bambini 89,09% caduta dopo 4 giorni
96,13% caduta dopo 6 giorni
Nessuna complicazione !!
Az.cicatrizzante Echinacee
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Echinacee
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Mirtillo rosso americano, cranberry
Fam.: Ericacee
Habitat: Nord America
Forme farmaceutiche: succo, succo concentrato, estratto secco titolato
Vaccinium macrocarpon
monografia ESCOP (Suppl. 2009):
Preparazione liquida in riferimento Farmacopea degli Stati Uniti:
non meno del 2.4% di destrosio, 0.7% di fruttosio, 0.9% di
acido quinico, 0.9% di acido citrico e 0.7% di acido malico.
Preparazione consigliata:
estratto concentrato di succo titolato in proantocianidine di tipo A all’1.2-1.4%
(o polifenoli al 15%).
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Costituenti principali:
• flavonoidi, catechine,
• triterpenoidi, tannini,
• acido beta-idrossibutirrico,
• acido citrico, malico,
• glucuronico, quinico,
• vitaminaA e C, sali minerali,
• pro-antocianidine
Vaccinium macrocarpon
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Vaccinium macrocarpon
proantocianidine
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Le infezioni delle vie urinarie in pediatria
Sono molto frequenti:
2° posto dopo le infezioni respiratorie
a 7 anni circa l’8% delle femmine e il 2% dei maschi ha presentato
almeno un episodio di IVU
Bambini che hanno già avuto una IVU:
rischio di re-infezione compreso fra 10-30%
Le recidive di IVU nei primi mesi di vita:
sono un segnale di uropatie malformative: circa 1/3 dei bambini con
recidiva ha un reflusso vescico-ureterale
Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Perché pensare ad una profilassi non
convenzionale delle IVU in pediatria?
La profilassi antibiotica pone problemi di:
Effetti collaterali
Sviluppo di antibiotico resistenza
Compliance
Costi elevati
Conway PH et al. Risk Factors and Association With Prophylactic
Antimicrobials Recurrent Urinary Tract Infections in Children.
JAMA. 2007;298:179-186
Vaccinium macrocarpon
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Studi in vitro: gli estratti di cranberry inibiscono l'adesione dei colibacilli alla parete dell'intestino e della vescica, fornendo così una spiegazione al loro uso come antidiarroici e disinfettanti urinari. In uno studio si è valutato l’effetto del succo di cranberry su due ceppi di Escherichia coli, il HB101 privo di fimbrie e il HB101pDC1 che è fimbriato osservando che inibiva l’adesione di entrambi i ceppi batterici già dopo 3 ore di incubazione, con un effetto maggiore sul ceppo fimbriato HB101pDC1. Tale effetto era legato alla modificazione delle macromolecole superficiali dei batteri, in particolare a riduzione della lunghezza delle fimbrie da 148 a 48 nm
Y. et al. Role of cranberry juice on molecular-scale surface characteristics and adhesion behaviorof Escherichia coli. Biotechnol Bioeng. 2005 Sep 2;
Vaccinium macrocarpon
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Vaccinium macrocarpon
Meccanismo d’azione NELLE IVU:
• adesione alla membrana delle cellule
uroepiteliali per mezzo di strutture proteiche
chiamate adesine, localizzate all’estremità
distale di sottili filamenti (pili o fimbrie) che si
proiettano dalla parete del batterio
• Fimbrie di tipo 1 (mannosio-sensibili): si legano a
glicoproteine contenenti mannosio
• Fimbrie P (mannosio-resistenti): si legano ad un
disaccaride del galattosio α-D-Gal(1,4)-β-D-gal
presente nelle cellule uropetiteliali e all’antigene
P degli eritrociti, che contiene un residuo Gal-Gal
Nell’80% dei casi è il batterio responsabile delle IVU
Escherichia
Coli
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Meccanismo di Azione
(Cranberry and prevention urinary tract infection in children –J.Chem 18-2006)
Vaccinium macrocarpon
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Meccanismo di Azione
(Cranberry and prevention urinary tract infection in children –J.Chem 18-2006)
Vaccinium macrocarpon
Inibizione del legame delle adesine dell’E.Coli con la superficie di
membrana delle cellule uroepiteliali
Attività antinfiammatoria locale:
Aumento dell’acido acetilsalicilico con conseguente aumento dei
salicilati urinari che inducono
Acidificazione delle urine:
Il succo è in grado di abbassare il pH urinario rendendolo più
acido e creando un ambiente sfavorevole alla proliferazione
batterica
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Uses based on scientific evidence
These uses have been tested in humans or animals. Safety and effectiveness have
not always been proven. Some of these conditions are potentially serious, and should
be evaluated by a qualified healthcare provider.
Grade*
Urinary tract infection (UTI) prevention B
There are multiple studies of cranberry (juice or capsules) for the
prevention of urinary tract infections in healthy women and nursing
home residents. While no single study convincingly demonstrates the
ability of cranberry to prevent UTIs, the sum total of favorable
evidence combined with laboratory research tends to support this use.
It is not clear what dose is best. Most research has focused on the
bacteria E. coli, although laboratory research suggests possible
effects against other bacteria such as Proteus or Pseudomonas.
Cranberry seems to work by preventing bacteria from sticking to cells
that line the bladder. Contrary to prior belief, urine acidification does
not appear to play a role. Notably, many studies have been sponsored
by the cranberry product manufacturer Ocean Spray®. Additional
research is needed in this area before a strong recommendation can
be made.
Urinary tract infection (UTI) treatment C
There are no well-designed human studies of cranberry for the
treatment of urinary tract infections. Laboratory research suggests that
cranberry may not be an effective treatment when used alone,
although it may be helpful as an adjunct to other therapies such as
antibiotics.
Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Cochrane Database Syst Rev. 2001;
(3):CD001321.
Cranberries for preventing urinary tract
infections.
Jepson RG, Mihaljevic L, Craig J.
Cochrane Database Syst Rev. 2004;
(2):CD001321.
Cranberries for preventing urinary tract
infections.
Jepson RG, Mihaljevic L, Craig J.
Cochrane Database Syst Rev. 2008 Jan
23;(1):CD001321.
Cranberries for preventing urinary tract
infections.
Jepson RG, Craig JC
PRECEDENTI
REVISIONI
COCHRANE
DELLA
LETTERATURA
Vaccinium macrocarpon
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Cochrane Database Syst Rev. 2012 Oct 17;10:CD001321. doi:
10.1002/14651858.CD001321.pub5.
Cranberries for preventing urinary tract infections.
Jepson RG1, Williams G, Craig JC.
……. l'evidenza che il beneficio per prevenire l'UTI è piccolo, il succo di
mirtillo non può attualmente essere raccomandato per la prevenzione
delle infezioni del tratto urinario. Altre preparazioni (come le polveri) devono
essere quantificate usando metodi standardizzati per garantire la potenza e
contenere abbastanza ingredienti "attivi", prima di essere valutati in studi clinici
o raccomandati per l'uso.
AUTHORS' CONCLUSIONS:
Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Perché pensare ad una profilassi non
convenzionale delle IVU in pediatria?
La profilassi antibiotica pone problemi di:
Effetti collaterali
Sviluppo di antibiotico resistenza
Costi elevati
Vaccinium macrocarpon
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Perché pensare ad una profilassi non
convenzionale delle IVU in pediatria?
La profilassi antibiotica pone problemi di:
Effetti collaterali
Sviluppo di antibiotico resistenza
Costi elevati
Vaccinium macrocarpon
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Vaccinium macrocarpon
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Vaccinium macrocarpon
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Zingiber officinale
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Utilizzi tradizionali
( non tutti avvalorati da dati sperimentali o clinici )
Antiemetico
Digestivo
Antiulcera
Antiaggregante
Antinfiammatorio ,Antipiretico, Trattamento Mal. osteorticolari
Epatoprotettivo
Vasoattivo
Antinfettivo
Antischistosomiasi
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FAMIGLIA: Zingiberaceae.
HABITAT: originario dell'India, è attualmente coltivato nel sud-
est asiatico, nel sud della Cina, nelle Indie Occidentali e in
Africa.
PARTE USATA: il rizoma.
PREPARAZIONE FARMACEUTICA CONSIGLIATA:.
estratto secco titolato in olio essenziale min. 0,8% (B.H.P. 1990)
o in gingeroli min. 4% (Commissione E tedesca).
Presente schede ESCOP e MONOGRAPH. WHO
Zingiber officinale
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Usi Medici
“ Profilassi della nausea e del vomito
associati a cinetosi
Nausea post-operatoria
Vomito gravidico
Mal di mare “
Indicazioni terapeutiche
Profilassi della nausea e del vomito
associati a cinetosi
Nausea post-operatoria per chirugia “
minore “
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COMPOSIZIONE CHIMICA
Il rizoma dello zenzero è assai ricco di amidi (circa
60%) e contiene una discreta quantità di olio essenziale,
compresa tra lo 0,8 e il 2%.
I costituenti responsabili del sapore tipico della droga
sono chiamati gingeroli.
Zingiber officinale
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Amidi Olio e. 1- 3 % Oleoresina 4 - 7,5%
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Attività antiemetica
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Attività antiemetica
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Attività antiemetica
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Attività antiemetica2003
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Attività Antinfiammatoria
Inibizione LipOX e CicloOx 2 Percezione del dolore …………..
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Titolazione riferibile a studi sperimentali e ad
indicazioni Monografie ESCOP/WHO
ESCOP/WHO 0,5-2 g droga secca pazienti oltre 6 aa.
ABC 7 mg/Kg e.s. / ogni 4 ore
Zingiber officinale
PREPARAZIONE FARMACEUTICA CONSIGLIATA:.
estratto secco titolato in olio essenziale min. 0,8%
(B.H.P. 1990) o in gingeroli min. 4% (Commissione
E tedesca).
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“ Extrapyramidal reactions in children treated
with metoclopramide “ AA.VV. Ist Sup
Sanita’ – Ital.Journ.Ped. N.1, 2004
METOCLOPRAMIDE CONTROINDICATA
IN SOGGETTI INFERIORI AI 16 ANNI
“ Boll. Inf. Farm n.2- 2004 “
Plasil
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“ Restrizione Domperidone “
Per possibili effetti collaterali
Per limitate evidenza scientifiche
………!!!
Dompe
ridone
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Zingiber officinale
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Zingiber officinale
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Zingiber officinale
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Vale 29
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Cosa si trova sul mercato?
Vale 29
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DISPONIBILITA’
PRODOTTO
IDONEO
“ Pediatrico “
Vale 42
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OPPORTUNITA’
APPLICABILITA’
INTERAZIONI
Vale 41
competenze
professionali
DISPONIBILITA’
PRODOTTO
IDONEO
“ Pediatrico “
STANDARDIZZATI E TITOLATI
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EVITARE
l’AUTOPRESCRIZIONE
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Dr . Sandro Valentini
Pediatra di famiglia
Docente Fitoterapia Ped. Master II liv. Univ. di Siena
Tre principi fitoterapici –
Echinacea, zenzero, cranberry