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Suggestions for next time • Macuvision • Discuss specific indications instead of genaralities eg curcumin for arthritis (cf: anti-inflammatory) • Problems With St John's Wort: Another important message in the guideline is regarding the potential problems with the popular herbal therapy St John's wort, sold over the counter at drug stores and in health food stores. http://annals.org/article.aspx?articleid=2490527 Complementary Therapies Ingrid Johnston Consultant Pharmacist Define the following • Complementary therapy • Alternative therapy • Where do you find evidence for benefit or harm? Overview • • • • • • • • • Benefits and risks of complementary therapies Cranberry Calcium and vitamin D Fish/Krill oil Glucosamine Curcumin Probiotics CoQ10 Case study What are potential problems with complementary therapies? 1. Adverse effects 2. Drug interactions 3. Cost 4. Delay of more effective therapy 5. False hope/disappointment CRANBERRY Cranberry Main actions – Interferes with attachment of bacteria to urinary tract – Overall human studies suggest it does not acidify the urine Evidence – No evidence for treating UTIs – Conflicting evidence but may have some benefits for UTI prevention Cranberry Practice points – Juice may contain high sugar content – GI upset (3L or greater!) Interactions – Warfarin: possible so INR should be monitored – Large amounts of juice can promote formation of oxalate kidney stones VITAMIN D & CALCIUM Vitamin D Main actions – Essential for Ca and phosphate homeostasis – Important for optimal bone and muscle function – Diverse roles throughout the body Evidence – reduce fracture risk in older people (when combined with adequate calcium) – Deficiency is an independent predictor of falls – Conflicting/unsubstantiated for many other conditions Which came first – deficiency or disease? Vitamin D deficiency Restricted/inadequate sun exposure Medications – Corticosteroids – Anticonvulsants (phenytoin, valproate, carbamazepine) Malabsorptive diseases – Coeliac – Crohns – Cystic fibrosis Other diseases – Pancreatic insufficiency – Chronic hepatitis Vitamin D Practice points – Check levels at the end of winter or beginning of spring in those at high risk – Ensure appropriate levels of supplementation Interactions – May interfere with action of calcium channel blockers Vitamin D Note: Large annual doses of vitamin D are not recommended either to treat vitamin D deficiency or to prevent fractures. Calcium Main actions Essential mineral for many body processes Evidence Prevention and treatment of deficiency for BMD and overall health and wellbeing Calcium deficiency Low Vitamin D levels Low amounts of acid in the GUT – Calcium carbonate needs an acidic environment – Calcium citrate does not need an acidic environment Increasing Age – By 65 years of age absorption is 50% of adolescent levels Low oestrogen levels High fibre diet Corticosteroids Calcium and cardiovascular risk “Calcium intake and the risk of heart attack and stroke is the subject of ongoing research. Because adverse events have not been a major focus of osteoporosis prevention trials, it is important that adverse outcomes are verified in the available studies. When externally verified cardiovascular disease event rates (such as heart attacks) in women, as opposed to self-reported but non-verified events and events occurring in men are considered, no adverse effect of calcium supplementation and vitamin D supplementation on heart attacks or cardiovascular events have been identified.” - Osteoporosis Australia Statement on Calcium and Vitamin D supplements Reviewed June 2015 Calcium – practice points Practice points – aim to reach total calcium dose of 1000–1300 mg/day – when dietary intake of calcium is not sufficient, supplements may be required at a daily dose of around 500-600 mg per day Interactions – Possible with many medications FISH OIL Fish Oil Background – Most studied components are omega-3 polyunsaturated essential fatty acids – eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) – most concentrated dietary source of both EPA and DHA is deepsea oily fish Fish vs fish oil supplements? EPA/DHA content and ratio? Fish Oil - evidence Cardiovascular disease – Fish and fish oil supplements reduce the risk of both primary and secondary cardiovascular disease – Decrease death from coronary heart disease – Hypertension – Hypertriglyceridaemia Osteoarthritis Rheumatoid arthritis Fish Oil – Practice Points Dose and duration of treatment varies Adverse effects – – – – GI upset Fishy taste/burps Fishy odour of skin and urine Raised LDL Interactions - Possible with high doses and antiplatelets or anticoagulants Oils ain’t oils? Krill oil – Lower EPA:DHA content – Increased bioavailability Algal oil – Predominantly DHA Calamari oil? Salmon oil? GLUCOSAMINE Glucosamine Main actions – Essential for the synthesis of many body tissues including cartilage, ligaments, tendons and synovial fluid – Osteoarthritis Evidence – – – – Conflicting for pain relief and structure-modification Sulfate vs hydrochloride? With chondroitin? With methylsulfonylmethane (MSM)? Glucosamine Practice points – No apparent adverse effects – 2 to 3 month trial – 3+ years to slow joint degeneration Interactions – None documented CURCUMIN Curcumin Main actions – Major constituent of turmeric – Anti-inflammatory – Anti-oxidant Evidence – Currently insufficient evidence to support use for any health condition Curcumin Practice points – Take with food to increase absorption – May cause GI upset and bleeding – Avoid in PU disease and GORD Interactions – ?antiplatelets and anticoagulants – ?cyclophosphamide – reduced effect Curcumin Curcuma longa, Curcuma domestica 100-300mg standardized extract (95% curcumin) daily Do not confuse with Javanese turmeric (Curcuma xanthorrhiza) or Zedoary (Curcuma zedoaria) PROBIOTICS Probiotics Background – Diverse range of live micro-organisms that confer benefit on the host – Often from cultured milk products – Lactobacillus, Bifidobacterium, Enterococcus, Streptococcus, Bacillus, E.coli, Saccharomyces yeasts Proposed actions – Inhibit pathogens in the gut – Enhance gut mucosal function – Modulate host immune responses Probiotics – evidence Complicated by wide variety of different strains Possible indications – – – – – – Acute infectious diarrhoea Prevention of antibiotic associated diarrhoea Travellers diarrhoea Inflammatory bowel disease Genitourinary infections Infant colic and reflux Probiotics Practice points – – – – Take with food Some need refrigeration Flatulence and diarrhoea common May need to take long term for maximum benefits Interactions – Antibiotics – separate dose by 2 hours COENZYMEQ10 CoQ10 Background – Ubiquinone, ubiquinol, ubidecarenone – Occurs naturally in most cells – Contained in meats and seafood Main actions – Antioxidant – Membrane stabiliser – Enzyme co-factor CoQ10 Evidence – ?Heart failure – ?Hypertension – ?Statin induced myopathy Practice Points – May take 10 – 12 weeks to improve heart conditions – Food increases absorption – May cause GI upset and skin rash CoQ10 Interactions – Antihypertensive – effect may be potentiated – Cancer chemotherapy/radiotherapy – antioxidant properties may protect tumor cells and decrease effect – ?warfarin – Theophylline - may delay theophylline clearance CASE STUDY 88 year old man in residential care • • • • • • Osteoarthritis Falls/risk of falls Asthma Hypertension Ankle oedema Vascular dementia – Severe • Cramps • Parkinson's Disease • • • • • • • • Dyspepsia Cataracts Degenerative disc disease Hearing problems Peptic ulcer disease Sciatica COPD Non-english speaking Case Study Prescribed medication • • • • • • Sinemet 100 mg/25 mg Tramadol 100 mg SR Tramadol 50 mg Coloxyl with Senna Lactulose Temaze 10 mg 1 tds 1 bd 1 midday 2n 20 mL bd prn 1 n prn Parkinson's disease Moderate analgesia Moderate analgesia Constipation Constipation Insomnia Ming Gold 3 at 8am & 3 at 12.30pm Increase stamina and performance Orbitol Plus 2 bd Antioxidant Prostality 1 bd Prostate Orachel Tablets 1 bd Protect against heart disease Cascading Revenol 1n Antioxidants Chelamin 1 tds Mineral supplement Feroxin 10 mL m Iron supplement Carnasine Booster Patch Apply to sternum Tues, Thurs & Sat To increase lifespan Glutathione Booster Patch Apply M, W F (Apply 4 fingers widths below umbilicus) Anti-ageing Energy enhancer patch Apply M, W, F. On 0700 off 1900 Tan patch left side White patch R side Increases energy Lactoflora Double Sachet 2m Probiotic Ming Dynasty VMM 3 tds . Supports immune response I lost count at 83 different ingredients Issues • Family provide the nutraceuticals as they have a business supplying these products. • Pharmacy packs into Websters • Doctor orders these products on the medication chart. • At times family do not supply stock in time so father goes without – This makes facility non-compliant with accreditation standards • Resident sometimes vomits after having these products administered. – Swallowing difficulties. Traditional Chinese Medicine (TCM) Traditional Chinese Medicine (TCM) Evidence and where to find it • National Institutes of Health Natural Centre for Complementary & Alternative Medicine (NCCAM) • MedlinePlus : Drugs, Supplements & Herbal information • IM Gateway – Integrative medicine • Australian Pharmaceutical Formulary • Braun and Cohen “Herbs and natural supplements” • Cochrane • Victorian Therapeutics Advisory Group Role of the health professional • Appreciate consumers cultural and social beliefs – Non-judgemental • Recognise and report adverse reactions and interactions • Influence on pathology results • Provide same level of evidence based advice as with all medicines • Remain up to date • Be aware of evidence on safety and efficacy Quality Use of Medicine • Provide latest evidence on CAMs • Discuss use of CAMs at MAC meetings – Draft Policy and Procedure – Complementary Therapy Care Plan – Sample letter to residents regarding CAMs Summary “There is no alternative medicine. There is only medicine that works and medicine that doesn’t work.” - Richard Dawkins Professor of the Public Understanding of Science Oxford What quality improvement activities are you likely to implement following this session in regards to your own work? 1. _____________________________________ _____________________________________ 2. _____________________________________ _____________________________________ 3. _____________________________________ _____________________________________