Download Nutriceuticals and the Eye

Nutriceuticals and the Eye
Bruce E. Onofrey, OD, RPh, FAAO
Lovelace Medical Center
Albuquerque, New Mexico
CAM
Complementary and Alternative Medicine
CAM treatments and healthcare practices:
•not taught in medical schools
•not used in hospitals
•not reimbursed by medical insurance
INTEGRATIVE MEDICINE
Combine best of Western medicine with complementary techniques that have
proven efficacy
CAM
•33.8% in 1990
•42.7% in 1997
•62.0% in 2002
•39% - disclosure to doctors
•84.9% used herbs
•76.3% used megavitamins
You Can Never Be…...
•Too thin
•Too young
•Too Rich
•Have too much hair
P.T. BARNUM WAS RIGHT
Buzz Words
•All natural = SAFE AND BETTER
•“Cures”
•Strengthens the immune system
•Non-pharmaceutical therapy
•Greater energy/youth
•Harmless
•Lose weight WITHOUT dieting
MOST CLAIMS ARE FALSE
•No current botanical cure for:
•Obesity
•Baldness
•Arthritis
•Cancer
•HIV
•Aging
The Top Selling Herbal Supplements
•Ginkgo: Alzheimers, memory loss, tinnitis
•St. John’s Wort: Depression
•Ginseng: Stimulant
•Garlic: Decrease cholesterol
•Echinacea: “colds”, flu, viral disease
•Saw Palmetto: Enlarged prostate
•Kava: Anxiety
•Valerian: Sedative/sleep aid
The Myths: Nutriceuticals are not drugs
•Nutriceuticals contain chemicals that produce physiologic changes (Both good and
bad)
•THAT’s A DRUG
•FDA just pulled Amcon antihypertensive pills-reserpine,diazapam,promethiazine,
HCTZ
•Gosh the only thing left out was the kitchen sink
Nutriceuticals are monitored for safety and efficacy by the FDA
•They tried to, but congress was inundated with lobbying against FDA control: A
billion dollar industry-LOTS of CLOUT
•Dietary supplement health and education act: Allows advertisement that includes
“potential” therapeutic benefits of the drug-must have disclaimer of no FDA
approval for TX of any disease
•No oversight for safety or efficacy
•Frequently claim a conspiracy by the major pharmaceutical companies to discredit
them
The benefits of nutriceuticals are well documented
A single “study” or testimonial campaign can launch a whole industry
There are NO adverse effects associated with nutriceuticals
•1994: Jin Bu Huan herbal tablets for sedative effect produced cases of fatal liver
toxicity
•1992: Gum guar tablets produced fatal esophageal obstruction
•Ma-huang/ephedra related deaths: See the latest “JOURNAL” articles
•Arnica (leopards bane): for arthritis produced fatal cardiotoxicity
If a little bit is good a lot is better
Megadosing common in patients with chronic/fatal disorders ie cancer, AIDS
If a food improves something put the active ingredient in a pill and it will provide
the same benefit
•Sometimes the
act of changing ones diet (ie increased fruits and vegetable) in place
of high fat foods provides the benefit instead of taking a pill containing a substance
like beta-carotene or lutein, etc
What’s on the label is in the bottle
•Absolutely no assurance of purity or content or standardized quantity of active
substance in the herb
•Therefore no way to standardize a dosage
Herbs and the Eye
•Ginkgo: Glaucoma, vascular disease
•Bilberry/Antioxidants/Lutein: ARMD
•Flaxseed oil: Dry eye/blepharitis
•Herbal GLC TX
BILBERRY
VACCINIUM MYRTILLUS
•flavonoid anthocyanosides
•Improved night vision-Britain?
•bilberry + vitamin E – stops cataract
•improves vision in diabetics
•glaucoma – facilitates aqueous outflow
Bilberry Study
Carotene and Cancer
Beta Carotene and Cancer
AREDS
•21 published reports
•likely to benefit from formula:
-extensive intermediate-size drusen
-at least one large drusen
-noncentral geographic atrophy
-advanced AMD
-vision loss in one eye
ARED (Age related eye disease) Study results
Archives of Ophthalmology-October 2001
•4,757 participants age 55-80
•Patients enrolled from 11/92-4/200 and followed until 4/2001 avg patient TX X 6.3
years
•Categories
•1. NO AMD
2. Mild AMD
•3. Moderate AMD
•4. Advanced AMD
ARED Study results
Archives of Ophthalmology-October 2001
•1. Patients over 55 years should have DFE to be evaluated for risk of AMD.
•2. If extensive intermed. Drusen, at least 1 large druse, non-central geographic
atrophy in 1 or both eyes or advanced AMD and no contraindications-TX
•3. Vit C 500mg, Vit E 400IU, Beta carotene 15mg + Zinc 80mg and Copper 2mg
(Oxides)
•8% decrease of progression from Cat 3 to 4
•Reduced visual acuity loss by 19% in Cat 3 and 4
IMPORTANT TO NOT TAKE THIS TOO FAR
•DID NOT PREVENT AMD
•DID NOT REVERSE AMD
The Bottom Line on ARMD/AREDS 1
•DON’T BE Northern European
•DON’T GET OLDER
•DON’T SMOKE
•DON’T GIVE SMOKERS ANTIOX
•DO INCREASE INTAKE OF LUTEIN RICH FOODS
•CONTROL VASCULAR DISEASE RISK FACTORS
•SUPPLEMENTS DON’T REPLACE A BAD LIFESTYLE
AREDS
For Smokers
•no beta-carotene for smokers
•substitute lutein for beta-carotene
•LAST study – vision improvement
•take zinc only – delays progression
but not vision loss
AREDS 2
•xanthophylls – lutein 10 mg and zeaxanthin 2 mg
•omega-3 polyunsaturated fatty acids
•eliminate beta-carotene
•reduce zinc to 40 mg/day
TOZAL STUDY
•named for nutritional elements
•taurine
•omega-3 fatty acids
•zinc
•antioxidants
•lutein
TOZAL STUDY
•37 patients
•mean age: 76.3 years
•TOZAL supplement vs. placebo
•2 capsules TID for 6 months
•56.7% showed improved BCVA
•20.0% maintained BCVA
•placebo: 1.5 lines of vision loss
WAFACS
Women’s Antioxidant Folic Acid Cardiovascular Study
•double-blind, placebo-controlled
•5,442 female health professionals
•aged 40 or more years
•pre-existing cardiovascular disease
•OR ≥ 3 coronary risk factors
WAFACS
•AMD and CVD – similar mechanisms
and risk factors
•5,205 studied (no AMD at start of study)
•folic acid (2.5 mg qd)
•vitamin B6 (50 mg qd)
•vitamin B12 (1mg qd)
WAFACS
•↓ folic acid, vitamin B =  homocysteine
•hyperhomocysteinemia
- endothelial dysfunction
- impaired vascular reactivity
-  inflammatory processes
- causes atherosclerosis
•all involved with AMD
WAFACS
•7.3 years tx and follow-up
•137 cases of AMD
•70 visually significant AMD
•Tx – 55; placebo – 82 (AMD)
•Tx – 26; placebo – 44 (v.s. AMD)
•Tx reduced risk AMD – 34%
•Tx reduced risk v.s. AMD – 41%
RETINITIS PIGMENTOSA
•vitamin A palmitate, 15,000 IU qd
•slows progression by 2% per year
•beta-carotene – unreliably converted
•vitamin E decreases benefit of vitamin A
•omega-3 FA, DHA – slows disease
•vitamin A + DHA – 20 additional years of useful vision if started in 30’s
HYPERVITAMINOSIS A
•pseudotumor cerebri
•often associated with liver ingestion
• PTC in Eskimos – polar bear liver
•RDA is 5,000 IU/day; > 10,000 IU/day – toxic
•Preservision – 14,320 IU, 286% of RDA
GINKGO BILOBA
•flavonoids, ginkgolide B
•antioxidant for retina, brain
• retina, brain circulation 30%
•protects nerve cells from ischemia
•NAION, vasculopathic CN palsy
•60 mg BID or 40 mg TID (max. 130 mg/d)
•most recommended drug in Europe
GINKGO BILOBA
•Bleeding complications:
- hyphema
- subdural hematoma
- subarachnoid hemorrhage
- increased bleeding time
- caution with coumadin, ASA, Plavix
OPHTHALMIC SURGERY
BLEEDING COMPLICATIONS
•Dong quai (angelica sinensis)
•Echinacea (purple cone flower)
•Ephedra (ma-huang)
•Feverfew (tanacetum parthenium)
•Garlic (allium sativum)
•Ginger (zingiber officinale)
•Ginkgo biloba (duck foot)
•Kava kava (intoxicating pepper)
•St. John’s wort (hypericum perforatum)
•Valerian (passion flower)
Documented Warfarin Interactions:
•Danshen (salvia miltiorrhiza)
•Devil’s claw (harpagophytum procumbens)
•Green tea (camellia sinensis)
•Ginseng (panax ginseng)
•Papain (carica papaya)
Miscellaneous Bleeding Agents
•vitamin E
•flaxseed oil
•fish oil
ST. JOHN’S WORT
•seratonin syndrome
•pupil dilation, visual hallucinations, oculogyric crisis, nystagmus
•ataxia, hypereflexia, tremor
•seizures, confusion, agitation
•hyperthermia, tachycardia, hypertension
Key to Management
•Find the Cause, if possible
•Identify exacerbating factors and cut them out
•STAGE the disease
•Step Therapy
Flaxseed oil and OSD
•Flaxseed oil composed of :
Alpha-linoleic acid omega 3 (57%)
Linoleic acid omega 6 (15%)
Oleic acid omega 9 (18%)
Flaxseed Oil and OSD
•A single 3 year study (200 patients) presented by CF Boerner at the American
Society of Cataract and refractive surgery
•Report of 85% success of complete resolution of dry eye symptoms (burning and
stinging)
•Marked decrease in artificial tear use
Flaxseed Oil and OSD
•Improved CL tolerance
•Improved VDT tolerance
•Improved post-op Lasik comfort
•Improved meibomian oil “quality”-clearer and less viscosity-less meibomian stasis
•Improvement in Rosacea blepharitis
•No help in Sjogrens or drug induced dry eye
DRY EYE
•omega-3 fatty acids
- EPA, eicosapentaenoic acid
- DHA, docosahexaenoic acid
•flaxseed oil
•cod liver oil, fish oil
•Am J Clin Nutr 2005; 82: 887-93.
MARIJUANA
•↓IOP 25% to 30%
•IOP reduction lasts 3-4 hours
•smoke joint 4 – 6 times daily
•Institute of Medicine – rejected use for glaucoma
•Jamaica – Canasol (Cannabis sativa)
ganja-based drops for glaucoma
THE END
THANK YOU