1. What medicines came from these plants and fungi? Willow Wintergreen berry Rye mold Bread mold Madagascar periwinkle Pacific yew Belladonna Foxglove Wormwood spp. Cassia spp. Autumn crocus Snakeroot (Rawulfia spp.)

2. Top-selling Herbs Garlic, ginko, ginseng, ginger, green tea extract Echinacea Saw palmetto Cranberry, and other berry extracts like acai, bilberry, blueberry and blackberry Soy isoflavones Black cohosh St. John’s wort Mild thistle Valerian Red yeast rice Guarana, mate Castor oil Senna Hot pepper oil Yohimbe, goat weed Hawthorne Ma huang (ephedra) Kava-kava, betel, coca leaf, qat, marijuana

3. Top-selling Supplements Glucosamine/chondroitin Calcium and vitamin D B vitamins Vitamin E Iron sulfate Fish oil (and flax oil) Probiotics, particularly lactobacillus Coenzyme Q Creating S-adenosyl methionine (SAMe) Melatonin Colloidal silver Innumerable “male enhancers” and “anabolic boosters” Innumerable “colon- or liver-cleansers/detoxifyers”

4. Reasons patients take herbs/supplements Natural = safe Natural = God’s will (i.e., not a product of human hubris) Supplements promise results that currently only illegal drugs can achieve Different system of health beliefs, i.e., Ayurveda, homeopathy and the doctine of signatures, traditional Chinese, Vodun-related beliefs Many pt’s mix and match beliefs and systems freely

5. Case 57 year old man with PMH of hypertension, on 2 HTN meds at baseline, comes to the ED complaining of severe headache and nausea, diminished urination Found to have bp of 235/140, ISTAT of 0.32, Cr 4.5 (baseline 1.1). Attempts to control bp with bolus IV labetalol and hydralazine not successful, finally simultaneous IV labetalol and NTG drips worked to get sbp down to 200’s, able to titrate off drips starting about 18h after admission, troponin declined, renal failure resolved by discharge.

6. General principles Herbs/supplements are poorly researched in general due primarily to funding issues Many herbs and supplements have effects, therefore side-effects Regulation is deliberately very light and poorly funded— and supplements are often deliberately spiked with illicit modern pharmaceuticals Consider subscribing to FDA alerts, browsing websites, subscribing to PDA herb/supplement databases Ask your pt’s what herbs/supplements they are taking!!

7. Useful websites www.nccam.nih,gov/health/herbsataglance.htm (short list of herbs, effects, side effects, uses)www.nccam.nih,gov/health/herbsataglance.htm www.naturaldatabase.com (definitive database, monographs on herbs/supplements written by ethnobotanists, botanists, pharmacologists and peer reviewed—database from which most reputable sites get their info, but by subscription only)www.naturaldatabase.com www.nlm.nih.gov/medlineplus/druginformation.html (information for patients in lay language)www.nlm.nih.gov/medlineplus/druginformation.html www.ods.od.nih.gov (office of dietary supplementswww.ods.od.nih.gov www.cfsan.fda.gov/~dms/ds-faq.html (frequently-asked questions about herbs/supplements and fda regulations)www.cfsan.fda.gov/~dms/ds-faq.html www.cfsan.fda.gov/~dms/ds-warn.html (recent fda warning about problems with specific brand supplements)www.cfsan.fda.gov/~dms/ds-warn.html