1. Complementary Medicines Jeff Whittle, MD, MPH Background information provided by Jennifer Koch, PharmD Clement J. Zablocki VA Pharmacy Service

2. Goals Define complementary medicine Define complementary medicine Understand concerns regarding use of complementary medicines Understand concerns regarding use of complementary medicines Discuss some complementary medicines with evidence of benefit Discuss some complementary medicines with evidence of benefit Discuss how to choose a complementary product safely Discuss how to choose a complementary product safely

3. Complementary Medicine Is... Any of several therapies that are not considered “conventional medicine” Any of several therapies that are not considered “conventional medicine” Commonly used, often by the same people who use conventional medicine Commonly used, often by the same people who use conventional medicine Examples: Examples: –Acupuncture/Homeopathy/Chiropractic? –Herbals/Supplements

4. Herbals/Supplements are NOT... … regulated by the FDA … regulated by the FDA … tested to ensure safety … tested to ensure safety … tested to ensure effectiveness … tested to ensure effectiveness … tested to ensure purity … tested to ensure purity

5. FDA Oversight is Limited “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”

6. What Oversight Does Exist? Sold as “dietary supplements” Sold as “dietary supplements” –Regulation is similar to that of food –Taken off market ONLY after proven unsafe “Good manufacturing practices” “Good manufacturing practices” –Started in 2008 for larger companies –All companies must follow by June 2010 –Employee training, record keeping, equipment upkeep and cleaning, etc. Disclaimer statement above Disclaimer statement above

7. Issues with Manufacturing Contaminants by other drugs Contaminants by other drugs –Pharmaceuticals – e.g., Digoxin –Other active drugs – e.g., caffeine Contamination with metals Contamination with metals –Lead, arsenic, mercury, etc. Unpredictable potency Unpredictable potency –Because active ingredient is not known –Because of manufacturing limitations

8. Evidence for Effectiveness Hard to interpret variable results Hard to interpret variable results –Black Cohosh for menopause –Gingko Biloba for dementia –Glucosamine +/- chondroitin Dose differs across preparation Dose differs across preparation –St. John’s Wort for depression –Hawthorn for hypertension

9. Some Almost Certainly Work! But how they work is often not clear But how they work is often not clear High-dose fish oil lowers triglycerides High-dose fish oil lowers triglycerides –Lower doses prevented 2 nd heart attacks Garlic lowers blood pressure modestly Garlic lowers blood pressure modestly –Alliin is likely what works (and smells!) Red yeast rice lowers cholesterol Red yeast rice lowers cholesterol –A statin-like effect (about 5 mg of lovastatin in one standard dose)

10. Choosing a Product “Natural” does not equal safe! “Natural” does not equal safe! Look for danger signs: Look for danger signs: –Product “cures” everything –Supposedly “no side effects” –Claim a “conspiracy” on the part of conventional medicine Use reliable third party advice: Use reliable third party advice: –http://my.clevelandclinic.org/ –http://www.mayoclinic.org/

11. Safe Product Selection Buy commercial products from reliable sources Buy commercial products from reliable sources Buy products that specify the content of the active ingredient Buy products that specify the content of the active ingredient –For example, fish oil has milligrams Avoid products without ingredients Avoid products without ingredients Avoid numerous ingredients Avoid numerous ingredients

12. What to Look for on Labels List ingredients in detail List ingredients in detail –Scientific name of herb –Amount of each ingredient Good manufacturing processes Good manufacturing processes –Batch or lot number –Date of manufacture –Expiration date –Name and address of manufacturer

13. Talk to Your Doctor! As with any drug, you should let your physician (and pharmacist) know about any complementary therapy you are using As with any drug, you should let your physician (and pharmacist) know about any complementary therapy you are using

14. Questions ?