CHAPTER 104 HERBAL SUPPLEMENTS

Herbal medicine can be defined as the use of plant-derived products to promote health
and relieve symptoms of disease.
- a plant or plant part valued for its medicinal, savory, or aromatic qualities
- most common form of alternative medicine (treatment practices that are not
widely accepted or practiced by
mainstream clinicians in a given culture)
- aka complementary, holistic, and integrative medicine
- available without prescription, reducing the cost and inconvenience of visiting a
prescriber
- frequently cheaper than conventional drugs
- use gives patients a sense of empowerment that comes from self-diagnosis and
self-prescribing
- patients turn to herbal therapy out of anger or frustration with the traditional
healthcare system
- patients use herbal supplements because of mistrust of conventional medicine
or may feel it has failed them
- strongest force driving the demand is aggressive marketing
- promises of enhanced immune function, easy weight loss, clearer
thinking, improved memory, better
sex lives, and healthier hearts and joints

I. LIMITED REGULATION: DIETARY SUPPLEMENT HEALTH AND EDUCATION ACT

Dietary Supplement Health and Education Act (DSHEA) of 1994 = a
bill that exempts vitamins,
minerals, and botanical products from meaningful FDA regulation
- states that dietary supplements can be manufactured and
marketed without giving the FDA
any proof they are safe or effective
- all a manufacturer has to do is notify FDA of efficacy claims
- products must be labeled as “dietary supplements”
- must not claim that the product can be used to diagnose,
prevent, or treat disease
- must state “This product is not intended to diagnose, treat,
cure, or prevent any
disease”
- is allowed to make claims about the product’s ability to
favorably influence body
structure or function
- products are presumed safe until proven hazardous (burden of
proof lies with the FDA, not
manufacturer)

Current Good Manufacturing Practices (CGMPs) = designed to ensure that

dietary supplements be
devoid of adulterants, contaminants, and impurities, and that
package labels accurately reflect
the identity, purity, quality, and strength of what’s inside
II. ADVERSE INTERACTIONS WITH CONVENTIONAL DRUGS
- herbs can interact with conventional drugs, sometimes with disastrous
results
- for ex., suppressed platelet aggregation, increased risk of bleeding,
elevated blood pressure,
heart and CNS stimulation, and accelerated metabolism of many
drugs
- principal concerns are increased toxicity and decreased therapeutic
effects

III. ORAL FORMULATIONS

A. TEAS, INFUSIONS, AND DECOCTIONS – aqueous extract made from active portion of
medicinal plant (roots, berries,
leaves, flowers)
- purest forms
- made by steeping the plant component in boiling or cold water, then
filtering to remove solid materials
B. TINCTURES AND FLUID EXTRACTS – made by placing the active portion of a plant in a
mixture of water and alcohol
- after a few weeks, solution is filtered or percolated to remove particulate
matter
- contain up to 60% alcohol, which is bad news for alcoholics, recovering
alcoholics, alcohol sensitive
patients, and those taking drugs that can block alcohol metabolism

C. SOLID EXTRACTS – fluid extracts from which all residual fluid has been removed,
either by evaporation or vacuum
distillation
- standard is put into pill or capsule form

IV. STANDARDIZATION OF HERBAL PRODUCTS

- herbal crops can vary from year to year and from place to place because
of sunshine, rainfall,
temperatures, and soil nutrients
- standardization can reduce variability
• prepares an extract of plant parts
• analyzes the extract for one or two known active ingredients
• dilutes or concentrates the extract such that the final product
contains a predetermined amount of the active ingredient(s)
- permits accurate dosing
- permits extrapolation of data obtained in clinical trials to the public in
general

V. DOSAGE
 - standardized products offer the best chance for precise dosing
- no guarantee that the concentration stated on the label is accurate

IV. COMMONLY USED MEDICINAL HERBS

A. ALOE – aloe vera, aloebarbadensis

- used primarily for topical therapy of skin ailments
- oral aloe is used to relieve constipation
- used as a laxative, it works!!
- fresh aloe gel appears to be effective for minor burns and abrasions
- beneficial actions may be lost during storage

Adverse Effects:
Topically – hypersensitivity reactions occur on occasion manifesting
as local or generalized
eruptions
Orally – can cause severe diarrhea, resulting in profound loss of fluid
and electrolytes

B. BLACK COHOSH
- used for acute symptoms of menopause, including hot flashes, vaginal
dryness, palpitations,
depression, irritability and sleep disturbance
- may also benefit premenstrual syndrome (PMS) and menstrual cramps
- suppresses the release of luteinizing hormone (LH) from pituitary gland

Adverse Effects:
- rarely, upset stomach
- not for pregnant women, especially during the 1st and 2nd trimesters
- do not take longer than 6 months
Drug Interactions:
- may potentiate hypotensive and hypoglycemic effects
- may potentiate estrogen effects used for hormone replacement or
contraception

C. BLUE COHOSH
- used for promotion of menstruation and labor
- more dangerous than Black Cohosh
- can elevate blood pressure, increase intestinal motility and accelerate
respiration
- can induce uterine contractions - - DO NOT USE WHILE PREGNANT

D. ECHINACEA
- most commonly used medicinal herb in the U.S.
- used orally and topically
oral – to stimulate immune function, suppress inflammation, and
treat viral infections, including
influenza and common cold
topically – to treat wounds, burns, eczema, psoriasis, and herpes
simplex infection
 Adverse Effects:
- unpleasant taste
- fever, nausea, vomiting
- rarely, allergic reactions to include acute asthma, urticaria,
angioedema, and anaphylaxis
- belongs to the daisy family, whose members include ragweed,
asters, chamomile, and
chrysanthemums – those allergic to these plants should avoid
use of this product
- patients with autoimmune diseases (lupus, rheumatoid arthritis)
should avoid use
- long-term therapy suppresses immune function, patients with HIV,
TB, and cancer should
avoid use

Drug Interactions:
- can oppose the effects of immunosuppressant drugs
- can compromise therapy of TB, cancer, and HIV

E. FEVERFEW
- used primarily for prophylaxis and treatment of migraines
- if taken prophylactically, does work to reduce the frequency and
severity of attacks
- less effective when taken for treatment
- can abort an ongoing attack, but benefits vary
- used to relieve fever, stimulate menstruation, reduce upset stomach, and
suppress inflammation
- topically used to treat infection and relieve toothache
- no reliable evidence of benefiting patients with rheumatoid arthritis or
other inflammatory conditions

Adverse Effects:
- very well tolerated
- mild reactions include abdominal pain, indigestion, diarrhea,
flatulence, nausea, and vomiting
- chewing leaves can cause oral ulceration, tongue irritation, and
swollen lips
- post-feverfew syndrome can manifest with nervousness, fatigue,
insomnia, tension headache,
and joint pain or stiffness
- those allergic to ragweed and other members of this family
(echinacea) may also be allergic to
feverfew

Drug Interactions:
- can suppress platelet aggregation, increasing risk of bleeding with
antiplatelet (aspirin) or
anticoagulants (warfarin, heparin)
G. GARLIC
- used primarily for effects on cardiovascular system
 - taken to reduce levels of triglycerides and low-density lipoprotein
(LDL) cholesterol
- taken to raise levels of high-density lipoprotein (HDL) cholesterol
- employed to reduce blood pressure, suppress platelet aggregation,
increase arterial elasticity
and decrease formation of atherosclerotic plaque
- used for antimicrobial and anticancer effects

Adverse Effects:
- generally well tolerated
- unpleasant taste and bad breath

Drug Interactions:
- has significant antiplatelet effects, increases bleeding with
antiplatelets (aspirin) or
anticoagulants (warfain, heparin)
- can potentiate hypoglycemic effects

H. GINGER ROOT
- used primarily to suppress nausea and vomiting caused by motion
sickness, morning sickness, and
perhaps cancer chemotherapy
- best source of ginger is the produce section at the supermarket
(chew raw or make tea)
- taken to improve appetite, calm stomach upset, and reduce flatulence
- has anti-inflammatory and analgesic properties that may help arthritis
and other chronic inflammatory
conditions

Adverse Effects:
- generally well tolerated
- hugely excessive doses have potential to cause CNS depression
and cardiac dysrhythmias
- use with caution during pregnancy
- high dose can stimulate uterus and might cause spontaneous
abortion

Drug Interactions:
- can inhibit production of thromboxane by platelets, suppressing
platelet aggregation (makes
blood thinner)
- can increase the risk of bleeding with antiplatelet (aspirin) or
anticoagulants (warfarin, heparin)

I. GINKGO
- used to improve memory, sharpen concentration, and promote clear
thinking
- can improve short-term memory in healthy adults as well as in
elderly patients with mild to
moderate memory impairment
 - used to treat senile dementia, and related conditions, including dizziness,
vertigo, tinnitus, headache,
and mood changes
- may help Alzheimer’s disease
- used to counteract erectile dysfunction (impotence) induced by
antidepressants - - especially Prozac
- can reduce the required dosage of anti-impotence drugs for all
others
- improves blood flow due to vasodilation
- appears to increase blood flow in the brain
- can improve hearing in 40% of those treated
- can increase peripheral blood flow up to 45%
- benefits men with SSRI-associated impotence

Adverse Effects:
- generally well tolerated
- causes stomach upset, headache, dizziness, or vertigo
- minimized by increasing the dosage slowly
- suppresses coagulation
- use caution in those taking antiplatelet drugs (aspirin) and
anticoagulant drugs
(warfarin, heparin)
- may promote seizures
- avoid if taking drugs that can lower seizure threshold
(antipsychotics, antidepressants,
decongestants, first-generation antihistamines)

J. KAVA – KAVA KAVA

- used to relieve anxiety, promote sleep, and relax muscles
- calmative and antidepressant
- being sold as a natural alternative to benxodiazepines (Valium) for
treating anxiety and stress
- can relax skeletal muscles and relieve both tension and anxiety without
causing mental clouding
- must be taken for weeks before anxiolytic effects develop
- cognitive function may actually improve

Adverse Effects:
- generally well tolerated
- can cause excessive CNS depression, skin problems, and liver
damage
- has effects like those of alcohol, including excessive CNS
depression, impaired vision, and
muscle incoordination
- should not drive, operate heavy equipment or engage in
other potentially dangerous
activities that require good judgment, coordination, and sharp
vision
- prolonged use can cause a skin disorder that resembles pellagra
- symptoms include, scaly, flaking skin; reddened eyes; and
yellow discoloration of the
 skin, hair, and nails
- takes weeks to months to develop and resolves after kava is
discontinued
- can cause hepatitis, cirrhosis, and even liver failure
- signs of liver damage (jaundice, brown urine, fatigue, nausea,
abdominal discomfort)
- discontinue use if signs appear
- evaluate liver enzymes
- not sold in Germany, Canada, Switzerland, France, and Australia
but is allowed in U.S.

Drug Interactions:
- because of its CNS depressant actions, can intensify effects of
other CNS depressants,
posing a risk of confusion, disorientation, lethargy, and
excessive sedation
- should not be combined with alcohol, benzodiazepines, opioids,
barbiturates, and other drugs
with CNS-depressant properties
- has unknown interactions with skeletal muscle relaxants, and drugs
for epilepsy and
Parkinson’s disease
- has some potential for abuse

K. MA HUANG – EPHEDRA
- a sympathomimetic agent and CNS stimulant
- identical to that of pharmaceutical ephedrine (speed)
- can be used to reduce appetite, increase energy, overcome tiredness,
treat narcolepsy, relieve
bronchospasm, enhance athletic performance, and suppress nasal
congestion in those with
allergies, influenza, and colds

Adverse Effects:
- potentially dangerous product
- excessive cardiovascular stimulation resulting in tachycardia,
palpitations, anginal pain, and
hypertension
- excessive CNS stimulation can result in agitation, irritability,
insomnia, and even psychosis
- can cause euphoria leading to ephedrine abuse
- can cause death
- side effects are dose dependent
- those with heart disease, hyperthyroidism, hypertension, diabetes,
or difficulty with urination
caused by enlarged prostate
- can cause heart attacks, bleeding in the brain, or stroke

Drug Interactions:
- can increase CNS stimulant effects (amphetamines, caffeine,
theophylline)
 - can increase nasal decongestion effects

L. ST. JOHN’S WORT

- used to relieve depression
- may be as effective as conventional antidepressants (“herbal valium”)
- used as OTC dietary supplement
- studies show it works with mild depression but not severe

Drug Interactions:
- increases metabolism of many drugs
- causes oral contraceptive to have break-through bleeding
- increases the chance of blood clots, reducing the effects of
Coumadin
- used with other serotonin drugs can prove fatal

M. SAW PALMETTO
- used to relieve urinary symptoms associated with benign prostatic
hypertrophy <BPH> (enlarged
prostate)
- often used as 1st line therapy to relieve urination problems associated
with BPH
- reduces urinary symptoms without reducing prostate size, users
should continue to see a
urologist on a regular basis

Adverse Effects:
- very well tolerated and safe
- rarely, causes upset stomach or headache
- high doses cause diarrhea
- can reduce levels of prostate specific antigen (PSA), a marker for
prostate cancer
- can cause false-negative results on PSA tests
- patients should undergo a PSA test before initiating
treatment
- represents danger to developing fetus
- pregnant women should avoid touching and taking it
- FDA Pregnancy Risk Category X – KNOWN DANGER

N. VALERIAN
- a sedative preparation used primarily to promote sleep
- used to reduce restlessness
- effects develop slowly

Adverse Effects:
- generally well tolerated
- possible side effects include daytime drowsiness, dizziness,
depression, dyspepsia, and
pruritus
- exercise caution when performing dangerous activities
- prolonged use may cause headache, nervousness, or cardiac
abnormalities
 - use with caution by those with psychiatric illnesses (depression,
dementia)
- may be a risk of paradoxical excitation and physical dependence
- breast-feeding or pregnant mothers should avoid
- does not interact with other CNS depressants