Complementary therapies Flashcards
1
Q
What is it
A
2
Q
Why is it important
A
- Up to 1 in 4 people in England used some form of CAM in past year
- Most people do not tell their doctors that they are using CAM
- Often perceived by the general public as safe as it is natural
- Community pharmacies sell CAM e.g. herbal, nutritional supplements (good profit margins)
- Pharmacists often asked for advice about CAM products
- Need to provide evidence-based advice re-effectiveness and safety
- May affect conventional therapy e.g. drug interactions
- Legislation/regulation much improved in past decade
3
Q
What is good evidence
A
- Gold standard in conventional medicine is the RCT
- Large RCTs
- Even stronger evidence are lots of RCTs together- a meta-analysis or systematic review
- Published in peer reviewed journals
4
Q
Difficulties faced by CAM researchers
A
- Treatment often not just one intervention
- Often difficult to have a comparator placebo
- Difficult to blind, so clinician and patient basis
- Lack of funding, so trial often small
- CAM easily purchased, so how to control
- Lack of standardisation of therapies
5
Q
Herbal medicines (rational phytotherapy)
A
- Often a complex mixture of ingredients
- Not clear what is the active ingredient
- Concentration of plant constituents may vary depending on environment (climate, altitude, growing conditions) or genetic factors
- Harvesting and storage can affect quality
- Part of the plant used => varying strength of active ingredient
- Patients purchase, so less structured system for reporting ADRs
6
Q
Herbal therapy
A
- Variation in amount of active ingredient between products and even between batches
- Only recommend licensed preparations
- If unlicensed, at least use a well known quality manufacturer
7
Q
Reference sources- medicines complete
A
- Stockleys drug interaction
- Stockleys herbal medicines interactions
- Herbal medicines
- Dietary supplements
8
Q
An example- St Johns wort
A
- Extract from the leaves and flowers of the plant hypericum perforatum
- Main active constituents- hypericin and hyperforin
- Indication- mild depression and lots of other claims
9
Q
Is it effective
A
- Evidence for use in depression
- Cochrane systematic review in 2008 looked at 29 studies in 5489 patients (with mild to moderate symptom) that compared treatment with SJW for 4-12 weeks with placebo or standard anti-depressants
- SJW superior to placebo
- Similarly effective to standard anti-depressants
- Results more favourable in German studies
- Concluded effective but can only apply to the preparations included in the studies
10
Q
Is it effective
A
- NICE found evidence from RCTs suggesting that compared to placebo, SJW increased the likelihood of achieving a 50% reduction of symptoms of depression
- BUT
- Insufficient evidence to determine if it was effective for achieving remission
- NICE advises that SJW should NOT be prescribed for treating depression because there is an absence of long term data, dose uncertainty, variability, potency and serious interaction with other medication
11
Q
Mechanism of action
A
- Serotonergic 5HT-3 and 4 receptor antagonist
- Down regulates beta-adrenergic serotonergic 5-HT1 and 2 receptor
- Hyperforin also inhibits GABA and L-glutamate
- Hypericin has an affinity for sigma receptors and acts as a receptor antagonist at adenosine, BDZ, GABA-A and B and IP3 receptors
- Hypericin inhibits COMT and MAO in vitro
12
Q
Is it safe
A
- Cochrane review concluded that there were fewer side effects with SJW than with standard antidepressants
- Most common: GI, insomnia, restlessness, dizziness, fatigue, dry mouth
- Evidence that taking 2-4g daily can increase the risk of photosensitivity
- BUT it is a potent inducer of some CYP450 enzymes
13
Q
Drug interactions
A
- Differences between preparations make interactions difficult to predict
- Interacts with (everything)
- Always ask about patients full drug history
- Do not co-prescribe with a conventional anti-depressant
- If switching from SJW to or from conventional anti-depressants you need to allow for a “wash out” period
14
Q
Conclusion SJW
A
- Provided patient is not more than mildly depressed and not taking any interacting drugs, not pregnant or breastfeeding SJW can be recommended
- BUT ideally should see medical help for CBT (proven effective for mild depression)
- Advice that patient it will take 2-4 weeks before seeing the beneficial effect
- Stick to the same preparation
- Report any side effects (then can yellow card report)
15
Q
An example- Glucosamine
A
- Extract from marine exoskeletan or made synthetically
- Commonly available as: Glucosamine sulphate, hydrochloride and in combination with chondroitin sulphate
- Indication- joint pain in OA
25
Q
Summary
A
