II. Epidemiology: United States

  1. Adults on Herbals and prescribed medication: 15 Million
    1. Adults alerting doctor of concurrent herbal use: 50%
  2. Americans spent $4 billion on Herbals in 1998
  3. Worldwide use: 4 billion people
  4. Most commonly used herbal products in the United States
    1. Echinacea
    2. St. John's Wort
    3. Ginkgo Biloba
    4. Garlic
    5. Saw Palmetto
    6. Ginseng
    7. Goldenseal
    8. Aloe
    9. Siberian Ginseng
    10. Valerian

III. Background

  1. Traditional medicine is basis for 80% world healthcare
  2. Most medications are synthesized from plant sources
    1. Plant Derivatives: 75% of modern medications
    2. Direct Extracts: 25% of modern medications
  3. Little efficacy data exists for Herbals
    1. Only 30-40 of 1200 herbs have evidence of benefit
    2. Prescribed medications by contrast must show benefit
  4. Modern drugs directly derived from plant sources
    1. Acetylsalicylic acid (Aspirin) from willow bark
    2. Atropine from deadly nightshade plant
    3. Cantharidin from Blister beetle (for Wart Treatment)
    4. Colchicine from meadow saffron plant
    5. Cortisone from Mexican Discorea species
    6. Digitalis (Digoxin) from the foxglove plant
    7. Morphine and other Narcotics from the opium poppy
    8. Pilocarpine from the South American Jaborandi Tree
    9. Podophyllin or Podophyllum from mayapple plant
    10. Pyrethrins from chrysanthemums (for lice treatment)
    11. Quinine from yellow cinchona
    12. Reserpine from the snakeroot plant
    13. Scopolamine from Colombian Datura arborea tree
    14. Senna Laxatives from the senna plant
    15. Taxol from the yew tree
    16. Vincristine, Vinblastine from rosy periwinkle plant
    17. Yohimbine from black currant trees (Rubiaceae)

IV. Disadvantages: Related to herbal medication use

  1. No enforced labeling of efficacy
  2. No quality control regulation
    1. USP Verified Mark may be found on some products
  3. Adverse effects are not routinely labeled
    1. See below as well as specific herbal medications
    2. Serious Drug Interactions may exist
      1. St. John's Wort reduces Oral Contraceptive effectiveness
      2. American Ginseng decreases INR for patients on Warfarin
  4. No standardization of concentration and potency
    1. Many herbal preparations are mislabeled
    2. Some contain little if any active ingredient
  5. Preparations may contain contaminants
    1. Pesticides
    2. Heavy metals (often found in folk remedies)
      1. Arsenic
      2. Mercury
      3. Lead (see Lead-Containing Herbal Remedies)
      4. Cadmium
    3. Prescription drugs illicitly placed in product
      1. Phenylbutazone
      2. Aminopyrine
      3. Prednisone
      4. Testosterone
      5. Diazepam
      6. Indomethacin
  6. Serious Drug Interactions may occur
    1. Goldenseal (high risk of interactions with multiple agents)
    2. St John's Wort (high risk of interactions with multiple agents)
    3. Ginkgo Biloba (increased bleeding risk with Warfarin)
    4. Milk Thistle (multiple interactions)
    5. Asian Ginseng (multiple interactions)
    6. Curcumin (decreases levels of many psychiatric medications)
  7. Many plants are highly poisonous (fatal at low dose)
    1. Deadly nightshade
    2. Hemlock
    3. Mistletoe
    4. Oleander
    5. Daphne Berry
    6. Rosary Pea
    7. Jasmine
    8. Red sage
    9. Yew
    10. http://aggie-horticulture.tamu.edu/earthkind/landscape/poisonous-plants-resources/common-poisonous-plants-and-plant-parts/

V. Adverse Effects

  1. General
    1. Patient should report adverse effects to physician
    2. Notify FDA of adverse effects
      1. FDA MedWatch
        1. http://www.fda.gov/medwatch/
        2. Phone: 1-800-332-1088
  2. Cyanide Poisoning risk with seeds, bark, or leaves
    1. Apricot
    2. Cassava beans
    3. Cherries
    4. Choke cherries
    5. Peaches
    6. Plums
  3. Hepatotoxicity
    1. See Hepatotoxin
  4. Allergic Reaction Risk for those with ragweed allergy
    1. Goldenrod
    2. Marigold
    3. Yarrow
    4. St. John's Wort
    5. Chamomile (or Mayweed or dog fennel)
  5. Anticholinergic and Hallucinogenic Risks
    1. Catnip
    2. Juniper
    3. Lobelia
    4. Jimsonweed
    5. Wormwood
    6. Nutmeg
  6. Laxative abuse risk
    1. Buckthorn bark
    2. Senna
    3. Dock roots
    4. Aloe vera
  7. Abortion risk in pregnancy
    1. Devil's claw root
    2. Barberry
    3. Dong Quai
    4. High concentrations of Ruta, Hydrastis or Oregano
  8. Bleeding risk (Anticoagulant activity)
    1. Ginkgo Biloba
    2. Feverfew
    3. Garlic
    4. Ginseng
    5. Dong Quai
    6. Red Clover
  9. Cardiovascular effects
    1. See Herbals Affecting Blood Pressure
    2. Arrhythmias
      1. Yohimbine
    3. Strong Stimulants (result in ED visits for Palpitations, Chest Pain)
      1. See Ephedra and Caffeine
      2. Guarana
      3. Yerba mate
      4. Kola nut
      5. Bitter Orange

VI. History

  1. Do you use Alternative Medicines?
    1. Herbal Product?
    2. Herbal Supplement?
    3. Natural Remedy?
  2. What other prescribed or OTC medications do you use?
  3. For how long have you used this herbal product?
  4. Do you have any allergies to plant products?
  5. Are you currently pregnant or Breast Feeding?

VII. Precautions: Pointers for patients purchasing herbal products

  1. Purchased products should be labeled appropriately
    1. Botanical name of herb
    2. Strength or concentration of active ingredient
    3. Batch or lot number
    4. Expiration date
    5. Name of manufacturer and contact information
  2. Avoid herbal products in pregnancy and Lactation
    1. Be particularly cautious in first trimester
    2. See adverse effects above or see specific herb
  3. Use herbal therapies with caution if immunocompromised
    1. Herbal therapies may be contaminated with microbes
  4. Use the lowest effective dose of a product
  5. Avoid prolonged use of any product
  6. Stop herbal therapies 2 weeks before elective surgery
  7. Avoid mixing herbal products
  8. Discuss herbal use with your physician
    1. Discuss potential Drug Interactions with physician
    2. Discuss adverse effects (see above)
    3. Reevaluate efficacy and safety on regular basis
  9. Avoid potentially sedating agents prior to driving or other activity requiring full concentration
    1. Relaxation drinks (e.g. Neuro Bliss, Just Chill, Marley's Mellow Mood)
      1. Contain Valerian Root, Kava xtract, GABA and Melatonin
      2. (2014) Presc Lett 21(1): 5
  10. Check manufacturer quality
    1. ConsumerLab.com
      1. http://www.consumerlab.com

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Ontology: Alternative Medicine (C0002346)

Definition (PSY) Treatments, health care practices, or culturally based healing traditions which are not generally used in conventional medical practice.
Definition (CSP) diagnostic or therapeutic technique which is presently outside the field of conventional medical practice; for use as a 'tag' term index at 'T' emphasis level.
Concepts Biomedical Occupation or Discipline (T091)
MSH D000529
English Alternative Medicine, Medicine, Alternative, ALTERNATIVE MED, MED ALTERNATIVE, alternative medicines, alternative medicine, Alternative medicine, CAM, Alternative Therapy
Czech alternativní lékařství, alternativní medicína
Portuguese Medicina Alternativa
Spanish Medicina Alternativa
German Alternative Medizin, Medizin, alternative
Italian Medicina alternativa
French Médecine non conventionnelle, Médecine alternative
Croatian ALTERNATIVNA MEDICINA
Norwegian Alternativ medisin, Medisin, alternativ
Dutch Geneeskunde, alternatieve

Ontology: Phytotherapy (C0242388)

Definition (NCI_NCI-GLOSS) A type of medicine that uses roots, stems, leaves, flowers, or seeds of plants to improve health, prevent disease, and treat illness.
Definition (NCI) Therapy based on plant-derived preparations which include the following: Individual herbs - Ginkgo biloba, Hypericum, Garlic, Ginseng, Echinacea, Saw palmetto, Urtica diocia (nettle), Kava kava, Hawthorne, Witch Hazel, Bilberry, Ginger, Aloe vera, Capsicum, Feverfew, Green tea, Tee Tree oil, Licorice root, Yohimbe, Valerian, Bee Pollen, Cat's Claw, Evening Primrose, Dong Quai, Fenugreek, Marshmallow, Psyllium, Turmeric. Combinations include: Padma 28, Hoxey, Essiac, Saw palmetto, Pygeum africanum.
Definition (MSH) Use of plants or herbs to treat diseases or to alleviate pain.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D008517
SnomedCT 414392008
Japanese フィトテラピー, フィトテラピー, 植物療法, ハーブ療法
Swedish Fytoterapi
English HERB THER, HERBAL THER, PHYTOTHER, Botanical Therapy, Phytotherapy or Herbalism, Herbal Medicine / Botanical Therapy, Phytotherapy, herb therapy, phytotherapies, herbal therapy, herb therapies, herbal therapies, herbs therapy, phytotherapy, Herb Therapy, Herbal Therapy, herbal medicine, Herbal therapy (regime/therapy), Herbal therapy, herbal medicine / botanical therapy
Czech fytoterapie, Fytoterapie
Finnish Yrttihoito
Italian Terapia erboristica, Terapia con le erbe, Fitoterapia
Russian TRAVY, TRAVOLECHENIE, FITOTERAPIIA, ТРАВОЛЕЧЕНИЕ, ТРАВЫ, ФИТОТЕРАПИЯ
French Thérapie par les plantes, Thérapie végétale, Phytothérapie
Polish Fitoterapia
Croatian Not Translated[Phytotherapy]
Hungarian Fitoterápia
Norwegian Urteterapi, Fytoterapi
Portuguese Terapia Herbária, Fitoterapia, Terapia de Ervas
Dutch phytotherapie, Phytotherapie, Kruidentherapie
German Phytotherapie, Kräutertherapie
Spanish terapia herbaria (régimen/tratamiento), terapia herbaria, Fitoterapia, Terapia Herbaria

Ontology: Chinese herbal medicine (C1273412)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 393109002, 394060007, 395114000
English chinese herbal medicine, chinese herbal medicines, Chinese herbal medicine (regime/therapy), Chinese herbal medicine
Spanish medicina china con hierbas (régimen/tratamiento), medicina china con hierbas

Ontology: Natural Products (C1566558)

Definition (NCI) Any whole or part of a plant (including plant exudates), animal or microorganism that is unprocessed (raw material), or that has been processed, pulverized or extracted. Many of the natural products have some biological and/or pharmacological activity or are used for a specific purpose, not necessarily medicinal (food, aroma therapy, research and etc.). This class does not include any individual substance derived from plants/animals or other organisms with specific pharmacologic activity (See Drug, Natural Product).
Concepts Biologically Active Substance (T123)
MSH D001688
English Natural Product, naturals products, product natural, natural products, natural product, Natural Products, Products, Natural
Portuguese Produtos Naturais
Spanish Productos Naturales
French Produits naturels, Substances naturelles
German Naturprodukte
Czech přírodní produkty
Italian Prodotti naturali

Ontology: Herbal medicine (product) (C2240391)

Concepts Pharmacologic Substance (T121)
SnomedCT 349365008
English herbal medicines (medication), herbal medicines, Herbal medicine (product), Herbal medicine, Herbal medicine (substance)
Spanish medicina herbal (producto), medicina herbal

Ontology: Herbal toxicity (C2721638)

Concepts Injury or Poisoning (T037)
English Herbal toxicity
Spanish Toxicidad por plantas
Portuguese Toxicidade de uma fitoterapia
French Toxicité d'une phytothérapie
Italian Tossicità di erbe
German Toxizitaet von Kraeutern
Dutch kruiden toxiciteit
Czech Toxicita rostlin
Japanese ハーブ毒性, ハーブドクセイ
Hungarian Gyógynövény toxicitás

Ontology: Herbal interaction (C2938878)

Concepts Pathologic Function (T046)
English Herbal interaction
Dutch wisselwerking tussen kruiden
Spanish Interacción de fitoterapia
Portuguese Interacção de fitoterapia
Italian Interazione da erbe medicinali
German Wechselwirkung mit pflanzlichen Mitteln
French Interaction de phytothérapie
Japanese ハーブソウゴサヨウ, ハーブ相互作用
Czech Rostlinná interakce
Hungarian Gyógynövény kölcsönhatás