Clinical Herbal Medicine Session 1 Naturopathic Medicine ... · PDF fileGIT Herbal Actions o...

© Endeavour College of Natural Health endeavour.edu.au 1

WHMC311

Clinical Herbal Medicine

Session 1

Naturopathic Medicine

Department


WHMC311

Assessment Tasks

TypeLearning Outcomes

Assessed

Session Content Delivered Session Due Weighting

Mid Semester Examination

(1 hour)1,3,4,5 1-18 19 20%

Case Study Report

(2000 words)1-5 1-27

Sunday following

Session 2730%

Final Examination

(3 hours)1,3,4,5 1-39 Final Exam Period 50%

Subject Outline and Assessment


WHMC311Assessment

Mid-semester Exam

• Multiple choice – 20 questions; 20 marks

• Short answer questions – 4 questions; 20 marks

• Case study – 20 marks

Case Study Report

• See Case Study Report and Template Guidelines

Final Exam

• Case study 1 – 50 marks

• Case study 2 – 50 marks


WHMC311

Session 1

Gastrointestinal &

Alimentary Disease Part I


Topic Overview

o Introduction to clinical decision making

o Revision of basic pharmacology principles

o Principles and considerations in herbal medicine

management of the GIT

o Review anatomy & physiology of the GIT

o Herbal management of specific GIT conditions

• Gastro-oesophageal reflux disease

o Consideration of drug-herb interactions


Pharmacology

o Pharmacology is the study of drugs, including their

actions & effects in living systems. It deals with the

principles behind the prescribing process

o WHO definition of drug

• “Any substance or product that is used or intended to

be used to modify or explore physiological systems or

pathological states for the benefit of the recipient” (WHO 2013)

o It considers the complex interaction between the patient

and the drug


PHARMACEUTICAL PHASE

Disintegration of dosage form to

Dissolution

PHARMACOKINETIC PHASE *

Drug in systemic circulation

Drug available for distribution

Drug distributed to organs & tissues

PHARMACODYNAMIC PHASE

Drug-molecular target interaction

Effect

Drug metabolised

or excreted

Elimination

(Bryant & Knights, 2010, p129)

Drug available for absorption

Administration

Dose of formulated drug


Integrated Pharmacology

o Integrated pharmacology is an evolving field that

encompasses the interface of pharmacotherapy and

herb/nutrient therapy

o Includes negative interactions, adverse effects and

positive interactions/potentiation

o Promotes the combined use of drug therapies and

complementary therapies in the safest and most

efficacious manner to ensure optimal management of

patient health and well-being


Integrative Interactions

o Encompasses several different possible outcomes when

drug therapies are combined with herbs, nutrients or

foods

o Some interactions are considered detrimental with the

potential for serious adverse effects, while others are

beneficial and may be used to manipulate outcomes

o The four main categories of interactions are

• Pharmacokinetic + or –

• Pharmacodynamic + or –

• Disease + or –

• Physiochemical + or –

(Bryant & Knights 2011, p190)


Integrative Interactions

o Thus combination of a drug therapy with a natural

therapy may result in:

• Reduced effect of drug

• Reduced effect of herb / nutrient

• Increased or decreased incidence of adverse effects

• Synergistic effect that is beneficial

• Synergistic effect that is negative

• Improvement in overall treatment of disease process, even

if the nutrient doesn’t interact with the prescribed drug

• Changes to any pharmacokinetic or pharmacodynamic

properties of drug/herb/nutrient - with varying outcomes.



Interactions - Pharmacokinetic

o Pharmacokinetic interactions occur when the

combination of drug-drug, drug-herb or drug-nutrient

results in any alteration in absorption, distribution,

metabolism or excretion.

o The change thus relates to the duration or magnitude of

drug effect, rather than the type of effect.



Interactions - Absorption

o Most orally administered drugs are absorbed in the small

intestine. Interactions may affect the rate of absorption or

extent of absorption

o Substances that alter gut motility

• Substances that either increase of decrease the rate of gut

motility can influence drug absorption e.g. laxatives

o Mucilaginous substances

• May form a physical barrier that affects absorption e.g. psyllium,

slippery elm.

o Substances that affect gastric acid

(Braun & Cohen, 2010 p95)


P-glycoprotein

o This is a protein that assist in the transport of drugs out

of cells (efflux pump)

o P-gp expression can be altered by factors such as

certain pharmacological therapies, herbal therapies and

some foods

o Inhibition of P-gp leads to an increase in absorption,

distribution and bioavailability

o Induction of P-gp leads to a decrease in absorption,

distribution and bioavailability

(Braun & Cohen 2010, p96)


Inhibition of P-glycoprotein

o Grapefruit juice Orange and apple juice

o Rosemary extract

o Isoflavones – Genestein and diadezein

o Resveratrol

o Quercetin

o Green tea polyphenols

o Piperine (found in black pepper)



Interactions –

Pharmacokinetic Metabolism• Metabolism occurs mainly in the liver and the extent of metabolism

will affect how much drug reaches systemic circulation

• The most well known metabolic interactions relate to influences on

the Cytochrome P450 system

• Interactions may be due to either the inhibition or induction of the

Cytochrome P450 enzymes

• The most important CYP enzymes in terms of interactions are

CYP1A2, CYP2D6, CYP3A4.

• These three enzymes are responsible for the metabolism of over

50% of most medicines

(Braun & Cohen, 2010, p97)


CYP Enzyme Inhibition

o Slows down rate of metabolism and raises serum levels

of drugs metabolised via this pathway

o Small changes in drug bioavailability can have significant

clinical effects on drugs with a narrow therapeutic index

o Grapefruit juice may cause CYP enzyme inhibition which

can significantly increase bioavailability of some drugs

e.g. the calcium channel blocker, felodipine.

o Drugs that inhibit CYP enzymes include fluoxetine and

cimetidine


Interactions –

Pharmacokinetic Metabolism

o Drugs with a narrow therapeutic index are most

affected by changes to CYP enzyme activity as there is a

greater risk of toxicity or sub-therapeutic dosing

o Inducers will accelerate drug metabolism and reduce

blood levels

o Inhibitors will slow down drug metabolism and increase

blood levels

(Bryant & Knights 2011, p186-7)


Phase 1 Metabolism

o Phase 1 reactions are classified into oxidation, reduction

and hydrolysis

o The largest family of membrane-bound, nonspecific,

mixed-function enzymes is called the cytochrome P450

system

(Schonborn 2010)


Phase II Metabolism

o Phase 2 reactions are conjugation reactions.

o There are several phase two detoxification pathways:

• Glutathione conjugation

• Amino Acid conjugation

• Methylation

• Sulphation

• Acetylation

• Glucuronidation

• Sulphoxidation



Interactions –

Pharmacokinetic Excretion

o Factors that alter urine pH will influence renal drug

excretion

o Herbal medicine with the action of diuretic may also

influence renal drug excretion



Interactions - Pharmacodynamic

o Fairly predictable through a knowledge of mechanism of

action of both substances, however strength of effects

and clinical relevance is not always known

o There may be variations in clinical response due to

• Dose of substances used together

• Individuals response

• Time frames of use




o Additive or synergistic interactions: improved patient

outcomes

• Drug + drug (e.g. 2 different analgesics or antibiotics used

in combination)

• Herb + herb (e.g. 2 different nervines)

• Drug + herb (e.g. antihypertensive + Allium sativum)

o Additive effects may also be detrimental

• e.g. both drug and herb cause drowsiness → excessive

response possible e.g. Likely interaction between selective

Gamma-Aminobutyric Acid (GABA) medications and

Scutellaria baicalensis(Johnston et al 2009)



Antagonistic interactions → where effects of drugs and

food/herb counteract each other.

For example.

o Sedative drug (e.g. benzodiazepine) with stimulant

substance (e.g. coffee)

o Immuno-modulator herb (e.g. Echinacea with Immuno -

suppressive drug (e.g. Cyclosporin)


Interactions - Physiochemical

o Where a chemical interaction occurs between two

compounds, usually resulting in either reduced or

increased absorption

• Vitamin C increases the absorption of iron

• Slippery elm reduces the absorption of other substances if

taken concomitantly

o Chelation refers to interaction between a metal ion and

another substance leading to reduced activity or

inactivation of the mineral and/or drug

• e.g. iron + tetracyclines

(Braun & Cohen, 2010, p101)


Interactions - Disease

o When a substance alters a disease state

o Positive effects (Desirable outcome and the reason for

therapy) e.g. Harpagophytum procumbens seem to

reduce low back pain more than placebo (Gagnier et al 2007)

o Negative effects (To be avoided if risk does not

outweigh the benefit) e.g. pregnancy and Caulophyllum

thalictroides (Tiran 2003)


Interactions - Integrative

o When using drugs in combination with herbs or nutrients,

the risk-benefit ratio should be considered so as not to

place the patient at risk.

o The benefits are the perceived or expected

improvements in health or disease management with

use of the prescribed medication / treatment

o Risks are evaluated vs. benefits (i.e. Risk: Benefit Ratio)


Interactions - Integrative

o The safety of using drugs and herbs/nutrients

concurrently depends on factors such as:

• Predicted potential for an interaction

• Appropriate use (dose, indication, route of administration

etc); applies to drugs, herbs and nutrients

• Quality of products used. Contaminants may be the cause

of an adverse interaction rather than the herb or nutrient

itself.


Gastrointestinal Tract


Review of the GIT

Functions

1. Ingestion

2. Secretion (Cells within the GIT secrete up to 9L per day

of various acids, buffers or enzymes into the GIT)

3. Mixing and propulsion

4. Digestion: Both mechanical and chemical

5. Absorption: of macronutrients and micronutrients.

6. Defaecation: removal of waste products


Review of the GIT

o An intelligent self-correcting disassembly line

o Coordinated absorption, secretion and motility

o Immune and nervous system inter-relationship

o Disturbed gut permeability

o Intestinal flora

o Stomach and chemical mediators of digestive activity

(Mills & Bone, 2012, pp.183 – 188)


Naturopathic Diagnosis

o Iris:

• The Assimilation Ring (colour and thickness)

• The ‘Ruff Zone’ represents the integrity and function

of stomach and Intestinal tissue (size and colour)

• Stomach halo

• ANW

• Radii solaris

(Jensen, 1952)


GIT Herbal Actions

o Laxatives - bulking &

anthraquinone

o Emetics - saponins

o Demulcent - mucilages

o Bitter

o Sialagogue

o Carminative

o Choleric

o Cholagogue

o Hepatoprotective

o MM trophorestorative

o Tannins

o Pungent

o Volatile Spasmolytics

o Resins

(Mills & Bone, 2012, p.183–214)


Common GIT Herbs

o Matricaria chamomilla

o Chelidonium majus

o Cynara scolymus

o Glycyrrhiza glabra

o Silybum marianum

o Schisandra chinensis

o Gentian luteum

o Frangula purshianus

o Aloe vera

o Taraxacum officinale

o Foeniculum vulgare

o Althea officinalis

o Filipendula ulmaria

o Ulmus fulva

o Geranium maculatum

o Mentha piperita


Gastro-Oesophageal Reflux

Disease (GORD)


GORDo GORD develops when the oesophageal mucosa is

exposed to gastric contents for prolonged periods of

time.

o This can be related to:

• Reduced sphincter tone. May be related to coffee,

chocolate, fatty foods, mints, cigarette smoking,

carbonated beverages and alcohol (Murray & Pizzorno

2006:661)

• Inappropriate sphincter relaxation; reflux with intra-

abdominal pressure rises (Haslett et al 2002:775)

• Raised intra-abdominal pressure may be caused by

overeating or obesity (Murray & Pizzorno 2006:661)


Pathophysiology

(Tortora & Grabowski, 2003, pp.861-62)


Naturopathic Treatment

o Case taking: S.O.A.P.

o Assessment - Naturopathic principles (First do no harm –

integrative pharmacology), Therapeutic order, Process of

disease and healing, naturopathic diagnosis

o Treatment

• S.M.A.R.T. - Short and long term goals

• Actions

• Treatment – building a formula, posology


Clinical Presentation

o Major symptoms: heartburn and regurgitation (often provoked by bending, straining or lying down)

o ‘Waterbrash’ is often present

o Some patients are woken at night by choking as refluxed fluid irritates the larynx.

o May develop odynophagia or dysphagia.

o A few present with atypical chest pain which maybe

severe, can mimic angina and is probably due to reflux

induced oesophageal spasm.

(Davidson & Haslett, 2002, p.776)


Red Flags

o Weight loss

o Dysphagia

o Epigastric mass

o Anaemia

o Signs of internal bleeding

o No response to treatment within six weeks - refer(Hawrelak, 2014, p.103)


Pharmaceutical Management

Drug therapy for GORD is directed at:

Decreasing/neutralising the acidity of the reflux

o Antacids, H2-blockers, PPIs

‘Raft’ antacids

o Alginic acid, sucralfate

Increasing gastric emptying

o Metoclopramide, domperidone

Improving LOS tone and pressure

o Metoclopramide

(Kumar & Clark, 2009)



Antacids

Mode of Actiono Neutralise gastric acid by increasing bicarbonate and mucus

secretions, inactivate pepsin, bind bile salts & enhance gastric

microcirculation.

o Magnesium & aluminum based antacids are the most common.

Magnesium hydroxide is the most potent acid neutralising

compound with the longest action. All require regular dosing.

Side Effectso Diarrhoea (magnesium), constipation (aluminum).

o Hypophosphataemia (if low phosphate intake), Hypercalcaemia (if

susceptible to alkalosis)

(Bullock et.al. 2007)(Bryant & Knights, 2007)



‘Raft’ Antacids - Alginic Acid, Sucralfate

Mode of Action

o Create a slimy jelly (‘raft’) when combined with acid that forms a

protective layer that prevents the diffusion of acid, pepsin and bile

salts towards the gastric mucosa.

o Sucralfate increases bicarbonate and mucus production, local

prostaglandin release and synthesis allowing repair and restitution

of the gastric epithelial cells.

(Bullock, Manias & Galbraith, 2007)

Side Effects

o Low incidence (less than 5% of patients). Constipation

o Sucralfate can cause nausea, headache, rash, dizziness & indigestion

(Bryant & Knights, 2007)


Pharmaceutical ManagementProton Pump Inhibitors (PPI)

Mode of Action

o Form a non-competitive and irreversible bond with the enzyme

H+/K+ - ATPase on the surface of the gastric parietal cells to reduce

gastric acid output (lasts for several days after discontinuation of the

drug).

o Treatment can produce rapid relief of symptoms and healing of

oesophagitis in patients with GORD. Relapse is common.

Side Effects

o Diarrhoea, nausea, abdominal pain. Headache.

o Sustained reduction in hydrochloric acid production causes a

proportional increase in release of gastrin (linked to carcinoid tumor

formation in rat trials).

(Bullock et.al. 2007)(Bryant & Knights, 2007)



Dopamine 2 Antagonists - Metaclopramide, Domperidone

Mode of Action

o Dopamine antagonist which blocks the inhibitory effect of dopamine on gut motility to increase gastric emptying & increases lower oesophageal sphincter tone.

o Domperidone is less effective in treating GORD but it is utilised by clients that have increased side effects from metaclopramide.

Side Effects

o Metoclopramide causes drowsiness, sedation, fatigue, nervousness, anxiety, weakness, diarrhoea, insomnia, extrapyramidal symptoms (e.g. acute dystonia, tardive dyskinesia)

o Domperidone has less CNS effects as it minimally crosses BBB.

(Bullock et.al, 2007)(Bryant & Knights, 2007)


Information Gathering

o Establish particulars

• How long have they had GORD? Severity? Triggers?

Symptoms? Diet? Stress? Medication? Weight? Referral?

o Determine causative factors

• Diet, alcohol, lifestyle, high BMI, medications, genetics, poor

oesophageal tone, digestive irregularities, inflammation

o Formulate treatment plan

• Diet/nutrients, lifestyle, herbal, exercise


Treatment Considerations

o The level of treatment of GORD is determined by the

severity of the disease.

o In all cases of GORD, lifestyle modifications are an

essential component in treating this condition.

o Patients with mild, intermittent GORD may respond to

lifestyle modifications alone.


Treatment Aims

o Relieve symptoms of reflux

o Reduce frequency of reflux

o Improve mucosal resistance

o Avoid recurrence of symptoms

o Prevent development of complications

o Eliminate exacerbating factors

• Encourage lifestyle modifications

• Dietary changes(Hawrelak, 2014, p.104)


Herbal Actions

o Demulcent – Improve mucosal resistance (after meals

and before bed)

o Anti-inflammatory

o Carminative

o Astringent – tone LOS

o Consider nervous system stress levels and treat

accordingly

o Bitter – low dose to increase LOS tone, improve saliva

output and accelerate gastric emptying. Used cautiously.(Mills & Bone 2013, pp195-196, Hawrelak 2014, p.104-107)


Treatment Considerations

o Demulcents

• Althea officinalis, Ulmus fulva, Glycyrrhiza glabra

o Anti-inflammatory

• Filipendula ulmaria, Curcuma longa, Glycyrrhiza glabra,

Matricaria recutita, Calendula officinalis, Symphytum officinale,

Aloe barbadensis

o Astringent (tone lower oesophageal sphincter)

• Germanium maculatum, Achillea millefolium, Calendula

officinalis, Hamamelis viginiana, Agrimonia eupatorium(Hawrelak 2014, p.104-108)


Prevention

o One of the more serious complication of GORD is the

development of Barrett's oesophagus, a metaplastic

change of the lining of the oesophagus that is associated

with an increased risk of oesophageal adenocarcinoma

o Prevent reflux

o Reduce oxidative stress

o Lifestyle/dietary factors


Drug-Herb Interactions

o Prokinetics:

• Metoclopramide may have an additive effect with

Asparagus racemosus (Shatavaria) (Dalvi et al 1990, as cited in

Braun & Cohen 2010, p863)

• Metoclopramide may interact with Kava (Mills & Bone 2005

p162)

o Antacids:

• Zingiber officinale (Ginger) may decrease

effectiveness of drug. Theoretical concern due to

increased gastric secretory activity, inhibition platelet

aggregation. No cases reported (Mills & Bone 2005, p59)



o Antacids:

• Capsicum minimum frequent consumption causes

alimentary mucosa irritation due to increased gastric acid

production, gastric mucosal exfoliation and bleeding (Brinker

2010, p.91)

• Amoracia rusticana may antagonise and irritate mucosa

due to the membrane irritating effect of the volatile oils on

the mucosa (Brinker 2010, p.205)

• Brassica alba/juncea/nigra (white, Chinese and black

mustard) may antagonise and irritate mucosa due to

irritation caused by allyl isothiocyanate release (Brinker 2010,

p.249)



o H2 Antagonists:

• Cranberry juice increases absorption of Vitamin B12

when used concurrently with PPI’s – Beneficial

interaction (Saltzman et al 1994)

• Glycyrrhiza glabra (Licorice), adjunct to treatment. (Braun & Cohen 2010, p657)

• Hypericum perforatum (St. Johns Wort), monitor for

signs of reduced drug effectiveness. (Braun & Cohen 2010)


Readings for this session

o Reading 1: “Introduction to the practice of integrative

medicine” Braun, L Cohen, M Herbs and Natural

Supplements: An evidence based guide.

o Reading 2: “Slippery elm” Braun, L Cohen, M Herbs and

Natural Supplements: An evidence based guide

o Reading 3: “Interaction with herbal and natural

medicines” Braun, L Cohen, M Herbs and Natural

Supplements: An evidence based guide


Readings for next session

o Reading 1: Arthur, R 2014 “Dear Doctor”

http://rachelarthur.com.au/dear-doctor/

o Reading 2: “Safety of Complementary Medicines”

Braun, L Cohen, M Herbs and Natural Supplements: An

evidence based guide

http://rachelarthur.com.au/dear-doctor/


ReferencesBaron, J 1963, Studies of Basal and Peak Acid Output with an Augmented Histamine Test, Gut, Vol.4,

p.136-144.

Barrie, S 2006, Heidelberg pH Capsule Gastric Analysis, Chapter 21. Cited in Murray MT, & Pizzorno, J

2006, Textbook of Natural Medicine, 3rd ed., Churchill-Livingston, Missouri.

Begg, E 2003, Instant Clinical Pharmacology. Blackwell Publishing Ltd

Birckelbaw Kopacek K, 2007, Merck Manual Online Medical Library.

Bone, K Mills, S, 2013 Principles and Practice of Phytotherapy: Modern Herbal Medicine, 2nd Edn,

Churchill Livingstone, Edinburgh

Boon, N.A,Colledge, N.R, Walker, B.R, 2006, Davidson’s Principles and Practice of Medicine, 19th edn,

Churchill Livingstone, United States.

Braun, L 2007, ‘Being Sensible about Interactions’, The Journal of Complementary Medicine, vol. 6 no.

1, pp. 5.

Braun, L Cohen M, 2010, Herbs and Natural Supplements, An Evidence-based Guide, 3rd edn, Elsevier,

Australia.

Brinker, F 2010, Herbal Contraindications and Drug interactions plus Herbal Adjuncts with Medicines, 4th

Edn, Eclectic Medical Publications, Sandy, Oregon

Brunton, L Lazo, J Parker K, 1996, Goodman and Gilman: The Pharmacological Basis of Therapeutics,

9th edn, McGraw-Hill.

Bryant B, Knights K, 2011, Pharmacology for Health Professionals, 3rd edn, Mosby, Australia.

Bullock, S., Manias, E. & Galbraith, A 2007 Fundamentals of Pharmacology 5th edn, Pearson, NSW

Davidson, S Haslett, C 2002, Davidson’s Principles and Practice of Medicine, 19th edn, Churchill

Livingstone, United States.

Dorland,W.A.N,2003, Dorland's Illustrated Medical Dictionary, 30th Edition, Elsevier, Canada.


ReferencesDi Piro JT et al. 1997. Pharmacotherapy, A Pathophysiological Approach, 3rd edn, Appelton Lange USA.

Gagnier JJ, van Tulder MW, Berman B, Bombardier C. 2007, Spine (Phila Pa 1976), Herbal medicine for

low back pain: a Cochrane review, Jan 1, Vol 32, Issue 1, pp. 82-92

Galbraith, A Bullock, S Manias, E 2004, Fundamentals of Pharmacology, 4th edn, Pearson, Aust.

Hampel, H Abraham, N El-Serag, H 2005, Meta-Analysis: Obesity and the Risk for Gastroesophageal

Reflux Disease and Its Complications, Annals of Internal Medicine, vol.143, no.3 pp. 199-211,

Haslett, C Chilvers, E Boon, N Colledge, N eds. 2002, Davidson’s Principles and Practice of Medicine,

Churchill-Livingston, London.

Hawrelak, J 2014 ‘Gastro-oesophageal reflux disease’, in J Sarris & J Wardle (eds), Clinical naturopathy:

an evidence based guide to practice, Churchill Livingston Elsevier, Sydney

Itagaki,S et al. 2010. Grapefruit juice enhances the uptake of coenzyme Q10 in the human intestinal cell-

line Caco-2, Food Chemistry Vol 120. Iss 2. pp. 552-555Jensen, B 1952, The Science and Practice of Iridology Vol.I & Vol.II, Jensen Publishers, USA.

Johnston, G Chebib, M Duke, R Fernandez, S Hanrahan, J Hinton, T Mewett, K 2009, Herbal Products

and GABA Receptors, Encyclopedia of Neuroscience, vol. 4, pp. 1095-1101

Katzung, B Masters, S Trevor, A 1992, Basic and Clinical Pharmacology, 5th edn, Prentice-Hall

International Inc.

Mills, S Bone, K 2000, Principles and Practice of Phytotherapy: Modern Herbal Medicine, Churchill-

Livingston, London.

Mills, S Bone, K 2005, The Essential Guide to Herbal Safety, Elsevier, Churchill Livingstone.

MIMS Annual 2006 MIMS Desk Reference April/May 2006

Nilsson, M Johnsen, R Ye, W Hveem, K Lagergren, J 2003, Obesity and Estrogen as Risk Factors for

Gastroesophageal Reflux Symptoms, Journal of American Medical Association, Vol.290, No.1 pp. 66-72


ReferencesMarcuard, S Albernaz, L Khazine, P 1994, Omeprazole Therapy Causes Malabsorption of Cyanobalamin

(vitamin B12), Annals of Internal Medicine, Vol.120, No.3 pp.211-215

Morgan, A McAdam, W Pacsoo, C Darnborough, A 1982, ‘Comparison between cimetidine and Caved-S

in the treatment of gastric ulceration, and subsequent maintenance therapy’, Gut, vol.23, no.6, pp.545-

551.

Murray, M & Pizzorno, J 2006, Textbook of Natural Medicine, 3rd edn, Churchill-Livingston, Missouri.

Pert, C 1997, Molecules of Emotion: The Science Behind Mind-body Medicine, Scribner, New York.

Pert, C Snyder S, 1973. “Opiate receptor: Demonstration in Nervous Tissue”, Science,

Vol.179,no.4077,pp.1011-1014

Saller, R, Pfister-Hotz, G, Iten, F, Melze,r J, Reichling, J, 2002, “Iberogast: a modern phytotherapeutic

combined herbal drug for the treatment of functional disorders of the gastrointestinal tract (dyspepsia,

irritable bowel syndrome)--from phytomedicine to "evidence based phytotherapy." A systematic review”.

Forsch Komplementarmed Klass Naturheilkd. Dec;9 Suppl 1, pp.1-20.

Schonborn, J 2010, The Role of the Liver in Drug Metabolism, Anaesthesia Tutorial of the Week 179

Speight, T Holford, N 1997, Avery’s Drug Treatment, A Guide to the Properties, Choice, Therapeutic Use

and Economic Value of Drugs in Disease Management, 4th edn, Adis International, Wiley-Blackwell

Szelenyi, I Thiemer I, 1979, Pharmacological experiments with compounds of chamomile. Experimental

studies of the ulcer protective effect of chamomile, Planta Medica, vol.35, pp.218-227.

Tiran, D 2003, The use of herbs by pregnant and childbearing women: a risk–benefit assessment ,

Complementary Therapies in Nursing & Midwifery, Vol 9, pp.176–181

Tortora, G Grabowski, S 2003, Principles of Anatomy and Physiology 10th edn, Wiley International, vol.24

pp.861-862

WHO 2013: The Importance of Pharmacovigilance - Safety Monitoring of Medicinal Products

(2002; 52 pages)

http://apps.who.int/medicinedocs/en/d/Js4893e/

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