Herbals, Vitamins & Supplements - Laulima · PDF filemade by plants and fungi. A Beale PHRM...

Herbals, Vitamins & Supplements

PHRM 203 Allison Beale

A Beale PHRM 203 Herbals 2

Herbals •  National Center for Complementary and Alternative Medicine, National Institutes of Health –  http://nccam.nih.gov/health/

herbsataglance.htm –  http://nccam.nih.gov/health/

stjohnswort/

•  National Library of Medicine –  http://

dietarysupplements.nlm.nih.gov/dietary/

•  Linus Pauling Institute at Oregon State University –  http://lpi.oregonstate.edu/


Herbals

•  FDA regulates dietary supplements under different regulations than drugs –  Dietary Supplement Health &

Education Act (DSHEA)

Center for Food Safety and Nutrition

•  www.cfsan.fda.gov/~dms/supplmnt.html

Ephedra


www.cfsan.fda.gov/~dms/supplmnt.html

Herbals •  Dietary supplements are

defined as:

–  Vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glandulars, and metabolites.

–  Dietary supplements can also be extracts or concentrates.


www.cfsan.fda.gov/~dms/supplmnt.html

Herbals •  Formulations include –  Tablets –  Capsules –  Softgels –  Gelcaps –  Liquids –  Powders –  They can also be in other

forms, such as a bar, but if they are, information on their label must not represent the product as a conventional food or a sole item of a meal or diet.


Vitamins

•  Organic substances required in minute amounts for growth and metabolism –  Coenzyme, cofactor

or regulator –  Available from a

balanced diet –  Supplements

www.vrp.com/prodimgs/3094w200.jpg

http://photos.upi.com/story/t/501e99934a652bf22ec535dbd3fc40b5/A_glass_of_milk_can_benefit_bad_hearts.jpg

Vitamin D is actually a group of steroid prohormones (fatty fish are loaded with it because of their diet). The “D” provitamins are numbered. D3 is made in the skin, D2 made by plants and fungi.


Minerals

•  Elements, none of which can be synthesized –  Available in

•  Food •  Water •  Supplements


Nutrients

•  Chemicals that must be ingested –  Can’t synthesize –  Can’t synthesize fast

enough –  Proteins, fats,

carbohydrates, vitamins and minerals

Photo by Gabe Palmer www.faqs.org/nutrition/images/nwaz_02_img0168.jpg


Fat Soluble Vitamins Adapted from: Focus on Nursing Pharmacology, 4th Ed, by AM Karch, Lippincott, Williams & Wilkins 2008

Vitamin Therapeutic use

A

Severe dietary deficiency(500K IU/d for 3 d, then 50K IU/d for 2 wk IM or PO. Excess Vitamin A can cause bone demineralization, blurred vision, ataxia, nausea and death.

E

In Premature infants to reduce the toxic effects of oxygen on the lungs and retinas. Do not give IV. High levels prolong Prothrombin Time.

Food sources: liver, milk, colorful fruits & veggies

Food sources: nuts & seeds, wheat germ oil, leafy greens




Calcifediol (calcidiol, D3)

Metabolic bone disease or hypocalcemia in patients receiving chronic renal dialysis or corticosteroids. (calcidiol = precursor to calicitriol, a hormone).

Chole-calciferol (D3)

Vitamin D deficiency (Osteomalacia, adults; Rickets, kids), hypocalcemic tetany & hypoparathyroidism. (Cholecalciferol = adipose & liver storage form) Form in many vitamin supplements.

Dihydro-tachysterol

(DHT)

Post-op tetany, idiopathic tetany, hypoparathyroidism. Synthetic vitamin D that is activated in the liver without renal hydroxylation as required with ergocalciferol (D2).

Ergo-calciferol (D2)

IM for GI, biliary or liver disease, refractory rickets, hypopara-thyroidism, familial hypophosphatemia. This is a form found in many vitamin supplements & is derived from fungi, not animals.

Vit D Sources: sunlight, some fish (salmon…), few foods

70% of <21yr olds are Vit D deficient




Phytonadione (K)

Hypoprothrombinemia due to anticoagulant use, hemorrhagic disease of the newborn, hypoprothrombinemia in adults. Do not give IV.

Vitamin K reverses the effects of WARFARIN

It DOES NOT reverse the effects of HEPARIN!! (Protamine may be used, but heparin shouldn’t be reversed, just allowed to degrade)

Rich food sources: Green leafy veggies (cabbage, kale, spinach, Swiss chard, parsley) and some veggie oils (soybean, olive, cottonseed &

canola)


Vitamin A Linus Pauling Institute, Oregon State University (http://lpi.oregonstate.edu/ )

Overview Functions

Vit. A = generic term for related retinoids. Retinol and retinal = “preformed vitamin A.” Retinal converted into retinoic acid, the gene active form. β-carotene (etc.) are converted to retinol.

Vision - retinol binds to opsin to make rhodopsin (visual purple)

Gene expression - Retinoic acid acts as a hormone to control cell differentiation & some protein synthesis

Immunity - Retinol required to maintain integrity and function of epithelium & lymphocytes. T-cells require retinoic acid receptor binding

Growth & development - Birth defects w/too much or too little. Retinoic acid regulates hGH synthesis

RBC production - Stem cells require retinoids to differentiate & to incorporate iron into hemoglobin


Vitamin E Linus Pauling Institute, Oregon State University (http://lpi.oregonstate.edu/ )

Overview Antioxidant Functions (unclear)

Vitamin E is a family of 8 antioxidants; 4 tocopherols (α, β, γ, & δ) and 4 tocotrienols (α, β, γ, & δ). α-tocopherol is the only form active in us. It is the form on which the RDA is based.

CV disease & CNS- supplementation may prevent 2nd MI and slow progression of Alzheimer’s dementia

Cataracts - May be prevented by antioxidant supplementation

Immunity - α-tocopherol enhances β lymphocyte function

Cancer - α-tocopherol may neutralize free radicals known to damage DNA leading to cancer.

Diabetes mellitus - Diabetes increases oxidative stress which α-tocopherol counters.


Vitamin D Linus Pauling Institute, Oregon State University (http://lpi.oregonstate.edu/ )

Overview Functions

Vitamin D is a prohormone that is metabolized to a variety of active forms. D3 is an intermediate formed in the skin. Further metabolism occurs in the liver and kidneys to the most potent form.

Calcium balance - PTH stimulates activation of Vit D which then ↑GI Ca++ absorption, kidney reabsorption and mobilization of Ca++ from bone.

Gene expression - Vitamin D acts as a hormone to control cell differentiation & proliferation

Immunity - Vit D receptor (VDR) on all WBCs. Vit D is a potent immune system modulator.

Insulin secretion - VDR on β-islet cells promoting insulin secretion when needed.

Blood pressure regulation - VDR control of renin production

Low sunlight exposure associated with Hi BP

Vit D deficiency linked to insulin resistance


Vitamin K Linus Pauling Institute, Oregon State University (http://lpi.oregonstate.edu/ )

Overview Functions

Vitamin K is essential for numerous blood clotting proteins. 2 naturally occurring sources: K1 - from plants and called phylloquinone. Bacterial forms are called menaquinone-n (“n” refers to the side chain size)

Coagulation - enables the binding of Ca++ by Vit K dependant clotting factors. The body stores very little Vit K; warfarin works by blocking the recycling of Vit K. Bone Mineralization - 3 Vit K dependent proteins in bone related to osteoblast activity. The synthesis of 1 of these proteins is controlled by Vit D.

Cell growth - not well understood, but a Vit K dependant protein is known to be a growth regulator with cell-signaling activities.


Water Soluble Vitamin examples Adapted from: Focus on Nursing Pharmacology, 4th Ed, by AM Karch, Lippincott, Williams & Wilkins 2008


Ascorbic acid (C)

PO, IM, slow IV, SC. Treats Scurvy, enhanced wound healing, burns. Studied to treat colds, asthma, CAD, cancer, schizophrenia. Toxic at high doses.

Cyano-cobalamin (B12)

Pernicious anemia (nasally with folic acid, for life)

Folates, Folic Acid

(B9)

Macrocytic anemia, prevention of birth defects (neural tube defects), reduce homocysteine levels for CV health

Sources: most fruits and veggies

Sources: liver, clams, trout, fortified foods

Sources: green, leafy veggies (foliage), citrus, legumes


Water Soluble Vitamins Adapted from: Focus on Nursing Pharmacology, 4th Ed, by AM Karch, Lippincott, Williams & Wilkins 2008


Niacin (B3)

AKA Nicotinamide

Pellagra, niacin deficiency, hyperlipidemia if no response to diet and exercise. Feelings of warmth or flushing usually pass within a couple of hours of administration. Sources: Meat (fish, fowl, mammal), fortified foods

Pellagra is a complication of INH therapy and

malnutrition (a potential complication of alcoholism!)

Pellagra manifests 4 “D’s” 1.  Diarrhea 2.  Photosensitive Dermatitis

•  “Pellagra necklace” 3.  Dementia 4.  Death




P (bioflavonoids)

Bleeding, abortion, poliomyelitis, diabetes, and other conditions, but little evidence that the antioxidant activity of these materials is efficacious

Pyridoxine HCl (B6)

Deficiency, isoniazid poisoning. Reduces L-dopa levels. Used since 1940’s to treat morning sickness.

Sources: chicken, turkey, salmon, russet potatoes, spinach, bananas, fortified foods




Riboflavin (B2)

Deficiency (Ariboflavinosis). May cause yellow or orange urine.

Thiamine (B1)

Wet beriberi or beriberi. Used PO to repel mosquitoes. Feelings of warmth or flushing should subside with hours.

Sources: milk, eggs, fowl, salmon, almonds, broccoli, fortified foods

Sources: wheat germ, peas, rice (enriched), pork, some nuts, milk, some fruits and veggies, fortified foods


B Vitamins (all water soluble) Linus Pauling Institute, Oregon State University (http://lpi.oregonstate.edu/ )

Vitamin Name Deficiency

B1 Thiamine Wet (CV) beriberi or dry (CNS/ANS) beriberi.

B2 Riboflavin Ariboflavinosis

B3 Niacin Pellegra (along with tryptophan)

B5 Pantothenic acid Acne, paresthesia

B6 Pyridoxine Anemia, etc.

B7 Biotin Kids: impaired growth, CNS

B9 Folic acid Macrocytic anemia, birth defects

B12 Cobalamin Macrocytic anemia, CNS

There are about 20 additional “B” vitamins under debate, including B4 (adenine), B10 (PABA) and Bp (Choline)


Nutrients Linus Pauling Institute, Oregon State University (http://lpi.oregonstate.edu/ )

Nutrient Function

L-Carnitine “Conditionally” essential micronutrient required for β-oxidation of long-chain fatty acids for energy

Choline (Bp) Used to synthesize cell membrane components (phospholipids, phosphatidylcholine & sphingomyelin), Acetyl Choline, chylomicrons, betaine (a source of methyl groups for metabolism)

Coenzyme Q10

Only required in hereditary mitochondrial conditions - it is required for mitochondrial respiration. Side note on CoQ10 – levels are lowered by statins. Taking a supplement may help to reduce muscle pain. Use a “gelcap” in oil or Vit E base to improve CoQ10 absorption.

Essential Fatty Acids

α-linolenic acid (Ω3, or ω3) & linoleic acid (Ω6) are essential. All the long chain Ω3 & Ω6 FA, and their metabolites, are synthesized from these precursors


Minerals Linus Pauling Institute, Oregon State University (http://lpi.oregonstate.edu/ )

Mineral Use

Calcium 99% in bones and teeth, but circulating levels must be maintained within critical, narrow limits

Chromium Required, but not understood. Increases insulin actions.

Copper Required for Redox RXNs, in “cuproenzymes” like cytochrome c oxidase (energy production), lysyl oxidase (connective tissue formation) and MAOs

Fluoride Improves density of teeth and bones, reduces dental caries



Mineral Use

Iodine Required for thyroid hormone synthesis.

Iron Key to metabolism, essential for 100’s of proteins

Magnesium Over 300 metabolic RXNs require Mg including energy production & cell signaling and migration

Manganese Essential co-enzyme in metabolism, bone growth, wound healing and antioxidant functions

Molybdenum

Cofactor for many enzymes including sulfite oxidase (metabolizes S-containing amino acids), xanthine oxidase (metabolizes nucleotides to uric acid), aldehyde oxidase (important metabolic detoxification RXNs).



Mineral Use

Phosphorous Formation of bone

Potassium Critical electrolyte, also a cofactor for enzymes

Selenium Trace element for Se-dependent enzymes (glutathione peroxidases, etc.)

Sodium (chloride) Both are critical electrolytes

Zinc Trace element in catalytic, structural and regulatory cell processes


Botanicals Adapted from: Focus on Nursing Pharmacology, 4th Ed, by AM Karch, Lippincott, Williams & Wilkins 2008

Bee Pollen

Reported use

Allergies, asthma, impotence, prostatitis, decrease cholesterol. Risk of hyperglycemia.

Potential drug-herb interactions (adapted from A-Z Guide to Drug-Herb-Vitamin Interactions, 2nd Ed. Ed. AR Gaby, MD. Three Rivers Press 2006 & Solve it with Supplements2, RA Schulman, MD. Rodale, 2007)

None currently reported

Cautions2 Allergic reactions, including anaphylaxis, possible.



Aloe

Reported use Topical burns, wounds; PO constipation (may have a laxative action)

Potential interactions (A-Z Guide to Drug-Herb-Vitamin Interactions1, 2nd Ed. Ed. AR Gaby, MD. Three Rivers Press 2006 & Solve it with Supplements2, RA Schulman, MD. Rodale, 2007)

Oral corticosteroids1

Laxatives may ↑electrolyte loss which may amplify the electrolyte loss caused by the corticosteroids; applying aloe topically with an OC enhanced the OC antiinflammatory effects on the skin

Glyburide1 Aloe juice + glyburide improved blood sugar and lipids in diabetics

Cautions2 Co-administration with laxatives, loop diuretics, zidovudine (AZT), diabetes drugs, anti-arrhythmics (including herbals)


Botanicals Adapted from: Focus on Nursing Pharmacology, 4th Ed, by AM Karch,

Lippincott, Williams & Wilkins 2008 http://nccam.nih.gov/health/images/blackcohosh_big.gif

Black cohosh

Reported use PMS, menopausal disorders, rheumatoid arthritis. Contains phytoestrogens, do not use with oral contraceptives, hormone replacement therapy, sedatives or antihypertensives


No well known drug interactions reported1

Cautions2 Not for use in pregnant women, children, patients with a history of blood clots, strokes, seizures or allergy to salicylic acid.



Lippincott, Williams & Wilkins 2008 http://dnr.alaska.gov/ag/PMCwebsite/pmcweb/images/pic45.jpg

Chamomile

Reported use

Topical wound treatment and conjunctivitis, PO - migraines, gastric cramps, anxiolytic. Caution - may contain coumarin. May cause depression. Not for use in pregnant women. May have cross-reacting allergy with ragweed


Chemotherapy agents 1

↓ ADRs of Cisplatin, cyclophosphamide, docetaxel, fluorouracil, methotrexate, paclitaxel - (may ↓ mouth sores)

Cautions2 Allergy to aster-family plants; may ↑ effects of warfarin, heparin, clopidogrel, ticlopidine, and pentoxifylline

Other supplements with potential anti-coagulant properties include: Vit E, garlic, ginkgo, ginseng, ginger, feverfew, Dong Quai and red clover



Lippincott, Williams & Wilkins 2008 www.michigan.gov/images/coneflower_macro_25702_7.jpg

Echinacea

Reported use Cold remedy. Avoid use >8weeks, may be hepatotoxic, avoid antifungals and use by SLE, TB and AIDs patients


Cyclophos-phamide 1

In a small study, adding echinacea resulted in a slightly improved cancer survival rate.

Cautions2

Allergy to aster-family plants. Echinacea should not be taken with immunosuppressants like corticosteroids, cyclosporine, amiodarone, methotrexate and ketoconazole. Echinacea may interact adversely with liver metabolism.

Herbals often made from E. purpurea, E. angustifolia, or E. palida & the chemicial composition varies wildly



Lippincott, Williams & Wilkins 2008 www.kmc.nsw.gov.au/resources/images/ginger-lilly2.jpg

Ginger

Reported use Antiemetic. Do not give with anticoagulants.


Chemotherapy agents 1 Antiemetic adjuvant

Anticoagulants 1 Ginger may reduce platelet adhesion

Cautions2 Ginger may interfere with anti-diabetic, cardiac, anticoagulant, and GI medications.

Other supplements with potential anti-coagulant properties include: Vit E, chamomile, garlic, ginkgo, ginseng, feverfew, Dong Quai and red clover


Botanicals Adapted from: Focus on Nursing Pharmacology, 4th Ed, by AM Karch, Lippincott,

Williams & Wilkins 2008 www.dem.ri.gov/programs/bpoladm/stratpp/forprod/graphics/ginseng1.jpg

Ginseng

Reported use

PO aphrodisiac, mood enhancer, tonic, antihypertensive, decreases cholesterol and blood glucose, cancer therapy adjuvant. May cause irritability, inhibits clotting (do not use with anticoagulants including NSAIDs). May interact with digoxin, estrogens and corticosteroids.


Cautions2 Do not take with anticoagulants, haloperidol, morphine, phenelzine (or other MAOIs). Use with caution if taking insulin or oral hyperglycemic medication

Other supplements with potential anti-coagulant properties include: Vit E, chamomile, garlic, ginkgo, ginger, feverfew, Dong Quai and red clover



Licorice

Reported use

PO soothes coughs, chronic fatigue syndrome and duodenal ulcer. Acts like aldosterone and blocks spironolactone. Can lead to digoxin toxicity. Contraindicated if severe liver or kidney disease exists, or hypertension or CAD. Do not take with thyroid drugs, antihypertensives or oral contraceptives.


Diuretics1 The ADRs of all potassium-depleting diuretics are enhanced (thiazide and loop).

Cautions2

Muscle pain and numbness may occur as well as pseudoaldosteronism which can cause headaches, high blood pressure and possibly, heart attack. It may cause water retention.



Lippincott, Williams & Wilkins 2008 http://stca.tas.gov.au/wp-content/uploads/2008/12/st-john-2.jpg

St. John’s Wort

Reported use

PO antidepressant, PMS treatment, antiviral. Topical treatment of wounds, insect bites. Avoid tyramine-containing foods as a hypertensive crisis is possible. May increase photosensitivity, don’t combine with photo-sensitizers. Serious interactions with SSRIs, MAOIs, kava, digoxin, theophylline, AIDs antivirals, antineoplastics, oral contraceptives.


Altered pharmacokinetics1

Atazanavir, benzodiazepines, cyclosporine, digoxin, fexofenadine, fluoxetine, fluvoxamine, fosamprenavir, indinavir, oral contraceptives, paroxetine, phenelzine, sertraline, theophylline, aminophylline, trazodone, TCAs, venlafaxine, warfarin.

Cautions2 Do not take with antidepressants, anxiolytics, anticoagulants, protease inhibitors (AIDs antivirals), steroids, antineoplastics

P450↑


Herbals you want your patient to tell you about (before surgery)

•  Bleeding risk –  Chamomile –  Gingko biloba –  Garlic –  Ginseng –  Fish oil –  Dong Quai (“Angelica”) –  Feverfew

•  Sedatives –  Kava –  St. John’s wort –  Valerian root

•  Hypertensives –  Ephedra –  Garlic

•  Dangerous drug interactions –  Licorice –  St. John’s wort –  Kava –  Valerian –  Echinacea –  Goldenseal

SOURCES: Rowe, D.J. Aesthetic Surgery Journal, March/April 2009; vol 29: pp 150-157. David J. Rowe, MD, MS, assistant professor, department of plastic surgery, University Hospitals Case Medical Center, Lyndhurst, Ohio. Chun-Su Yuan, MD, PhD, director, Tang Center for Herbal Medicine Research, Pritzker School of Medicine, University of Chicago. Heller, J. Plastic and Reconstructive Surgery, February 2006; vol 118: pp 436-445.


Other supplements Compound Use

Acidophilus

Uncomplicated diarrhea, especially that caused by rotavirus. UTIs, irritable bowel syndrome, shorten diarrhea caused by other bacteria (e.g., C. difficile) and eczema in children.

Creatine KREE ah tin

Enhance athletic performance and lean muscle mass (creatinine is metabolite excreted in urine)

DHEA (dihydro epiandosterone) Androgenic effects, improves vigor

Glucosamine PO osteoarthritis and joint pain/disease


Acidophilus

•  Probiotic - “friendly” bacteria

•  Regulated as “food” if taken PO

•  ADRs –  Mild bloating or gas


Creatine Phosphate

•  High-energy compound –  Critical energy source

for brain and muscle –  In muscle cells

•  Converts ADP into ATP by donating phosphate molecules to the ADP. ATP then used as energy source.

•  1st 2-7 seconds of Anaerobic activity

May ↑ lean body mass & strength, depending on diet, muscle fiber type, etc. Since it is added to sports drinks with sugar to improve uptake, energy “boost” may be due to sugar. Studies show it probably does not improve performance.


Dehydroepiandrosterone (DHEA)

•  Produced by adrenals –  Precursor of

testosterone and estrogen

•  ADRs –  Acne –  Hirsutism (in women) –  ↑ breast and prostate

cancer risk


Glucosamine sulfate •  Normal part of glycoaminoglycans

found in cartilage and synovial fluid –  Made from glucose + glutamine in the

body & from chitin in the lab

•  Only glucosamine sulfate has been shown to improve joint health

•  <12% bioavailable PO (low) –  Product may also only contain a

fraction (0-100%) of what is on label

–  May contain another form of glucosamine than what is on label

www.fsinh.com/Store/images/glucosamine%20sulfate.jpg

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Herbals, Vitamins & Supplements - Laulima · PDF filemade by plants and fungi. A Beale PHRM...

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