Post on 03-Oct-2020
transcript
Phytomedicine 2.0
Botanical Medicine in Clinical Practice
Aviva Romm, MD
Learning Objectives
Upon completion of this session, participants will be better able to:
1. Describe the role of botanical medicines as part of the continuum of “food as medicine.”
2. Be familiar with a selection of evidence-based phytomedicines for intestinal hyperpermeability, GERD, insulin resistance, dyslipidemia, and as anti-inflammatory agents.
3. Integrate evidence-based botanical medicines into an overall integrative treatment plan.
Food or Medicine?
It’s a Continuum
Food Herbs/Spices Herbal Medicine
Botanical Safety
Safe Medicine?
Case Study 1: JRA
Katie is 2 years old
Diagnosed with polyarticular JRA use by rheumatologist at 18 mo. old
Chronic pain, chronic NSAID use, regular steroid injections
Symptoms began after chronic NSAID and PPI use
Rheumatologist wants to begin methotrexate
Mom, an RN, is seeking alternatives
What’s Going On?
History
PMH
Born by NSVD, mother on insulin for poorly controlled GDM, then IDDM postpartum.
Live rurally + pesticide exposure, + heavy metal contamination, ? arsenic exposure
Antibiotic use history
Eczema
Gastritis
Mother is gluten intolerant
Nutrition Review
Picky eater
Hx low vitamin 25 OH-D
Evaluation/ Testing
Lyme (WB + ELISA, coinfx) negative
EBV negative
Celiac HLA, Gluten Abs negative
MTHFR +/-
Urine toxic metals elevated lead body burden
Iron deficiency anemia
Stool testing + roundworm, tx.
Detox studies low GSH
General Initial
Approach
Elimination diet Anti-inflammatory diet (including extended GF/DF)
4R program for gut hyper permeability
Anti-inflammatory botanicals
Observe for flare triggers
Reduce environmental toxin exposures
4 R Program
Remove: Triggers and irritants
Repair: Provide nutrients that nourish and heal the intestinal membranes and healthy flora. Consider L-glutamine, aloe vera gel, licorice root extract (or DGL), marshmallow root, zinc, and larch arabinogalactan.
Replace: Digestive enzymes and hydrochloric acid, for example, are replaced in this phase.
Reinoculate: Prebiotics and probiotics, along with good quality fiber
Supplements
Multivitamin
Omega 3 fats twice daily
Licorice root extract, marshmallow root, chamomile, ginger in powdered and liquid extract forms in foods
Meriva form of curcumin, 500 mg BID
Vitamin D3 2000 units/day
L-Glutamine 2.5 g twice daily
Infant Formula Probiotic
GSH topically
Licorice Traditional uses: cough, colds, sore throat, GERD,
gastritis, IBD Compounds in licorice increase local prostaglandin
levels that promote mucus secretion and cell proliferation in the stomach
Preparations without glycyrrhizin are called DGL
Dose 700-800 mg (760 mg) Chewable tablets
Safety Avoid in pts with HTN, hyperaldo (risk of hypoK), on
steroids Likely safe in healthy adults when used at doses not
exceeding 3 grams/d for periods up to 3-4 weeks. Avoid licorice in pregnancy, DGL likely ok
Chamomile
Traditionally widely used
Evidence based uses include: Colic (w/fennel, lemon balm) Pediatric “stomach aches” Diarrhea (w/apple pectin) Dyspepsia (in Iberogast) Oral mucositis Anxiety/GAD
Dose 1 ml TID (less for pediatric use)
Safety May cause allergic reaction in some individuals
(rare) w/ragweed allergy.
Turmeric What the Science Says
NIH: positive studies for UC, Crohn’s, rheumatoid d/o
In vitro and animal studies show it increases phase II enzymes and inhibits phase I CYP1A
Antioxidant effects: Down regulates COX2, LOX, NFkB, AP-1, TNF
Safety
Warfarin interaction, bleeding risk at high doses
Dose (Adult)
1200-2400 mg/d curcumin for IBD
India: average daily intake = 60 mg curcumin (2.5 gm/d of turmeric)
20 mg black pepper/1 kg curcumin -> approx. 2000% absorption increase
Ginger What the Science Says
Clinical research shows that taking ginger extracts can modestly improve pain in some patients with osteoarthritis.
May be comparable to ibuprofen in a dose of 500 mg twice daily
Also compared favorably to diclofenac + glucosamine sulfate
There is some preliminary evidence that ginger might be helpful for decreasing joint pain in patients with RA.
Dose (Adult)
250 mg ginger extract four times daily, dosing may vary according to the preparation
Marshmallow Root
Approved by the German Commission E for the treatment of oral and pharyngeal ulcers, and mild inflammation of gastric mucosa.
Potential anti-inflammatory effect based on in vitro effects on cytokines, TNF, and IL-6.
Lack of clinical research.
Considered quite safe; primary constituents are mucilage polysaccharides and flavonoids.
Treatment/Outcome
Had 1 (prescheduled) joint injection at the outset
Within 8 months no further need for NSAIDs or steroids
Per rheumatologist, methotrexate no longer indicated
Per rheumatologist, only 1 joint (index finger) remains slightly swollen compared to 8 joints before starting care
Able to run, play, dance without pain, just like other kids in family!
Case Study 2: Complex Adult
46 yo woman with:
BPAD, Anxiety, paranoia
CFIDS/ME, FM
Circadian rhythm sleep disorder
Hunger/ NES
GERD
Nausea, gastritis
SIBO
Lactose intolerance – (eats
dairy daily)
Insulin resistance
Osteopenia
Hypothyroidism
Joint pain
Dental caries
Hx hypovitaminosis D
Hx anemia
“Brain fog”
Decreased libido
FHx
Indian descent
Mother: obesity, inflammatory arthritis, dementia, depression
Father: obesity, depression
Sisters: cancer, obesity, depression, bipolar
Children: depression, ADD, SA SA (caffeine, MJ, ETOH)
Paternal Grandmother: depression
Uncles: depression
All family members, including pt., tapeworm hx
Soc Hx
Moved to US in 20s
Lives with husband, son in college – ADD on meds
Husband verbally abusive but also loving/attentive (he grew up with an abusive mother)
Financially comfortable
Stay at home mother
Family primarily in India
Meds/Allergies
Medications
Remeron for sleep-wake cycle - has also noticed increased appetite and weight gain on it
Lexapro - alternates because effectiveness goes away
Allergies: NKDA
Environmental HX
Mold growing up in India
No tuna or other fish
Composites as an adult; no fillings as a kid; 4 cavities past 4 yrs.
Household chemical exposures- lots of bleach
No other known toxic exposures
Physical Exam
Vitals
MSQ 74, BP 113/69, Ht 60, Wt 146.5, BMI 28.61, Waist Circ 36.5
Exam
Anxious, hyper speech, pleasant
Overweight, soft, doughy, “Damp”
Dark circles under eyes
Hair thin
Food Journal
Pertinent Labs
CBC: low normal Hb & Hct, Ferretin 14
NMR: HLD w/insulin resistance LDL-P 2187, LDL-C 123, HDL C-50, LDL-p 1320, Patt B, LP-IR 55
A1C 6.1
TSH initially 2.38, FT3 3.2, Iodine 38, RT3 19, neg abs, CRP 3.97
Glucose F 81, 1hr 189, 2 hr 145 (H)
Ins 1 hr 188 (H)
MTHFR A1298C +/+
Hcy 6.7
Vitamin D deficiency
Iodine low
Functional
Detoxification issues on ION
4+ yeast, SIBO, Leaky gut
Sl . Depressed AM cortisol w/H nl MN
Hg 20 on ION (post); Bismuth H
Leaky Gut
K.R. Functional Medicine Matrix
K.R. Initial Treatment
Plan
Mind Body Strategy Options: Select 2
15 minutes of breathing/relaxation exercises per day.
Biofeedback with Heart Math
Audiotapes - available on line to listen to before bed.
Biofeedback.
Do something for yourself everyday.
Take a warm bath several nights each week with 1 cup of Epsom salts and 5-7 drops of lavender essential oil in the bath for relaxation.
Diet
Low Glycemic/Portfolio Diet:
Low grains, eliminate white rice completely, no sugar and emphasize meats - willing to eat fish, chicken, lamb.
Dairy free
Avoid caffeine which increases anxiety and sleep problems
Exercise/ Osteopenia
Start with walking for 45 minutes 3 times/week.
Hypothyroid
Armour thyroid
CFIDS/ME, FM
Reduce inflammation and support detoxification and mitochondrial function
CoQ10
NAC
Turmeric in the form of Meriva, 2000 mg/day
A proprietary blend containing proteolytic enzymes, Boswellia, Ginger, Turmeric, Quercetin, Rosemary, and Resveratrol
Cardiometabolic Issues
Portfolio Diet
Flax seeds, olive oil, almonds, meta-sitosterol
Anemia
Iron chelate + buffered Vit C, Vitamin D 3000 u/d
Gut repair/GERD
4 R Program
Xifaxan for SIBO x 14 days
Nystatin x 30 days
Digestive Enzymes, Betaine HCL
Herbal product containing: L-Glutamine (5000 mg), Arabinogalactans (1000 mg), DGL (500 mg), Aloe Vera Leaf Extract 250 mg, Slippery Elm Bark (200 mg), Zinc Carnosine (100 mg), Marshmallow Root (100 mg)
DGL tablets, chew 2-3, 15 min before meals + before bed, PRN
Circadian rhythm sleep disorder NOS/ NES
Sleep hygiene practices
Balance blood sugar, and eating protein at meals and snacks will help. Also, we will look at your nutrition, gut flora, and for parasites to see if any of these are a contributing issue.
A proprietary blend containing B-complex, Magnesium, L-theanine, Valerian, Passionflower, Lemon balm, and Ashwagandha
A proprietary blend containing GABA (750 mg), L-tyrosine (1200 mg), Inositol (600 mg), Taurine (600 mg), 5-HTP (150 mg)
Melatonin 1-3 mg qhs
Anxiety
Lavela (lavender oil)
Bipolar affective disorder, depressed, moderate
EPA/DHA
Added in Deplin 7.5
GIFX post- treatment with 4R Plan
SIBO
What Can Happen…
Lost 25 + LBS
Said:
”I continue to feel so much better because of you”
“Anxiety has completely disappeared – the neurolink is so helpful”
“My stomach doing so well” - able to take her supplements
“Armour has helped so much” - feverish feeling resolved, sex drive returning
“Sleep is perfect”
“No joint pain”
“Mood better than [she] believed possible”
Is still tired by 5 pm
Diet - for 3 mo. was “religious” and lost so much weight. Started eating yogurt and gluten again - after a week started feeling unwell, couldn't walk properly - so went back off completely and within a week the inflammation is gone.
Summary of Lab (+) Changes
10 months into treatment:
LDL-P 1817, LDL-C 103, LDL-p 1084
A1C 5.6
Glucose F 93, 1hr 166, 2 hr. 116
Ins 1 hr. 127
Vit D 61
TSH > 5 started on Armour TSH 1.0 FT3 2.9
Hct >30 37.4
Ferritin 14 3553 after iron chelate and buffered vitamin C
Metabolic Syndrome
Flax Seeds
Actions
high fiber, anti-inflammatory, anticholesterolemic, antidiabetic, +/- reductions in breast CA, menopausal sx, mastalgia
Evidence
lignans weak phytoestrogens w/possible antiestrogenic effects
Dose
25-40 gm/day
Contraindications
Usually well-tolerated
Can significantly increase the number of bowel movements
Doses > 45 grams per day may not be tolerated for this reason
Some concern that large amounts could -> bowel obstruction; not likely to occur if consumed with adequate fluids
Olive Oil Reduced risk of CVD including risk of 1st MI by 82%
@4 TBS/day Reductions in cholesterol Modified diet including high amounts of EVOO over
6 months, with conventional treatments for hypertension, can significantly improve BP and lead to decrease doses or discontinued use of anti-hypertensives.
FDA allows olive oil and olive oil-containing food labels to state that limited evidence suggests that consuming 23 grams/day (~ TBS) of olive oil instead of saturated fats may reduce the risk of heart disease.
Lower risk of breast and colon CA associated with regular intake
Olive leaf extract taken orally can also be anti-hypertensive
Pomegranate
50 mL/day of juice leads to reduced intima-media thickness of the carotid artery by up to 35% after one year.
Drinking concentrated pomegranate juice 40 grams/day can significantly reduce total cholesterol and low-density lipoprotein (LDL) cholesterol in patients with hyperlipidemia and DM2.
Drinking pomegranate juice 50 mL/day for up to 1 year can reduce systolic blood pressure by 5% to 21%
POM Wonderful 240 mL daily for 3 months decreases stress-induced myocardial ischemia in patients with coronary heart disease.
Cinnamon 1, 3, or 6 g daily for 40 days lowered
fasting serum glucose by 18% to 29%, triglycerides by 23% to 30%, low-density lipoprotein (LDL) by 7% to 27%, and total Chol by 12% to 26% in pts. with type 2 diabetes
MA of 8 trials demonstrates that cinnamon reduces blood sugar modestly but effectively in DM2 pts
3 studies found no significant effect on blood glucose, HbA1C, Chol, or triglycerides when used in doses of 1-3 g daily up to 4 months
Hypoglycemic activity comparable to metformin
MA of 5 trials failed to identify improvement in 5 parameters including FBG, A1C
Safety
Overall safe, caution w/other DM meds
Milk thistle
Actions
Decreases insulin resistance, hepatoprotective, potent impacts on Phase I and Phase II detoxification, decreased NFK-b, COX-2, increased GSH, inflamm leukotrienese
Dose
200 mg TID stand. to 80% silymarin
Contraindications: n/a
45
Depression and Anxiety
St. John’s Wort Cochrane 2008: 29 RCTs on various preparations in MA. N = total
of 5489 patients
18 RCTs compared SJW w/ placebo; 17 RCTs compared SJW w/ Rx drugs
Superior to placebo in patients with major depression; similarly effective as standard antidepressants; fewer side effects than standard ADS.
Dose
Products standardized to 0.3% hypericin and/or 3-5% hyperforin
300-600 mg TID
Safety
Induces CYP3A4 subset of P-450 enzymes that metabolize many pharmaceuticals
Interacts with P- glycoprotein
Potential H-D interactions include warfarin, digoxin, cyclosporine, indinavir, irinotecan, and OCPs
Rhodiola
“Adaptogen”
Preliminary data suggests efficacy in the tx of GAD
Also helpful with stress, memory, and fatigue
Studies done in military cadets, college students, night shift workers
Dose
Clinical trials use products containing 2-3% rosavin and 0.8-1% salidroside.
Dose 100mg-400mg/day
Safety
Overall high safety profile
Care should be taken with BPAD
Lavender Promising data using oil extract for tx of
generalized and test anxiety
Study of a proprietary product showed effects comparable to lorazapam in the tx of anxiety based on HAM-A and SAS scores
Alleviates anxiety related sleep disturbance and improves sleep quality
Dose
Per package, typically 1 gel cap qhs
Safety
No sedative effects
No addictive or abuse potential
Kava kava Anxiety: Most evidence shows extracts
standardized to 70% kavalactones superior to placebo, and possibly comparable to low-dose benzodiazepines.
Most clinical studies have used the standardized extract WS 1490 (Schwabe), standardized to contain 70% kava-lactones (also known as kavapyrones). This extract is more than 2x as concentrated as most commercially available products.
Some evidence that upwardly titrating kava over 1 week while tapering benzodiazepine over 2 weeks can prevent withdrawal symptoms in some people with non-psychotic anxiety.
Kava kava (cont.)
• 2 small trials have shown that kava standardized to 15% or 70% kava-lactones is superior to placebo taken orally for short-term treatment of neurovegetative and anxiety symptoms related to climacteric. Significant improvement occurred after one week of treatment.
• Preliminary clinical research in healthy volunteers suggests that taking kava orally might reduce physiological reactivity during stressful situations.
Dose
• For anxiety disorders, most clinical trials have used kava extract standardized to 70% kava-lactone content. Doses of the kava extract were most commonly 100 mg (70 mg kava-lactones) three times daily
• Treatment for 1-8 weeks may be necessary for significant improvement though acute reductions in anxiety are possible
Safety
• Realistic concerns regarding hepatotoxicity, though rare occurrence given frequency of use globally.
• Unpredictability is the challenge.
• Check LFTs q. 6 weeks (no data on timing)
Key Clinical Take Home Points
1.The use of plant medicines (foods, botanicals) as alternatives to pharmaceuticals is not simply an ideological approach - it is a sound and important public health approach in the face of existing environmental and human costs of pharmaceutical overuse.
2.Botanicals have demonstrated safety and efficacy, some comparing even favorably to pharmaceuticals, in the treatment of common acute and common health problems.
3.Reliable resources are available for learning about and applying botanicals in clinical practice so that you can begin to safely and effectively integrate them into practice whether as foods or supplements.
Want to Learn (MUCH) More?
https://avivaromm.com/courses/fim-pro-training/sales/
References
Chamomile
McKay DL, Blumberg JB. A review of the bioactivity and potential health benefits of chamomile tea (Matricaria recutita L.). Phytother Res. 2006 Jul;20(7):519-30.
Ross SM. Generalized anxiety disorder (GAD): efficacy of standardized Matricaria recutita (German chamomile) extract in the treatment of generalized anxiety disorder. Holist Nurs Pract. 2013 Nov-Dec;27(6):366-8.
Srivastava JK, Shankar E, and Gupta S. Chamomile: A herbal medicine of the past with bright future. Mol Med Report. Nov 1, 2010; 3(6): 895–901.
Cinnamon
Baker WL, Gutierrez-Williams G, et al. Effect of cinnamon on glucose control and lipid parameters. Diabetes Care. 2008;31:41-3.
Crawford P. Effectiveness of cinnamon for lowering hemoglobin A1C in patients with type 2 diabetes: a randomized, controlled trial. J Am Board Fam Med. 2009;22:507-12.
Khan A, Safdar M, et al. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care. 2003;26:3215-8.
Curcumin/Turmeric
Chandran B, Goel A. A randomized, pilot study to assess the efficacy and safety of curcumin in patients with active rheumatoid arthritis. Phytother Res 2012;26:1719-25.
Taylor RA, Leonard MC. Curcumin for inflammatory bowel disease: a review of human studies. Altern Med Rev. 2011 Jun;16(2):152-6.
Thapliyal R, Deshpande SS, Maru GB. Mechanism(s) of turmeric-mediated protective effects against benzo(a)pyrene-derived DNA adducts. Cancer Lett 2002;175:79-88.
Flaxseed
Brooks JD, Ward WE, Lewis JE, et al. Supplementation with flaxseed alters estrogen metabolism in postmenopausal women to a greater extent than does supplementation with an equal amount of soy. Am J Clin Nutr 2004;79:318-25
Herbs At A Glance: Flaxseed and Flaxseed Oil, Accessed at http://nccam.nih.gov/health/flaxseed/ataglance.htm
Pan A, Yu D, et al. Meta-analysis of the effects of flaxseed interventions on blood lipids. Am J Clin Nutr. 2009 Aug;90(2):288-9
Garlic
Ackermann RT, et al. Garlic shows promise for improving some cardiovascular risk factors. Arch Intern Med. 2001; 161: 813-24.
Ried K, Frank OR, Stocks NP, Fakler P, Sullivan T. Effect of garlic on blood pressure: a systematic review and meta-analysis. BMC Cardiovasc Disord. 2008;8:13.
Silagy C, et al. A meta-analysis of the effect of garlic on blood pressure. JR Coll Phys. London 1994; 28:2-8.
Warshafsky S, et al. Effect of garlic on total semm cholesterol. A meta-analysis. Ann Int Med. 1993; 19:599-605.
Ginger
Altman RD, Marcussen KC. Effects of a ginger extract on knee pain in patients with osteoarthritis. Arthritis Rheum. 2001 Nov;44(11):2531-8.
Srivastava K. C, Mustafa T. Ginger (Zingiber officinale) in rheumatism and musculoskeletal disorders. Med Hypotheses. 1992;39(4):342–8
Kava Kava
Lakhan SE, Vieira KF. Nutritional and herbal supplements for anxiety and anxiety-related disorders: systematic review. Nutr J. 2010 Oct 7;9:42.
Sarris J, Stough C, et al. Kava in the treatment of generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychopharmacol. 2013 Oct;33(5):643-8.
Sarris J, Kavanagh DJ, et al. The Kava Anxiety Depression Spectrum Study (KADSS): a randomized, placebo-controlled crossover trial using an aqueous extract of Piper methysticum. Psychopharmacology (Berl). 2009 Aug;205(3):399-407.
Lavender
Kasper S, Gastpar M, et al. Silexan, an orally administered Lavandula oil preparation, is effective in the treatment of 'subsyndromal' anxiety disorder: a randomized, double-blind, placebo controlled trial. Int Clin Psychopharmacol. 2010 Sep;25(5):277-87.
Licorice (DGL)
Morgan AG, Pacsoo C, McAdam WA. Maintenance therapy: a two year comparison between Caved-S and cimetidine treatment in the prevention of symptomatic gastric ulcer recurrence. Gut. 1985; 26)6):599-602.
Ruetzler K, Fleck M, et al. A randomized, double-blind comparison of licorice versus sugar-water gargle for prevention of postoperative sore throat and postextubation coughing. Anesth Analg. 2013 Sep;117(3):614-21.
Milk Thistle
Rambaldi A, et al. Milk thistle for alcoholic and/or hepatitis B or C liver diseases--a systematic cochrane hepato-biliary group review with meta-analyses of randomized clinical trials. Am J Gastroenterol. 2005; 100(11):2583-91.
Olive Oil
Bendinelli B, Masala G, Saieva C, et al. Fruit, vegetables, and olive oil and risk of coronary heart disease in Italian women: the EPICOR Study. Am J Clin Nutr, 2011 (93):275–283.
Ros E, Martínez-González MA, et al. Mediterranean diet and cardiovascular health: Teachings of the PREDIMED study. Adv Nutr. 2014 May 14;5(3):330S-6S.
Peppermint Oil
Ford AC, Talley NJ, Spiegel BM, Foxx-Orenstein AE, Schiller L, Quigley EM, Moayyedi P. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ. 2008;337:a2313.
Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014 Jul;48(6):505-12.
Pomegranate
Hamoud S, Hayek T, et al. Pomegranate extract (POMx) decreases the atherogenicity of serum and of human monocyte-derived macrophages (HMDM) in simvastatin-treated hypercholesterolemic patients: a double-blinded, placebo-controlled, randomized, prospective pilot study. Atherosclerosis. 2014 Jan;232(1):204-10.
Zarfeshany A, Asgary S, Javanmard SH. Potent health effects of pomegranate. Adv Biomed Res. 2014 Mar 25;3:100.
Rhodiola
Bystritsky A, Kerwin L, Feusner JD. A pilot study of Rhodiola rosea (Rhodax) for generalized anxiety
Hung SK, Perry R, Ernst E. The effectiveness and efficacy of Rhodiola rosea L.: a systematic review of randomized clinical trials. Phytomedicine. February 15, 2011;18(4):235-244.
St John’s wort
Linde K, Berner MM, Kriston L. St John's wort for major depression. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD000448.