Alternative therapies (i.e. alternative to licensed products of proven quality, safety and efficacy) span a huge range from frank charlatanry (e.g. products based on unscientific postulates, composed of diluent or of snake oil), through physical therapies such as massage and aroma therapies which certainly please (‘placebo’ means ‘I will please’) and do a great deal less harm than some conventional therapies (e.g. surgery, chemotherapy), through to herbal medications with undoubted pharmacological activity and the potential to cause desired or adverse effects, albeit less predictably than the licensed products that have been derived from them in the past and will no doubt be so derived in the future. Medicine takes an empirical, evidence-based view of therapeutics and, if supported by sufficiently convincing evidence, alternative therapies can enter the mainstream of licensed products. Overall, efforts to test homeopathic products have been negative (Ernst, 2002) and it has been argued that no more resource should be wasted on testing products on the lunatic fringe, even when they come with royal endorsement and (disgracefully) public funding. Here we focus on herbal and nutraceutical products that may cause pharmacological effects.
Herbal remedies include dietary supplements (any product other than tobacco intended for ingestion as a supplement to the diet, including vitamins, minerals, anti-oxidants – Chapter 35 – and herbal products), phytomedicines (the use of plants or plants components to achieve a therapeutic effect/outcome) and botanical medicines (botanical supplements used as medicine). The recent increase in the use of herbal remedies by normal healthy humans, as well as patients, is likely to be multifactorial and related to:
(1) patient dissatisfaction with conventional medicine;
(2) patient desire to take more control of their medical treatment; and
(3) philosophical/cultural bias. In the USA, approximately one-third of the population used some form of complementary or alternative medicine (the majority consuming herbal products) in the past 12 months. At a clinical therapeutic level, it is disconcerting that 15–20 million Americans regularly take herbal remedies, while concomitantly receiving modern prescription drugs, implying a significant risk for herb–drug interactions. In Scotland, some 12% of general practitioners and 60% of general practices prescribe homeopathic medicines! Herbal remedies are particularly used by certain groups of patients, notably HIV and cancer patients. The stereotypical user is a well-educated, career professional, white female. From a therapeutic perspective, many concerns arise from the easy and widespread availability, lack of manufacturing or regulatory oversight, potential adulteration and contamination of these herbal products. Furthermore, there is often little or no rigorous clinical trial evidence for efficacy and only anecdotes about toxicity. Many patients who are highly attuned to potential harms of conventional drugs (such as digoxin, a high quality drug derived historically from extracts of dried foxglove of variable quality and potency) fail to recognize that current herbals have as great or greater potential toxicities, often putting their faith in the ‘naturalness’ of the herbal product as an assurance of safety.
Most commonly used herbal products as Alternative Medicine
Garlic Allium sativum Hyperlipidaemia– hypercholesterolaemia
Ginkgo Ginkgo biloba Dementia and claudication
Echinacea Echinacea purpurea Prevention of common cold
Soy Glycine max Symptoms of menopause
Saw palmetto Serenoa repens Prostatic hypertrophy
Ginseng Panax ginseng Fatigue
St John’s wort Hypericum perforatum Depression (mild)
Black cohosh Actaea racemosa Menopausal symptoms
Cranberry Vaccinia macrocarpon Cystitis and UTI
Valerian Valeriana officinalis Stress and sleeplessness
Milk thistle Silybum marianum Hepatitis and cirrhosis
Evening primrose Oenothera biennis Premenstrual symptoms
Bilberry Vaccinia myrtillus Diabetic retinopathy
Warnings about the toxicity of herbal products such as kava kava (hepatotoxicity), aristocholic acid (nephrotoxicity) and phen phen (pulmonary hypertension) have recently been communicated to prescribers and the public. PC-SPES, which was used by many prostate cancer patients because of anecdotal and uncontrolled studies of evidence of activity in prostate cancer, was withdrawn from sale by its suppliers after the FDA found it contained alprazolam and phytoestrogens.