The HERBAL Guide: Educate and Evaluate – DNI/DSI Webcast Part 5

Transcript - Part 5

The HERBAL Guide:  Educate and Evaluate

As far as education and evaluating, which is the second step of "The HERBAL Guide," one of the key things that we need to keep in mind is that this is an area that is confusing not just for the patients, also can be confusing for the clinician and that's okay. A lot of that comes from the regulatory aspect where the actual basis for that supplement is not very clear. And it is actually against the law for that supplement to say, for example, that it can be used for treatment of arthritis if it hasn't gone through the specific steps.

So in most cases, what you're going to see on the label is it cannot prevent, treat, or cure a condition. So in many cases, the label can be somewhat difficult if the patient doesn't know what they're looking for and does not have guidance. So in many cases, our input is important. The question that might be coming as a background to that might be, "Well, I'm not really prepared to counsel that patient."
I would have you trust me to say that the information that we have and the resources that we have are a great starting point. No one needs to be an herbal encyclopedia to help our patients know how to find a good brand, and what to consider, and what to avoid. As a general starting point, this is actually, as I've been pointing out, a number of studies where patients who are interested in CAM, complimentary alternative modalities, including supplements, actually really are pleased by the counseling and guidance that they get from physicians who even though they're not experts in the area, are able to give that patient a framework of how to choose wisely.

I think that's a really important starting point to help patients not stockpile supplements and find the right potential nutrient for their needs. Educating and evaluating proper use also starts at understanding the appropriateness of what the patient is using and how to gear it towards evidence-based sources. I'm going to give you three scenarios which I hope will point this out clearly.

The first one is a patient who is post-hospitalization, they are diabetic on Metformin, and as the literature points out, they continue on their Proton Pump Inhibitor, in some cases, it's not caught on discharge or immediately after discharge, and it can be a while before they're seen in the clinic.

And if that medication reconciliation does not happen immediately, it may be landing in our clinics. And this is a very prime example of someone who, let's say, is on a certain medication and should not be on it, in most cases long term, and is a set up for various reasons for nutrient depletion. The studies show that this is actually not only a patient safety issue, but also has additional significant costs.

In this scenario, simply having medication reconciliation, understanding that this PPI [proton pump inhibitor] doesn't need to be on board can do a lot to prevent two specific nutrient deficiencies, B12 and magnesium. We'll talk about the magnitude of that. As far as symptom, just a quick review, we know that B12 deficiency can cause a lot of associative neurological issues, including problems with memory, delirium, neuropathy, as well as spinal cord abnormalities, and various types of anemia.

Magnesium, the most common things that we need to keep in mind are that magnesium deficiency can be related to increased GI symptoms, specific constipation, muscle-related symptoms, including muscle spasm, muscle soreness, as well as cognitive and mood issues, including agitation, anxiety, sleep disorders, and in more severe cases, abnormal heart rhythms.

In keeping this in mind, the literature shows that being on metformin by itself can have a rate of deficiency of B12 of about 20%, but when that PPI enters the picture, that rate can go up to over 30%, and the longer that's in place that can become a bigger issue. In some cases, that's an appropriate medication mix. We just need to keep that in mind and use the right testing and supplementation, as appropriate, depending on the scenario which we'll also come back to.

So again, simply doing medication reconciliation, known as PPI, may not be appropriate in this case, significantly reduces the chances of ongoing deficiency or additive deficiency in this scenario.

The second scenario, which is one that counseling goes a long way to sort of even the playing field is supplements that are too good to be true. These are, in some cases, adulterated or their claims are beyond what should be allowed in the United States, and many of these supplements unfortunately are coming from outside the United States. Patients may not know that. And again, they're seeing them potentially as a safe alternative or a safe additive to their current lifestyle choices.

It's important to do counseling here, give them examples. One example that I'm going to point out, is the supplement that was named "Wow," it was previously known as "Reumofan Plus." And the FDA website actually did a recall on this and shut this supplement down because on further testing, it was found that this supplement came to the U.S. from south of the border, had a number of ingredients, including steroids, anti-inflammatories, muscle relaxants, which were undeclared adulterants.

So, if it sounds too good to be true, it in many cases can be. And this also happens, as the FDA references point out, with weight loss products, sexual enhancement products, body building, and sports performance supplements. So, things that are in those specific categories are really important to keep in mind that are trying to get quick results, and try to warn your patients and give them additional resources to know what to avoid.

The third scenario is finding a reputable brand, and this is hopefully the scenario that you'll spend most of your time on which really is where supplements can do their most good. When you are trying to help that patient with, let's say, migraine headaches, who's failed multiple therapies that you've overseen, and you want to try something in the supplement arena that might help. An example of that would be butterbur, which actually the American Academy of Neurology rates as a level-A evidence-based preventive agent.

One of the unfortunate parts is, in many cases, the recommendation may be simply, "Try some butterbur," and that is a scenario where it may not only not have benefit for that patient, it may also have some potential risk, because we know in the raw form, it may have some alkaloids which are hepatotoxic in certain scenarios. In fact, one recent analysis of 21 products on the shelf found that only seven of them actually contained the product that were supposed to and did not contain any of the potentially toxic alkaloids.

The Petadolex, which was the version that was in the majority of the migraine studies, and which is the one we should discussing, for example, with our migraine patients, met standards out of the seven that were clean, so to speak. All four of the Petadolex versions met that standard. So again, this is a scenario where using evidence-based formulations is both an issue of efficacy and safety.

Additional resources when we're looking at other supplements in other condition states, or in other scenarios, are to keep in mind some seals of approval or Good Housekeeping type seals that you might see on the label.

Ones to keep in mind are the USP [United States Pharmacopeia]. The USP's worked with the FDA since the 1800s looking at prescription medications. They're also now doing more with dietary supplements, that you will see the USP on the side, and that says that this product or this brand has voluntarily put their factory, as well as their supplements up to testing to make sure they have the right ingredients and none of the wrong ingredients and their facilities meets specs.

Same thing with NSF, slightly different version of a Good Housekeeping seal for supplements. And lastly, Consumer Lab, some of us have heard of that. They do end-product testing in a number of popular supplements, and their website is available to check the listings if you'd like to do that or have your patients do that before they look at supplements for purchase.

So in summary here, it's important to evaluate what the patients are using to make sure they're appropriate, make sure they're evidence-based, and help to reduce inappropriate use. And that's really the starting point for reducing potential interactions. It's also very important to work with reputable brands and products that do independent testing, have independent seals of approval, and that do clinical testing and have clinically-tested and verified formulations for specific conditions.

I think that's a big step that I spend a lot of my time in the clinic making patients know the difference between that and when they are going to choose a supplement that its one that has a good likelihood of helping them with their condition.

What I've mentioned here can be time consuming. I realized that. Some of this, as far as the basic steps of avoiding supplements that area inappropriate can actually be done outside the clinic with certain handouts and certain resources that are available online. The FDA and dietary supplements arena aspect of the FDA website has a lot of great handouts.

There's one that's called "Tips to the Savvy Supplement User," which was actually tested in the scenario and helped patients choose wiser as far as supplements. They ended up choosing less supplements, and hopefully, they were able to be guided towards the right supplements for their pertinent scenario. So those can do a lot, and you, and your nurses, and a clinical staff can use those resources.

A number of other resources are also listed here, including from the USDA. These will be part of the PDF that will be available in about a week or so after the webinar, so you will have these resources to get hose handouts available for your patients.

Another great Internet site is Office of Dietary Supplements. The ODS has a number of resources including handouts in Spanish on "Tips for the Savvy Supplement User," as well as specific nutrient based supplement handouts. So keep that in mind as well.