The HERBAL Guide: Agree to Discuss/Learn – DNI/DSI Webcast Part 7

Transcript - Part 7

The HERBAL Guide:  Agree to Discuss/Learn

We also want to talk about after we've completed those steps, then we need to Agree to discuss. As soon as the patient is out the door, in many cases, they are thinking, or seeing, or hearing about another potential nutrient or supplement. And that can be very appropriate, but we want to know about it to let them know and give them some counseling either to ourselves or our staff to let them know what direction or what resources might be available.

We always like to tell our patients or client, if they're considering anything else beyond what's on your supplement list, please let us know. Let us be part of that discussion as you are choosing.

One of the key reasons why supplements aren't many times stockpiled is because in many cases, that discussion point never happens. So a patient is trying to fix the bike while they're riding it. So if they're using a supplement for their knee pain, they may not have chosen it with anyone's guidance, any clinician. They don't know when to follow up, or what endpoints they're looking for.

So it's always nice to, if there's a supplement that's going to be utilized, to try to be specific as far as what brand, what dose, what are you looking for as far as the potential use, and when are you going to reevaluate that to see if it's a keeper or not? So that again, you can focus on the ones that are doing real good for your patients, and holding on to ones that may not be.

As far as ongoing learning, have resources at hand. We talked about the AAFP applet, which is going to be available soon, as well as other resources on nutrients on the AAFP app that's currently available, Natural Medicines, the Office of Dietary Supplement newsletter. And I'm a big fan also of the PubMed subset, which is specific for dietary supplements, so you can put in what is the evidence for supplement X and condition Y. That sometimes can be a good lead in to try to help your patients find information in that area.

Lastly, learning. One of the key things in the learning scenario is when there is a potential interaction or nutrient depletion that you're suspecting may be from a combination your patient is using, don't be overwhelmed. The research shows that if we are overwhelmed, many times we encounter this scenario, but we don't know what to do with it. So, try to realize that that's not uncommon scenario but there are resources there.

The one that I would recommend is Natural MedWatch. It's available for everybody, not just utilizers of natural medicines. If you sign up in advance, if you are already a user of the database, it prepopulates. So just within a few minutes, if you see, for example, a new supplement, if you happen to be seeing a patient that was on a supplement that may be one that might be adulterated or have other issues with it, you can very quickly report it. It's not implicating it definitively, but it's just adding to the record, which in many cases, the FDA may need to realize whether they need to take action or not. So, this is a step to keep in mind even as a busy clinician. It's very good to report this.

Finally, this is an ongoing learning topic. There are many scenarios out there. As an example, SAMe, which if you look at some of the databases, may actually say that it's not appropriate to use with SSRI. And at least two randomized controlled trials has been shown in a monitored setting to help with serotonin production, which on the flip side, the prescription medication can actually work better.

So this is an evolving scenario. These are some research findings that are emerging. So again, what may be potentially harmful or therapeutic really depends on how it's being counseled and monitored.

Another example, St. John's Wort, which we know has a ton of interactions, but in this case, it's actually helping to induce a medication in this scenario, where patients may have a difficulty with actual, full benefit from that prescription medication in this scenario. And St. John's Wort as an inducer of the CYP system, may actually help that medication work better. Again, these are emerging trends. Please keep the HERBAL mnemonic in mind or aspects of it that make the most sense for your clinical practice.

I think the difference is, in many cases, when we are talking about a combination of agents being therapeutically beneficial or harmful is our discussion point. How can we get the patient to disclose for us to know and have the opportunity to have some guidance and discussion, as well as some offline counseling such as with some of the handouts and resources, such as through the Office of Dietary Supplement, which may be very helpful.

Good communication and shared decision making can often avoid the most negative interactions and avoid potentials for depletion interaction, especially in our complex patients who may be on their therapeutic drugs or on very complex regiments for their complex disease. Those are the folks you really want to make sure, you ask very broadly, in a very open, non-stigmatizing manner, "Are you taking anything else for your health care needs, specifically supplements, vitamins, drinks, powders, teas, bars?" because these come in many forms, and it's important to keep that in mind when we're counseling patients.