The HERBAL Guide: Record/Be Aware – DNI/DSI Webcast Part 6

Transcript - Part 6

The HERBAL Guide:  Record/Be Aware

The next aspect of "The HERBAL Guide" is record. I think one of the key steps here is, it's not written down, it is of almost no good especially to other providers who maybe seeing that patient downstream. So, in one study of geriatric population, only about a third of the time were supplements recorded in the chart. In a Mayo Clinic study, that was actually looking at interaction, only about 26% of the time was it actually recorded.

And we know there are some stumbling blocks to having it recorded, but it's very important as that study and this study here shows to reconcile as best you can. So, the electronic medical record may not recognize it in the same way as a prescription medication, but doing our best to ask, review, and get rid of things that are no longer being used, and adding things in some level of notation, so that future providers and ourselves for our future business with that patient know what they are using. And if there's anything that sort of is a red flag, at least it's listed there and we can help with that counseling.

The next part of "The HERBAL Guide" is be aware. So, dietary supplement interactions and nutrient depletion issues happen in common patterns. And I'm going to go over some of those to make this hopefully a little more simple, to focus in on the key areas.

And this is a great study that was done at the Mayo Clinic. One of the key things that they found was that five dietary supplements accounted for two-thirds of all potential interactions. These were garlic, valerian, cava, ginkgo, and St. John's Wort. Four classes accounted for almost all potential interactions. These were blood thinners, antithrombotics, sedatives, antidepressants, and medications for diabetes and blood sugar management.

So, their conclusions were a very small number of prescription medication, dietary supplements accounted for most of the interactions. The good news I guess, is that the actual potential here was quite low, and the interaction level overall in the study of over a thousand potential interactions was actually, the actual harm was low, but keeping in mind the key arenas of potential interaction are important to kind of simplify it.

A more scientific overview of this topic was done recently by Health Canada. They looked at a number of prescription agents and dietary supplements. And you could see the ones in blue are the more likely ones to be either an actual interaction, or a more likely based on clinical studies. You can St. John's Wort has a number of blue. Ginkgo has a number of blue. So these are the ones to kind of keep in mind. This article is also available free online if you want further information.

Another quick way to remember some of the key ones here are the 4Gs: garlic, ginger, ginkgo biloba, and ginseng. It's not to say that their use is not appropriate in all cases. It can be, but for example, if there's a patient on seizure medication and they're not disclosing that they just started ginkgo for memory issues, for example, that's a potential interaction because we know that can reduce the efficacy of some anticonvulsants. Ginseng also may affect blood pressure medications.

Again, and a lot of this has to do with the dose. Garlic and ginger are food based, probably not an issue. At high doses or in supplement form in more potent versions, especially if not disclosed in a patient with multiple medications, that's a scenario that we're really talking about.

Natural Medicines a great resource, and I would highly recommend. They have a very quick cheat sheet for some of the more common potential supplements. This is hopefully going to be available as a resource in PDF form. If not, is available through the vendor, Natural Medicines, which is where the source of the applet, the AFP applet that I will be talking about comes from.

So the information that you're going to be using, the evidence-based interaction and nutrient depletion information, is coming from Natural Medicines, but there are various versions of that depending on how much time you have and what supplements you're looking for.

Another scenario to keep in mind is patients with neurotherapeutic drugs. There's a number of these listed. We know who those folks are on antithrombotics, etc. Also, patients with complex medication regiments who in many cases are also on neurotherapeutic medications, transplant medications, advanced cardio pulmonary disease patients. Those are the ones that we have to be very cautious.

Unfortunately, because in many cases they're worried about their medications, they often don't think about mentioning their supplements, and that's a scenario that's been noted in a number of recent articles. Those interactions that do happen in these unfortunate cases were many times preventable based on discussion.

Also patients on sedatives, antidepressants are very likely if they have less than satisfactory results or non-remission based on their prescription medications, to often look on the shelf to see if there's something additive they can use to kind of self manage that. That's an important scenario to really discuss, and counsel, and try to know what they are considering and know if it's appropriate or not.

Another key arena that many don't think about here are foods that maybe interaction potentials here. Juices are probably the most common one. Grapefruit juice is the stereotypical one that we all think about because of its alteration of the C biotic P450 metabolic pathway. However, there's a number of other medications, cranberry, pomegranate, grape, etc., that can also have an effect. These are on certain medications. In many cases, it can be some statins, but not all statins as an example.

As we are looking at statins as an example, we know it depends not just on the dose of the medication, but on the type of medication, because they, again, may use different pathways. So you cannot just say all statins can cause CoQ10 depletion. Although, there are some research articles that point in that direction. It really depends on what the patient is specifically using. And again, using the online resources for Natural Medicine, and the AAFP app, those can help you decipher this.

As an example, taking atorvastatin at 10 milligrams or pravastatin at 20 milligrams did not significantly alter CoQ10. But if you increase the dose and keep it for a longer period of time, the levels can increase by significant amount and cause changes in the efficacy of that medication.

So, I've mentioned a lot of potential scenarios. This can be a little bit overwhelming of what to recommend, whether it's testing or nutrient repletion. The main thing to keep in mind here is to individualize. I'm going to give you a few examples of what the literature says, but in some cases, there may not be an AAFP recommendation. So, keep in mind it depends on the risk factors the patient has, are they a diabetic on multiple medication, including metformin, do they have a history of previous deficiencies, is their dietary background poor, etc.

Those are cases where you may be more leaning towards testing and repletion versus not, but keep an individual frame of mind here, and have updated tools to help kind of decipher that.

Two examples of some literature that does tend to recommend, this is a highlight of folks who are having peripheral artery disease. In many cases these are folks on lipid lowering medications, they may be on antihypertensives and diabetic medications. At least from this standpoint, they say it's important to monitor levels of certain nutrients such as CoQ10, zinc, and B12 with the known possibility that in some cases, your lab may not have the best ability to test these. So, with that as a caveat, think about replacing it when appropriate, especially in high-risk patients.

Another study from the Journal of Diabetes and Metabolic Disorders, recommends from their standpoint, annual screening for B12 deficiency. Again, because a lot of these patients may be at risk for, simply because of the condition, and in addition to their medications for B12 deficiency, and what to test for. It's listed here. Specifically, replacing it is also mentioned in the article.

As far as more point of care tools, the AAFP applet, which is part of the AAFP app, which is available on multiple platforms, will have this interaction and nutrient depletion component as part of the AAFP app near the end of the month. So it's not currently available, but it will be there soon.

On this as just an example of the screen shot, you can go to specific medications, or class of medications, pick out the medications, then it will tell you about specific interactions that are either major, or minor, or not to worry about. There's also the ability to take that information and forward it, as well as to make notes about it.

So, if in your particular patient scenario, you may be seeing a lot of certain conditions or supplement users in certain categories, you can make notes about it, or specific brands in your area, you can make notes and keep that for future use. So, that's a resource that's just around the corner and keep an eye out on that.

For more detailed questions, I would highly recommend the Natural Medicines database. This is a website and resource I've been using for over 15 years. I'm a volunteer editor for Natural Medicines. I use it pretty much every day when I'm talking to patients about supplements.

As an example, if you have a patient with diabetes who's on metformin and you don't know how to test or when to test, one example of helping you with that while also balancing that with the AAFP recommendations would be going to Natural Medicines beyond the AAFP applet if you need it.

In this case, it tells you what risk factors you may be looking for. Are they on a specific restricted diet? Are they on a higher metformin dose? Have they been on it for more than three years? In this case, it talks about replacing it testing on a regular basis and replacing it. And that dosage and testing interval can also be noted on this site. So that's a resource to keep in mind.