Complementary therapies

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Alan Bensoussan · Kerryn Phelps · Vicki Kotsirilos · Penny Caldicott · Jennifer Hunter

DMAA was recently banned in Australia and other countries owing to toxicity, lack of health benefits, and concerns about long-term safety and potential for misuse. A trawl of the NSW Poisons Information database confirms the wisdom of the ban and suggests an expanded role for the database in future.

Jared A Brown · Nick A Buckley

Botanical taxonomy is a repository of medical biographical information. Such botanical memorials include the names of some indigenous orchids of Australia. By searching reference texts and journals relating to Australian botany and Australian orchidology, as well as Australian and international medical and botanical biographical texts, I identified 30 orchids indigenous to Australia whose names commemorate doctors and other medical professionals. Of these, 24 have names ...

John H Pearn MD, PhD, DSc

General practice: the integrative approach. Kerryn Phelps, Craig Hassed. Sydney: Churchill Livingstone, 2011 (xxiii + 993 pp, $150.00). ISBN 9780729538046. COMPLEMENTARY MEDICINES and practices are widely available to, and used by, the Australian public. Until now, there has not been a framework to integrate this into safe, evidence-based medical practice. We needed a book of this calibre.Both authors are leaders in the field of ...

Patrizia Boetto

ALTHOUGH THIS compendium cannot possibly encompass the depth and breadth of complementary and alternative medicines (CAMs) as they are practised today, it does provide an array of interesting insights into what is a relatively uncharted field within the “modern occidental” medical community.Aligned with the background of the editors — Ian Olver and Monica Robotin — from the Cancer Council Australia, Perspectives has a clear focus ...

Hosen Kiat

Friends of Science in Medicine should avoid threatening their own valuesScience has always been — and should be — a battleground for contending views on what is true. Because of the close connection between knowledge and power, however, the risk is always present that those who command the dominant theories or ideologies will rely on their positions of influence to overcome those who oppose them. ...

Paul A Komesaroff MB BS, PhD, FRACP · Amber Moore BChineseMed(Hons), BA(Hons) · Ian H Kerridge MPhil, FRACP, FRCPA

To the Editor: Complementary medicines may lack evidence of safety and efficacy, but conventional medicine lacks evidence of efficacy in 30%–40% of cases,1 and the breast implant and hip replacement debates demonstrate safety concerns. The debates about conventional versus complementary medicine expose how out of touch the medical profession is with the views of government and the people about complementary medicine. The medical profession was ...

Simon J Spedding

To the Editor: In their editorial, MacLennan and Morrison1 listed Curtin University’s Evidence Based Complementary Medicine as a pseudoscientific unit. This citation was completely unjustified. The unit, which is part of both the Bachelor of Pharmacy and Master of Pharmacy (graduate entry) degrees, was developed for the sole purpose of providing pharmacy graduates with the knowledge, ...

Jeffery D Hughes · Liesl A Blott

Narrowly defined, mindfulness is the tendency to encounter moment-to-moment experience without being lost in unhelpful or distressing thoughts triggered by the experience. Mindfulness training involves group instruction in and discussion of a variety of meditation styles aimed at enhancing this tendency in daily life. There is an accumulating evidence base, albeit of variable ...

Kaveh Monshat MPsychMed, MB BS, FRANZCP · David J Castle MSc, MD, FRANZCP

Increased research in the area of complementary and alternative medicine (CAM) is urgently required, in addition to a balanced appraisal and communication of the state of evidence in the field. Current challenges for clinicians and the public in accepting purported CAM evidence concern potential selective publication of results, marked differences in product quality ...

Jerome Sarris PhD, MHSc

Objective: To explore the current use of conventional and complementary medicines in Australians aged ≥ 50 years.Design, setting and participants: Cross-sectional postal survey sent to a random sample of 4500 Australians aged ≥ 50 years between June 2009 and February 2010.Main outcome measures: Prevalence of medicines use, reasons for medicines use and sources of medicines.Results: Response rate was 37.3%. Medicines use was very common; 87.1% of participants took one or more medicines and 43.3% took five or more in the previous 24 hours. Complementary medicines were used by 46.3% of participants, 87.4% of whom used both conventional and complementary medicines. The most commonly used medicines were antihypertensive agents (43.2% of participants), natural marine and animal products including fish oil and glucosamine (32.4%) and lipid-lowering agents (30.4%). Doctors recommended 79.3% of all medicines and 93.0% of conventional medicines. Pharmacists commonly recommended occasional medicines (ie, as needed), while friends, family and media most often influenced use of complementary medicines.Conclusions: The use of multiple medicines is common and higher than reported in the 1995 National Health Survey. Today, much medicines use is to prevent future disease by influencing risk factors. High levels of polypharmacy highlight the need to support the safe and effective use of medicines in the community. Although doctors recommend or prescribe most medicines, self-directed medication use is common. This highlights the need for consumer access to accurate information and strategies to improve health literacy about medicines.

Tessa K Morgan BSc, BA, MPH · Margaret Williamson BPharm, MPH, GradDipEpi · Marie Pirotta MB BS, MMed, PhD · Kay Stewart BPharm(Hons), PhD · Stephen P Myers PhD, BMed, ND · Joanne Barnes BPharm(Hons), PhD, MRPharmS

Patients with cardiovascular disease may be especially prone to the adverse effects of complementary medicines Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in Australia.1 Given the chronic nature of CVD, medical management is the most common mode of care, and medications are prescribed to most patients with CVD.2 In general practice, treatment of CVD accounts for almost one in five encounters, with hypertension the most commonly treated risk factor, followed by lipid disorders.2 Although effective management of CVD depends on a range of factors, one that is often neglected is the use of complementary medicine (CM). While CM can potentially benefit patients with CVD, it can have an adverse impact on the effectiveness of conventional CVD therapies in two main ways: through drug interaction or through reduced adherence to conventional therapies. In Australia, CM is defined as the use of medicines containing herbs, vitamins, minerals, nutritional supplements and homoeopathic medicines.3 The popularity of CM has increased in recent years,4 and in people with CVD, rates of use have been estimated at up to 42%, with up to 21% of these patients taking herbal supplements.5 The most common types of CM taken by people with CVD are multivitamins and minerals (34% of surveyed cardiac patients), calcium (22%), vitamin E (20%) and vitamin C (14%). The most common herbal agents used are mint or lemon balm (11%), nettle (8%), green tea (7%), echinacea (6%) and garlic (6%). The use of coenzyme Q10 (3%), fish oil or omega-3 fatty acids (2%) and hawthorn (1%) are surprisingly low.5 Although CM is often considered safe by patients, harmful effects associated with its use do exist. The use of CM alongside prescription medications has the potential of reducing the effectiveness or increasing the potency of therapy. These effects may be compounded in people with CVD for several reasons. First, CM users tend to consume more than one CM product concurrently over periods of months to years.5 Second, the likelihood of interference with prescribed therapy is increased since certain medications, such as digoxin and warfarin, have a narrow therapeutic window. Patients with CVD also tend to be elderly, are likely to suffer from multiple comorbidities and therefore are likely to be using multiple long-term medications.5 Several studies in people with CVD indicate that not only do a significant proportion use CM concurrently with prescribed therapy, but about half do not inform treating doctors about their use.5 The relatively widespread use of CM in people with CVD means it is vital that doctors are aware of CM use. Some commonly observed interactions between CM and conventional CVD medications and possible mechanisms are summarised in the Box. Apart from the possibility of drug interactions, the bioactive components of CM products can also directly cause adverse effects. Some examples of CM that are used in the treatment of CVD (and their adverse effects) include Aloe vera (diarrhoea and potassium depletion), fenugreek (diarrhoea and hypoglycaemia), garlic (inhibition of platelet function), ginseng (insomnia), ephedra (stroke and myocardial infarction), Ginkgo biloba (bleeding) and red yeast rice (myopathy and rhabdomyolysis).7 More generally, there are safety issues associated with the quality of CMs. These relate to the lack of standard dosing, which in part is due to variations in potency, depending on where plants are grown; the possibility of contamination by pesticides and heavy metals during cultivation; and the possibility of contamination by bacteria in the storage, transport or manufacturing processes.7 The second main mechanism in which CM use may impact on effective management of CVD is through reduced adherence to prescription medications. However, a limited number of studies investigating the impact of CM on cardiovascular medication adherence show inconsistent results. Some studies report a lower adherence to prescription medications among cardiovascular patients taking CM, while others found the opposite.5 Importantly, we found in our review that CM use was not disclosed by cardiac patients up to 65% of the time. The main reasons were fear of clinician disapproval and because clinicians had not asked about CM use.5,9 This strongly suggests that clinicians need to take a less judgemental and more proactive approach to encourage patient discussion of CM use, regardless of adherence to conventional treatment. What, then, are the identifying characteristics of a CM user? In the general population, use of CM is associated with higher levels of education and income10 but poorer self-reported health status. Although few differences have been found between cardiac patients who are CM users compared with non-users,5 it appears that people with chronic disease are more likely to use CM, especially if they have multiple comorbidities.10 As well as being aware of the potential impact of CM on prescribed therapy, clinicians should also be aware of the reasons patients use CM. About half of CM users with CVD believe that CM is of greater benefit than conventional treatment, or perceive that the CM used has proven benefits for their condition.5 Many CM users also believe that there are fewer side effects associated with “natural” therapies.5 CM therefore meets a real or perceived need for health care, and serves an important psychological function in enabling patients to manage their own health.11 Given the increasing prevalence of both CM use and CVD, it is likely that clinicians will see more cases of patients who are using CM either specifically for their cardiovascular condition or towards improving general health. Regardless of personal viewpoint, CM is now an integral part of the therapeutic armamentarium used by the Australian population. Thus, there is a need to better inform doctors about CM use and the associated potential for adverse reactions and herb–drug interactions. There are significant gaps in clinician knowledge of the risks and benefits associated with CM use, and clinicians report feeling ill-equipped to respond to patient enquiries about CM.12 Medical schools overseas, such as those in Asia, France, Germany, Switzerland and some in the United States, have incorporated CM into their medical curricula. Awareness of CM needs to be integrated into routine medical practice, such as by asking patients about CM as part of a medication review. CM modules should be included in continuing professional education programs for general practitioners and specialists alike. The key issues and complexities of CM that should be understood include the differing definitions of CM in different countries, such as the American and Australian classifications, and the processes underlying its regulation. In Australia, for example, the Therapeutic Goods Administration regulates CM products, and the difference between “listed” medicines (which are not evaluated for efficacy) versus “registered” medicines is important.3 There is growing research on the efficacy of select CMs for various conditions. Results from robust studies show that omega-3 fatty acids may assist in the treatment of hypertriglyceridaemia,13 reduce the incidence of thrombotic stroke14and coronary heart disease,15 and may prevent sudden cardiac death in patients with prior myocardial infarction.16 Coenzyme Q10 supplements appear to reduce the symptom of statin-induced myalgia17 and may have favourable effects in those with heart failure.18 Physical therapies such as qi gong also appear helpful for hypertension19 and are likely to be beneficial in some patient groups as alternatives to higher intensity physical activity. Furthermore, considerable efforts are being made to investigate the efficacy of CM in CVD prevention and risk factor reduction. Research bodies such as the National Institutes of Health in the US and the National Institute of Complementary Medicine in Australia are supporting studies investigating the effects of hawthorn leaf in milder forms of heart failure, the use of disodium edetate (EDTA) chelation therapy to treat coronary artery disease, vitamin D3 for prevention of CVD and melatonin for lowering hypertension. Further research is required to strengthen the evidence base for these and other CM therapies; however, certain CMs may prove to be efficacious for people with CVD, and critical awareness of this work is necessary for effective clinical practice. The use of CM is common among patients with cardiovascular conditions and a high proportion of patients using CM believe they have remedial benefits. Many CM users also believe that CM is as safe as or safer than their prescribed treatments, and are often unwilling to inform their doctors of their use of CM products. Commonly used CM products have the potential to interfere with the intended action of prescription medications although clinician knowledge of these interactions may be limited. We have restricted our discussion to patients with CVD, although the importance of considering CM in medical management applies equally to other patient groups, especially those with chronic disease. We emphasise the need for education about CM, so clinicians become more aware of patients’ CM use, become more knowledgeable about CM, and more capable of advising their patients about this issue. Letter p 660 Potential interactions of commonly used CM with cardiovascular medications6-8 CM (prevalence of use*) Possible herb–drug interactions and mechanism of action Coenzyme Q10 (3%) May partially antagonise antiplatelet effect of clopidogrel and decrease response to warfarin Vitamin E (20%) Contains curbicin, which antagonises the effect of vitamin K on coagulation, which, with clopidogrel, may increase the risk of bleeding and potentiate warfarin effects Garlic (6%) Additive antiplatelet effects may occur with clopidogrel and other anticoagulants Ginkgo biloba (4%) Ginkgo inhibits platelet aggregation and increases the effect of warfarin Fish oil (2%) Increases the effect of antiplatelet agents and vitamin K-dependent coagulation Concomitant use of warfarin and fish oils may increase risk of bleeding Vitamin D (4%) Improves calcium absorption, which increases the toxic effect of digoxin St John’s wort (2%) Reduces the effectiveness of statins, warfarin and digoxin through induction of hepatic enzymes and P-glycoprotein Hawthorn (1%) Increases the inotropic effects of digoxin Ginseng (4%) Has an additive effect with antiplatelet agents Decreases the effect of anticoagulants Glucosamine/chondroitin (4%) Increases the effect of anticoagulants Capsicum (5%) Increases the effect of antiplatelet agents Bilberry (1%) Increases the effect of anticoagulants Aloe vera (4%) Increases the effect of antiplatelet agents Produces hypokalaemia, leading to increased toxic effect of digoxin; enhances the effect of digoxin Liquorice (prevalence of use unknown) Mineralocorticoid effects promote potassium excretion. Causes hypokalaemia when used with some antihypertensive agents CM = complementary medicine. * Prevalence of use is based on figures from a systematic review of the literature combining data from multiple studies.5

Hosen Kiat MB BS, FRACP, FACC · Yu Sun Bin BSc(Hons) · Suzanne Grant BApplSc(TCM), MPS, PhD · Dennis Hsu-Tung Chang MB BS, MSc, PhD