Clinical Pharmacology: Complementary Medicine

Question 1

What is CAM?

Answer 1

The World Health Organisation defines complementary and alternative medicine (CAM) as:
-A ‘broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system’.

Question 2

Why can interpreting what constitutes CAM be very complex?

Answer 2

National, cultural, and ethnic differences, together with the extensive and expanding list of complementary and alternative medicines, make interpretation of what constitutes CAM very complex

Question 3

Give examples of CAM

Answer 3

-Herbal remedies
-Homeopathic therapies
-Chinese medicine
-Acupuncture
-Aromatherapy
-Reiki
-Shiatsu
-Yoga
-Hypnosis
-Meditation
-Reflexology
-Osteopathy
ETC.

Question 4

What are CAM approaches generally not supported by?

Answer 4

• Robust efficacy, effectiveness or safety data

- No way to report adverse events or reactions

Question 5

What high risk patient groups are at particular risk due to the lack of safety data for CAMs?

Answer 5

• Children
• Pregnancy: teratogenesis and fetogenesis
• Patients using prescribed medication
• Polypharmacy

Question 6

What concerns are there about CAMs?

Answer 6

• Implausibility of most therapies
• Lack of evidence for benefit
• Lack of safety data
• Evidence of harm
• Adverse Effects / Herb-Drug Interactions
• Unqualified practitioners / Missed diagnoses
• Stopping conventional medicine
• Cost-effectiveness?

Question 7

Who uses CAMs?

Answer 7

• 80% of the UK population
• 60% of all cancer patients use or have used CAM
• 60% of all pregnant women in the UK use CAM
• 1% of children under 1 year of age are prescribed

Question 8

Who is the typical CAM user?

Answer 8

Someone who is affluent and educated with family or friends who have used them

Question 9

Why do people turn to CAMs?

Answer 9

• Desire to have personal control over one’s own health.
• Dissatisfaction with conventional treatment
• Perception that conventional medicine lacks/disregards an holistic approach.
• Concerns about the side effects of prescribed medications
• Believe alternatives more congruent to their own beliefs and values

Question 10

Why do people use CAMs?

Answer 10

• Think they are safe and natural
• Chronic symptom control
• Hype
• Holistic
• Promotion of health
• Relatives use CAMs

Question 11

Why do healthcare professionals recommend CAMs?

Answer 11

• Patient demand
• Placebo effect
• Genuine belief in a therapy
• Experience -Seeing is Believing
• “Feel good” factor in terminal illness, distressing hospital experiences
• Use CAM themselves

Question 12

What are herbal medicines?

Answer 12

• Herbal medicines include herbs, herbal materials, herbal preparations and finished herbal products, that contain as active ingredients parts of plants, or other plant materials, or combinations.
• In the UK some herbal products are classified as food supplements or cosmetics and others as medicines

Question 13

What herbal supplements are most commonly implicated in drug reactions with breast cancer drugs?

Answer 13

• Soya
• Cranberry
• Echinacea
• Glucosamine
• Grapefruit
• Garlic

Question 14

What supplements do breast cancer patients tend to use?

Answer 14

1/3 report use of supplements with oestrogenic activity

• Soya
• Evening primrose
• Chamomile
• Garlic
• Black cohosh
• Red clover

Question 15

How common is it for CAMs to be used in early pregnancy?

Answer 15

• 2/3 of women use CAM during early pregnancy.
• 28 different CAM modalities.
• Herbal products are the most common (37% of women),
• 25 different herbal products used.

Question 16

How common is it for CAMs to be used in late pregnancy?

Answer 16

• 2/3 of women use CAM.
• A total of 30 different CAM modalities.
• Oral herbal products the most common (38% of respondents)
• 40 different products.

Question 17

Why is it important to know if someone who is pregnant is using CAMs?

Answer 17

• No safety or efficacy data
• Teratogenesis
• Fetogenesis
• Drug-Herb Interactions

Question 18

How much do we know about the efficacy of herbalism?

Answer 18

• Very little evidence
• There has been some very specific trials
• Little current NHS use

Question 19

How much doe know about the safety of herbalism?

Answer 19

• Contamination, adulteration and misidentification of herbal remedies.
• Variation between the labelled content of products and their actual content.
• Serious toxic effects from some.
• Biggest problem is lack of data.
• Drug-herb interactions are a major concern, esp St John’s Wort and multiple herbs with warfarin.

Question 20

What is homeopathy?

Answer 20

Belief that minute concentrations of a particular toxin could cure the very same symptoms it would cause in large doses

Question 21

How are homeopathic remedies made?

Answer 21

• Repeated dilutions

- Dilution level is printed on the bottle of medicine

Question 22

What are the healing powers of homeopathy attributed to?

Answer 22

‘Water memory’

The concept that water has the ability to remember the shape of the medicine it once contained

Question 23

What do we know about the efficacy of homeopathy?

Answer 23

• Scientifically implausible.
• Major issues with quality of studies.
• No convincing evidence.
• “Now doctors need to be bold and honest with their patients about homeopathy’s lack of benefit, and with themselves about the failings of modern medicine to address patients’ needs for personalised care.”

Question 24

What do we know about the safety of homeopathy?

Answer 24

• Homeopathy is generally regarded as safe and harmless.
• Rarely reports of adverse effects, including aggravation of symptoms, have been made.
• Missed diagnosis
• Inappropriate treatment
• Adulteration

Question 25

What is acupuncture?

Answer 25

- Based on traditional Chinese medicine it uses needles at trigger points to deal with pain - Vital force called "Qi" which circulates along channels called meridians. - There are 12 main meridians, and these correspond to 12 major functions or "organs" of the body. - Balance of “yin” and “yang”.

Question 26

How is acupuncture carried out?

Answer 26

- 4 -10 points are needled during a session. - Needles are left in place for 10-30 minutes, although can be shorter. - Needles may be stimulated by twirling or an electrical current. - A typical course of treatment for a chronic condition would be 6-12 sessions over 3 months. This might be followed by 'top up' treatments

Question 27

What do we know about the efficacy of acupuncture?

Answer 27

- Partially explicable within conventional physiology of pain. - Stimulates pain fibres entering the dorsal horn of the spinal cord. These cause inhibition of pain impulses. - Stimulate release of endogenous opioids and other neurotransmitters such as serotonin. - Some research evidence that acupuncture has effects greater than sham treatment or placebo in pain, but little evidence for use in other conditions.

Question 28

What do we know about the use of acupuncture in back pain?

Answer 28

- For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. - Acupuncture is not more effective than other conventional and "alternative" treatments. - The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain.

Question 29

What do we know about the use of acupuncture for stroke?

Answer 29

- Acupuncture appeared to be safe but without clear evidence of benefit. - The number of patients is too small to be certain whether acupuncture is effective for treatment of acute ischaemic or haemorrhagic stroke. - Larger, methodologically-sound trials are required.

Question 30

What do we know about the use of acupuncture in epilepsy and asthma?

Answer 30

- The current evidence does not support acupuncture as a treatment for epilepsy. Much larger high quality clinical trials employing appropriate controls are needed. - There is not enough evidence to make recommendations about the value of acupuncture in asthma treatment. Further research needs to consider the complexities and different types of acupuncture.

Question 31

What do we know about the safety of acupuncture?

Answer 31

Prospective studies suggest incidence of harm is rare (14 per 10 000 consultations). Serious problems similar to any harm with needle use. - Infection - Pneumothorax - Pneumopericardium - Organ puncture Related to training of therapist

Question 32

What is aromatherapy?

Answer 32

- Aromatherapy is the use of concentrated essential oils extracted from herbs, flowers, and other plants to treat diseases. - It is commonly administered by massaging into the skin.

Question 33

How can aromatherapy be administered?

Answer 33

- Inhalation - Massage - Diffusion - Hot or cold compress - Soaking baths

Question 34

In what ways can aromatherapy be harmful?

Answer 34

-Skin irritation with frequent use -Photosensitivity-Avoid prolonged exposure to the sun, -Excessive inhalation can cause headaches and fatigue; -Insomnia -peppermint, -Origanum, sage, savory, thyme, and wintergreen, are not safe for home use. -Skin irritation -basil, lemon grass, fennel, rosemary, and verbena -Bronchial spasms, and people with asthma should not use -Abortifacient- Avoid aromatherapy during pregnancy sage, rosemary, juniper.

Question 35

What oils should not be used in pregnancy?

Answer 35

- Aniseed - Basil ct estragole - Birch - Camphor - Hyssop - Mugwort - Parsley seed or loaf - Pennyroyal - Sage - Tansy - Tarragon - Thuja - Wintergreen - Wormwood

Question 36

What do we know about the efficacy of aromatherapy?

Answer 36

- Aromatherapy is generally regarded as being relatively safe and pleasant - However, there is not data to support any legitimate clinical indications for the use

Question 37

How can aromatherapy affect cancer symptoms?

Answer 37

- Massage and aromatherapy massage confer short term benefits on psychological wellbeing - Effect on anxiety supported by limited evidence. - Effects on physical symptoms may also occur. - Evidence is mixed as to whether aromatherapy enhances the effects of massage. Replication, longer follow up, and larger trials are need to accrue the necessary evidence.

Question 38

How are CAMs regulated in the UK

Answer 38

Homeopathy can be registered under Simplified Scheme 1992 or National Rules Scheme 2006. - Demonstrate quality and safety. - If want to have an indication and make any claim of efficacy – National Rules with evidence.

Question 39

What do doctors need to know in regards to CAM use?

Answer 39

- Be aware of what is available via complementary practitioners, on-line and over the counter. - Ask patients about CAM use, as may not disclose. - Be aware of the potential for significant harm to patients. - Be aware of the changing fashion in CAM use - How to evaluate evidence of safety and efficacy. - Appropriate use in the NHS.