Choosing and Using Alternative Medicine: Charles Fetrow, PharmD
Choosing and Using Alternative Medicine: Charles Fetrow, PharmD
By Charles Fetrow, PharmD
Alternative treatments are experiencing an unprecedented rise in acceptance and popularity in countries where western medicine is the norm. But what happens when traditional and alternative medicine mix? Can ancient and modern methods co-exist safely in your body? We asked alternative medicine expert Charles Fetrow, PharmD, when he was our guest on WebMD Live.
The opinions expressed herein are the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Hello, members, and welcome to WebMD Live. Joining us now is Charles Fetrow, PharmD, who is here to discuss choosing and using alternative medicine.
Member: I am concerned about drug/herb interactions. I have a multivitamin that contains a number of herbs and fear they may conflict with my Synthroid. Is there a source (book, website, etc.) that lists possible negative interactions?
Fetrow: Yes. I prefer textbooks. My book, The Complete Guide to Herbal Medicine, published by Spring House, critically evaluates herb/drug interactions for the consumer. Alternative sources on the internet would be:
The problem is there are very few things designed for the consumer that are not selling products along with it and therefore potentially biased.
Moderator: Off the top of your head, can you name some drug/supplement interactions that either block the effectiveness of the drug or may cause a dangerous interaction?
Fetrow: St. John's wort, an antiviral drug, interacts with AIDS drugs. St. John's wort increases metabolism of these drugs, necessitating higher doses of the antiviral drugs. There are several herbs that contain naturally occurring chemicals called coumarins, which are natural blood thinners and can cause bleeding in and of themselves, as well as enhancing anticoagulative, or blood thinning, effects of existing anticoagulants. Some examples of these herbs include red clover, St. John's wort, ginkgo biloba, garlic, and tumeric.
Member: I am looking for alternative medicines for lung cancer (non-small cell adenocarcinoma) -- to prevent recurrence.
Fetrow: It is my opinion there is nothing with data in sufficient quantity that I could even begin to recommend anything. You need to follow the traditional path set up by your healthcare provider. I can certainly understand a patient's desire to reach out for something else in this situation, but I cannot in good faith recommend anything, for a lack of efficacy or effectiveness. This is because of a lack of effectiveness and safety data, as well as the shear unreliability of the products due to a lack of standardization.
Member: I have an herbologist who put me on tumeric, modified citrus pectin, Chinese herbal mix, IP-6, vitamins E, C, selenium, and others.
Fetrow: I can speak to some of these. I do not know of the Chinese herbal mix (what are its contents?) or IP-6. There is little to no data for the use of tumeric and modified citrus pectin. I cannot support their use. Vitamin E and selenium have been touted as antioxidant agents.
Thus, they may play some role in disease states such as cancer. However, the theories have not been tested in large-scale clinical trials. They have typically only been studied in vitro (in the laboratory). Laboratory results don't necessarily pan out to produce clinical benefit in humans. So, in other words, just because it happens in a lab does not mean it will have a clinical benefit in humans. Since this has not been studied, I have problems endorsing it.
These things may have been written up in medical journals, however, the type of studies that have been done have been evaluating mechanisms of action, not clinical outcomes. For example, it's the same as placing an herb in a dish with a slice of disease tissue and looking for activity. This doesn't necessarily mean it will produce a benefit in humans. Chemicals inside the plant of tumeric have been shown to inhibit certain steps in formation of cancers. However, no study has shown or proved that tumeric prevents cancers or treats cancers in humans. These have all been in laboratory studies.
Member: What is your feeling on green tea?
Fetrow: Green tea is an extract that has been used for thousands of years. It has some effect on platelets, components of the blood which affect clotting. It has some cholesterol-lowering effects. Because of the caffeine in it, it increases alertness. And as a tea, I think it's fine, but I would not use it as a drug to prevent or treat anything because we just don't have this information. I don't think it's harmful but I would not take it in excessive quantities. But some of the information looks intriguing and we should probably study it or some of its components in greater detail to see if they will have any value in humans. At this point, its effects in clinical outcomes such as cancer and heart disease are unknown. That's the bottom line. However, again, it looks intriguing.
Member: Do you know any good alternative treatments for chronic pain?
Fetrow: There are some interesting and relatively harmless alternative therapies that may work:
I think they are relatively harmless and may actually work. I think the amount of data for the herbal entities suggested for pain leaves too much in question that I would sooner pursue things I thought were less risky, like those above, since they make good adjuncts to traditional allopathic practices and are relatively low-risk. We use those things just listed as adjuncts. They are never the sole reliever of the pain. They are used in combination with traditional allopathic analgesics (nonsteroidal). And I think that with the medicines we have, we understand well both the risks and the benefits, as opposed to the herbal ones where the risks are either not well-defined or unknown.
Moderator: And do you think that's where Western medicine is heading, not toward replacing drugs with herbs, say, but using traditional treatments in conjunction with alternative treatments?
Fetrow: Yes, I do think that's where it's headed. If you look at China and Germany, this is what they are doing. The Chinese government endorses its use in conjunction with allopathic, or traditional, medicine.
Member: Are any of the herbal appetite reducing drugs safe?
Fetrow: In the right patient, they can be safe. However, some problems exist in choosing the right patient and reliability of the dosage. Some of the original data with weight-loss drugs, some of the better data, examined ephedrine and caffeine and showed them to be effective weight loss entities in combination.
Ma huang contains ephedra alkaloids, which are related to ephedrine. That's why oftentimes you see ma huang in dietary supplements or ephedra in dietary supplements combined with caffeine or other stimulants. They appear to be effective; however, they can be dangerous in the wrong patient. Patients with existing heart disease such as coronary disease, arrhythmia (heart rhythm disturbances), cerebral vascular disease, and hypertension [high blood pressure] -- are some examples of those who should stay away from ephedra and dietary supplements containing ma huang.
Early trials suggested chromium was a valuable weight-loss agent. However, the most recent well-designed studies suggested no benefit of chromium vs. a sugar pill for weight loss. These are large, well-designed studies conducted over the last two to three years suggesting no benefit from chromium.
Ginseng has been touted as a weight-loss agent. It's a stimulant, much like caffeine, and increases alertness. And going back to what I said about ephedra and caffeine, it might make sense ginseng would be valuable. However, there is no data to say that it's good as a weight-loss agent. Plus, it's not without its own side effects. It can decrease the effect of coumadin, can cause hypoglycemia (low blood sugar), and has its own toxicity syndrome called the Ginseng Abuse Syndrome, characterized by hypertension, nervousness, excitation, etc. So even though it may work, I cannot exactly stand behind it.
Chitosan at one time I thought was promising, but now the most recent trials failed to show a difference over placebo in weight loss.
So to summarize, it doesn't appear there are a lot of entities out there that can promote weight loss, with the exception of a combination of ephedrine alkaloids and a CNS stimulant such as caffeine or ginseng or guarana. And the unfortunate circumstance is the products are still unreliable, and the selection of patients that could receive these entities is precarious due to potential heart attack, arrhythmia, and stroke. Unfortunately, once again even though they seem promising, I cannot support the use of these agents in the general population. Diet and exercise is an option! Those should be pursued first. People need to educate themselves, talk to their physician and dietician, and learn about nutrition and exercise.
Member: What foods, supplements, or herbs are best used in lieu of HRT for menopausal symptoms? I have heard a lot about soy, but I am unclear on amounts of soy (nuts, tofu, or soy milk), to take to get an equivalent dosage.
Fetrow: The problem with soy is that the dosage forms are unreliable. You get varying quantities of phytoestrogens. There is no consensus on how much to give. Even if there was, I would have difficulty recommending a product. In lieu of soy, I would recommend vitamin E.
Member: In the U.S., I think the law is that you can't ban an herbal product unless it is proved harmful (unlike pharmaceuticals, which have to be proved safe before they are sold). So how can I tell if a "natural" remedy is OK to use? I mean, hemlock is natural! Is anyone trying to safeguard the public?
Fetrow: In 1994, the government passed the Dietary Supplement Health Education Act. This prevented the FDA from legislating or regulating alternative medicines and dietary supplements. The FDA cannot remove a product from the shelves without being able to prove imminent harm to the consumer. So, literally, the burden of proof is on the FDA. Something has to happen first (something has to go wrong) or we have to have enough circumstantial or laboratory evidence in the beginning before the FDA can go after it. The only real stipulation of DSHEA suggested that manufacturers could not claim effectiveness for any disease state on the label. The FDA reviews the labels for that wording. They cannot review it for 30 days, the first 30 days the product is out, then they can go after it.
Again, these products have no standardization, no regulation, and no standards that they have to meet. In general, the doses of the products may be low enough that we don't see acute toxicity, but things like drug interactions, side effects, contamination of products, and adulteration of products, do occur and make these products more risky than allopathic medicines, where we understand both the benefit and the risk. Before you ever take a medicine, you always want to know that the benefit exceeds the risk. All chemicals have risks, some greater than others. Dietary supplements do not have complete risk profiles and usually incomplete efficacy profiles. This makes their application for any disease questionable. Or at least certainly not routine.
Member: Why do we have such screwy laws? Was the lobby for the herbal manufacturers so powerful that Congress forgot about the consumer?
Fetrow: Yes. They are very powerful.
Moderator: And doesn't it have something to do with the fact that most supplements are considered by the government to be food?
Fetrow: There are foods. There are drugs. There are dietary supplements. As of 1994 there were dietary supplements. At the making of DSHEA, any dietary supplement on the shelf that had no bad news associated with it was simply grandfathered into existence.
Member: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Fetrow?
Fetrow: Yes. As a clinician I understand people's desire to pursue these entities in two places. One is poor prognosis. People expect to die and I understand the need to reach out for more. Second is excessive morbidity [illness]. Patients with a poor quality-of-life -- like those with end-stage heart failure and end-stage rheumatoid arthritis -- where medicine fails to provide everything the patient needs, I understand why they wish to pursue these things. However, with all the unknowns I have mentioned in this discussion, it behooves the consumer and the doctor to become educated with regard to these entities. A patient must get their healthcare provider involved in this process
Give the healthcare provider time to educate themselves to help the patient make an informed decision about their healthcare. People need to temper their enthusiasm for these products. Because it's early. Some of these entities will offer promise. However, standardized dosage forms of the herbs or the important chemical within the herbs, need to be produced and studied in sufficient study designs before the medical community can understand where these entities play a role in the patient's therapeutic regimen.
Moderator: Unfortunately, we are out of time. Thanks for joining us, members, and thanks to Charles Fetrow, PharmD, for being our guest. Be well and goodbye!
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