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Do ‘natural’ treatments put your patients at risk?

From the May 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By William Hoffman

Alternative medicine resources

Atlanta—Alternative therapies like chaparral tea and kava received a skeptical review at a pre-Session presentation, “Complementary and Alternative Medicine: A Look at the Evidence.”

Panelists said that even the term “complementary and alternative medicine” is a deceptive misnomer. It lumps alternative medicine—unproven, if not hazardous, products and techniques—with complementary therapies, which supplement scientific medicine with supportive care for patients. They argued that all too often, alternative treatments lure sick people from scientifically tested, though not always efficacious, therapies and treatments.

Speakers at the session agreed that most alternative therapies have a long way to go before they can join the canon of scientific medicine. “We suffer from an under-reporting of effects,” said Katherine Gundling, FACP, an associate adjunct professor at the University of California, Davis, who has studied immunomodulatory properties of panax ginseng and the efficacy of gingko biloba for treating dementia.

John A. Astin, PhD, from the complementary medicine pro­gram at the University of Maryland School of Medicine, said that the accelerating proliferation of alternative medicine businesses, products and services makes clinical testing nearly im­possible. “Talk about a moving target!” he exclaimed.

Questionable effects

Max H. Pittler, MD, from the Univer­sity of Exeter in Great Britain, reviewed evidence from various studies of the top seven extracts sold in the United States.

One set of studies suggested that while garlic is superior to placebos in treating hypercholesterolemia, the effect is modest and its value debatable. His review found a “nonsignificant difference” between ginger and placebos in treating nausea and vomiting. He did find, however, that gingko biloba was superior to placebos for treating dementia and symptoms of intermittent claudication.

In these and most other cases, Dr. Pittler’s review found that rigorous clinical comparisons to more traditional medicines were insufficient or entirely absent.

Barrie R. Cassileth, PhD, chief of the integrative medicine service at Memorial Sloan-Kettering Cancer Center in New York City, recalled the cases of two young women, both diagnosed with early-stage breast cancer. One went to a “hands-on” healer who purported to draw out her cancer from across a room, while the other opted for massive vitamin doses, even though studies show some cancers feed on vitamins. Although both women died, Dr. Cassileth said she believed both were treatable.

Herb interactions

Herbs are popular, Dr. Cassileth noted, but although natural, they are actually dilute versions of powerful pharmaceuticals and therefore not necessarily safe. Even though science has not yet identified all active ingredients in herbs and other botanicals, she said that many patients assume that “natural” equals “safe.”

She pointed to the following interactions:

Chaparral tea, which allegedly has antioxidant properties, has been linked to liver failure requiring transplantation.

  • Ma huang, an herbal central nervous system stimulant also known as ephedra, has caused cardiac symptoms, seizures and deaths.

  • Saint John’s wort, used to treat mild to moderate depression, appears to interfere with the liver’s ability to process chemotherapies and may hasten organ rejection in transplant patients.

  • Kava, valerian and Saint John’s wort may interfere with how the body metabolizes anesthetics.

Dr. Cassileth indicated that adverse effects might be produced by the substance itself, a contaminant or some other factor. She noted that negative effects have been observed and documented for some popular remedies, but little is known about others, in part because current law prevents the FDA from conducting proscriptive tests on questionable claims. The law expressly forbids manufacturers from claiming their product can cure specific diseases, but it lets them make a wide range of other claims without evidence.

Complementary therapies

Despite their skeptical views of alternative therapies, panelists agreed that some complementary therapies merit investigation. Dr. Cassileth noted that massage techniques, for example, have proven effective in reducing stress.

“Acupuncture is well documented as an effective therapy for pain and nausea,” she said. She also noted that music therapy can effectively reduce anxiety and pain in terminally ill patients. She has seen similar positive results from various types of massage, relaxation and other mind-body techniques, as well as yoga, meditation and other complementary modalities.

What’s lacking is peer-reviewed scientific research to validate the efficacy of these medicines and therapies, speakers agreed. So far, grant money for such research has been sparse.

Dr. Cassileth suggested physicians need to separate “complementary” from “alternative” treatments and modalities to restore semantic perspective to the debate. “Integrated medicine is the best of complementary medicine and traditional therapies and treatments,” she said. “Complementary therapies are really an extension of traditional care.”

William Hoffman is a freelance writer in Fairfax, Va.

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Alternative medicine resources

From the May 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

At an Annual Session pre-Session course on alternative and complementary medicine, Philippe O. Szapary, ACP-ASIM Member, listed his favorite resources for information on alternative medicine. Dr. Szapary is assistant professor of medicine in the division of general internal medicine for the University of Pennsylvania Health System in Philadelphia.

Web sites

  • consumerlabs.comoffers independent tests of herbal, vitamin and mineral supplements.

  • FDA.gov offers information on alternative medicine products through its MedWatch reporting program and safety site (fda.gov/medwatch/index.html), which contains forms to report complications from natural products.

  • Later this summer, naturalstandard.com will offer content, expert advice, chat rooms and referral services for anyone interested in integrative medicine.

Publications

“Complementary/Alternative Medicine: An Evidence-Based Approach” provides an overview of major alternative medicine modalities and serves as a good introduction to the field. http://www.harcourthealth.com/fcgi-bin/displaypage.pl?isbn=0815129890.

“Cochrane Database of Systematic Reviews” is the first place to start when reviewing an alternative medicine topic, according to Dr. Szapary. http://www.library.mcgill.ca/peruse /cdsr.htm.

“The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines” is a concise resource on European phytotherapy published by the American Botanical Council. http://www.herbalgram.org/comm ission_e/index.html.

Dr. Szapary said that EMBASE offers the best scientific database for natural products with an international focus. http://library.dialog.com/ bluesheets/html/bl0072.html.

“Facts & Comparisons, The Review of Natural Products” offers quick, easy access to more than 300 monographs on herbs, botanicals, and natural products and supplement interactions. http://www.factsandcomparison s.com/efactsintro.asp.

“Focus on Alternative and Complementary Therapies” (FACT) provides brief reviews of current literature, books and software. http://www.ex.ac.uk/FACT/.

MEDLINE is a free database that has a growing number of alternative medicine citations and can be searched from any library. http://www.ncbi.nlm.nih.gov/entrez /query.fcgi.

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