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Herbs are the second most common complementary or alternative therapy used by older persons. In contrast to pharmaceuticals, the production, marketing, and sale of herbs and supplements is regulated only by the Dietary Supplement Health and Education Act, which does not regulate the purity, quality, or standardization of preparations. As a result, active ingredients can vary among manufacturers and even from lot to lot for a given manufacturer. Patients and physicians should select products made by larger, more reputable companies, which specify the amounts of ingredients and standardization of the active ingredients to an accepted standard. In addition, most herbs and supplements are not routinely covered by insurance, and as such, may be cost prohibitive for many older individuals on a fixed retirement income. Table 57–2 lists the typical doses and uses of the most common herbs and supplements.
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Blumenthal
M, Buse
WR, Goldberg
A
et al eds. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin, TX: American Botanical Council; 1998. ISBN 096555550X
http://nccam.nih.gov/health/herbsataglance.htm
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Ginkgo is the top-selling herbal medicine in the United States. There are concerns about antiplatelet and warfarin-like effects of gingko, which should be avoided in patients taking anticoagulants. Although shown to reduce blood viscosity and clotting factors, gingko does not appear to cause a statistically significant increase in bleeding risk over placebo in patients not on anticoagulants. Ginkgo is clinically used and studied for dementia, memory impairment, cerebral insufficiency, tinnitus, and intermittent claudication. Overall, studies of Ginkgo are weak and the most rigorous trials show benefit for the treatment of tinnitus but speak against the use of ginkgo for treatment of dementia, memory impairment or prevention of cardiovascular events.
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Canter
PH, Ernst
E Ginkgo biloba is not a smart drug: an updated systematic review of randomised clinical trials testing the nootropic effects of
G. biloba extracts in healthy people.
Hum Psychopharmacol. 2007;22(5):265-–278.
CrossRef
[PubMed: 17480002]
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Ernst
E The risk-benefit profile of commonly used herbal therapies: ginkgo, St. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava.
Ann Intern Med. 2002;136(1):42-–53.
CrossRef
[PubMed: 11777363]
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Kurz
A, Van Baelen
B Ginkgo biloba compared with cholinesterase inhibitors in the treatment of dementia: a review based on meta-analyses by the Cochrane collaboration.
Dement Geriatr Cogn Disord. 2004;18(2):217-–226.
CrossRef
[PubMed: 15237280]
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St. John’s wort is widely used in Europe to treat depression. St. John’s wort is believed to work through selective inhibition of the reuptake of serotonin, dopamine, and norepinephrine in the brain. Several meta-analyses and qualitative systemic reviews have found St. John’s wort to be superior to placebo and comparable to tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) with similar side effect rates but fewer withdrawals. St. John’s wort may be used cautiously in the treatment of mild depression but is not currently recommended for moderate-to-severe depression, which should be treated with pharmacologic or cognitive–behavioral interventions with more rigorous efficacy data. Patients should not take tricyclic antidepressants, SSRIs, or monoamine oxidase inhibitors while taking St. John’s wort. St. John’s wort activates P450 enzymes, so care should be used in treating patients who are also taking warfarin, digoxin, or other drugs with hepatic metabolism.
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Rahimi
R, Nikfar
S, Abdollahi
M Efficacy and tolerability of
Hypericum perforatum in major depressive disorder in comparison with selective serotonin reuptake inhibitors: a meta-analysis.
Prog Neuropsychopharmacol Biol Psychiatry. 2009;33(1):118-–127.
CrossRef
[PubMed: 19028540]
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Glucosamine/Chondroitin
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Glucosamine and chondroitin are commonly used for the treatment of osteoarthritis. Both glucosamine and chondroitin are components of proteoglycans found in articular cartilage and synovial fluid. How oral glucosamine or chondroitin work physiologically is not clear, and there is little evidence that patients with osteoarthritis are deficient in these substances or that oral glucosamine or chondroitin is selectively taken to joints. Studies have found these substances to be very safe, with no more side effects than placebo.
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Meta-analyses of early clinical trials of glucosamine and chondroitin have shown both to be superior to placebo in improving pain and disability. More recent trials have shown glucosamine, with or without chondroitin, to be as efficacious as nonsteroidal antiinflammatory drugs (NSAIDs) to reduce pain and disability in knee and hip osteoarthritis with fewer side effects. It is unknown whether glucosamine and chondroitin improve symptoms of osteoarthritis at other sites such as the hand or hip.
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Ernst
E Complementary and alternative medicine for pain management in rheumatic disease.
Curr Opin Rheumatol. 2002;14(1):58-–62.
CrossRef
[PubMed: 11790998]
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Reginster
JY, Deroisy
R, Rovati
LC
et al Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial.
Lancet. 2001;357(9252): 251-–256.
CrossRef
[PubMed: 11214126]
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Sawitzke
AD, Shi
H, Finco
MF
et al Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination,
celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT.
Ann Rheum Dis. 2010;69(8):1459-–1464.
CrossRef
[PubMed: 20525840]
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Thie
NM, Prasad
NG, Major
PW Evaluation of glucosamine sulfate compared to
ibuprofen for the treatment of temporomandibular joint osteoarthritis: a randomized double blind controlled 3 month clinical trial.
J Rheumatol. 2001;28(6):1347-–1355.
[PubMed: 11409130]
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Towheed
T, Maxwell
L, Anastassiades
TP
et al Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev. 2005;2. Art. No.: CD002946. DOI:10.1002/14651858.CD002946.pub2.
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Saw palmetto (also known as Serenoa repens) is commonly used to treat symptoms of benign prostatic hypertrophy (BPH) by inhibiting the 5α-reductase enzyme that converts testosterone to 5-dehydrotestosterone, prostaglandin synthesis, and growth factor actions. In Western Europe, saw palmetto is used much more commonly than finasteride or α blockers for BPH. Despite early evidence of benefit, the most recent meta-analysis and several randomized controlled trials found no improvement in urinary symptoms with the use of saw palmetto over placebo. There is also no evidence to support the use of saw palmetto to reduce the size of the prostate. It does not seem to affect prostate-specific antigen levels, but further studies are needed to determine the role of saw palmetto in men with or at risk of prostate cancer. Given the body of evidence speaking against the use of saw palmetto for symptoms of BPH, it should not be recommended for this use.
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Bent
S, Kane
C, Shinohara
K
et al Saw palmetto for benign prostatic hyperplasia.
N Engl J Med. 2006;354(6):557-–566.
CrossRef
[PubMed: 16467543]
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Tacklind
J, MacDonald
R, Rutks
I
et al Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2009;(2):CD001423.
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Ginseng is among the best-selling herbal supplements. It is also one of the herbs with the most reported benefits, including central nervous system effects of increased vigilance, increased concentration, increased sense of well-being, and increased relaxation along with systemic anticancer, antidiabetic, and aphrodisiac effects. The incidence of side effects is low but some can be serious, such as vaginal bleeding, Stevens-Johnson syndrome, hypertension, warfarin interactions, and hypoglycemia.
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Ginseng is traditionally used as a component of traditional Chinese medicine for overall health and antiaging. Multiple studies have attempted to determine the evidence for the multiple health claims made for ginseng. To date, reviews are limited by significant methodologic issues and possible publication bias. In healthy subjects, ginseng has been shown to improve cognitive performance and may delay onset of dementia. The evidence for benefit in patients with dementia is weaker. Early trials support the use of ginseng for cardiovascular health. Currently, there is moderate and mixed evidence that ginseng improves cardiac function and reduces vascular disease. More rigorous clinical trials are needed to better describe the role and benefit of ginseng as a therapeutic and preventive agent for cardiovascular disease. There is strong evidence that ginseng improves pulmonary function but does not enhance physical performance. Overall, there is limited data to support the widespread recommendation for ginseng.
+
Ernst
E The risk-benefit profile of commonly used herbal therapies: ginkgo, St. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava.
Ann Intern Med. 2002;136(1):42-–53.
CrossRef
[PubMed: 11777363]
+
Lee
NH, Son
CG Systematic review of randomized controlled trials evaluating the efficacy and safety of ginseng.
J Acupunct Meridian Stud. 2011;4(2):85-–97.
CrossRef
[PubMed: 21704950]
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Perry
E, Howes
MJ Medicinal plants and dementia therapy: herbal hopes for brain aging?
CNS Neurosci Ther. 2011;17(6):683-–698.
CrossRef
[PubMed: 22070157]
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Garlic is widely advertised and used in the United States with the aims of lowering cholesterol and blood pressure and preventing cancer. The active ingredient is allicin, and most preparations are standardized to contain 0.6% to 1.3% allicin. The most widely studied form is the Kwai powder, which contains 1.3% allicin. Side effects include odor, flatulence, diarrhea, and stomach upset. The most serious, although rare, side effect is increased bleeding, which may be a consequence of reductions in platelet aggregation.
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Garlic has been found to be superior to placebo in reducing total cholesterol but not blood pressure. The total reduction in cholesterol is 12–25 mg/dL at 3 months, which is similar to the effect of dietary intervention and less than the effect of statins. None of the underlying studies lasted more than 10 months, and 1 meta-analysis suggested that the benefit of garlic may not last beyond 6 months.
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Garlic was associated with reduced rates of stomach and colorectal cancer in cohort and case-control studies, but there are no randomized studies of garlic to support these findings. The effect of garlic on cancer at other sites has not been studied sufficiently to support any conclusions.
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Fleischauer
AT, Arab
L Garlic and cancer: a critical review of the epidemiologic literature.
J Nutr. 2001;131(3s):1032S-–1040S.
[PubMed: 11238811]
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Stevinson
C, Pittler
MH, Ernst
E Garlic for treating hypercholesterolemia. A meta-analysis of randomized clinical trials.
Ann Intern Med. 2000;133(6):420-–429.
CrossRef
[PubMed: 10975959]
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Ginger has been used in Chinese and Ayurvedic medicine for more than 2500 years for the treatment of musculoskeletal pain and gastrointestinal illnesses. Ginger has been studied for the prevention of postoperative nausea and motion sickness and the treatment of vertigo and osteoarthritis pain, with mixed but overall slightly positive results.
+
Altman
RD, Marcussen
KC Effects of a ginger extract on knee pain in patients with osteoarthritis.
Arthritis Rheum. 2001;44(11): 2531-–2538.
[PubMed: 11710709]
+
Bliddal
H, Rosetzsky
A, Schlichting
P
et al A randomized, placebo-controlled, cross-over study of ginger extracts and
ibuprofen in osteoarthritis.
Osteoarthritis Cartilage. 2000;8(1):9-–12.
[PubMed: 10607493]
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Ernst
E, Pittler
MH Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials.
Br J Anaesth. 2000;84(3):367-–371.
[PubMed: 10793599]
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Omega-3 (n-3) polyunsaturated fatty acids (PUFAs) are the most commonly used supplement in the United States; however, dietary sources appear to be the best way to enrich tissue levels. The richest sources of dietary PUFAs are from oily fish, such as tuna, salmon, sardines, mackerel, and herring. PUFAs can also be found in land meats (beef, pork, and chicken), but in much lower quantities. There is not currently a recommended daily allowance of PUFAs because of the paucity of scientific evidence for adequate intake levels in healthy adults; however, the American Heart Association recommends intake of 8 ounces of fish at least 2 times a week. Studies suggest 2–3 g/day to lower cholesterol and 1 g/day for secondary cardiovascular prevention. The maximum recommended daily amount is 3 g, although 4 g is often used.
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The role of n-3 PUFAs in disease prevention and treatment is still being elucidated, but is most likely a result of antiinflammation and immune modulation. Diseases associated with systemic inflammation increase production of cytokines, which can be modulated by n-3 PUFAs. Studies indicate that those with chronic inflammatory conditions are likely to be more sensitive to the antiinflammatory effects than are healthy people.
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The use of PUFAs for prevention of cardiovascular disease remains controversial. Early studies suggested a benefit in mortality and morbidity outcomes for both primary and secondary cardiovascular disease prevention. However, more recent randomized trials fail to reproduce this benefit in secondary prevention. There may still be a role for PUFAs in primary prevention of cardiovascular disease, and they are still recommended as part of a well-balanced, healthy diet. It is also reasonable to recommend PUFAs in people with cardiovascular disease who cannot tolerate HMG-CoA reductase inhibitors. A meta-analysis of 10 randomized controlled trials found a statistically significant reduction in arterial stiffness. Further clinical studies are needed to confirm if this equates to improved cardiovascular fitness and reduced disease and to uncover the role of PUFAs in prevention or treatment of retinal disease, cancer, mental illness, cognitive decline, and autoimmune diseases.
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Buhr
G, Bales
CW Nutritional supplements for older adults: review and recommendations—part II.
J Nutr Elder. 2010;29(1):42-–71.
CrossRef
[PubMed: 20391042]
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Kwak
SM, Lee
YJ, Seo
HG; Korean Meta-analysis Study Group.. Efficacy of omega-3 fatty acid supplements (eicosapentaenoic acid and docosahexaenoic acid) in the secondary prevention of cardiovascular disease: a meta-analysis of randomized, double-blind, placebo-controlled trials.
Arch Intern Med[Archives of Internal Medicine Full Text]. 2012;172(9):686-–694.
CrossRef
[PubMed: 22493407]
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Reidiger
ND, Othman
RA, Suh
M, Moghadasian
MH A systemic review of the roles of n-3 fatty acids in health and disease.
J Am Diet Assoc. 2009;109(4):668-–679.
CrossRef
[PubMed: 19328262]