| Dr
DIMITRIOS – JAMES MANOS
1 January 2012
Herbal medicine is a worldwide method
of complementary medicine.
However there are many stereotypes about its indications and
its safety. Unfortunately there
are fewer studies about herbal medicine, contrary to contemporary
medications. Furthermore, tests have revealed that
in some herbal or dietary supplement products the proportion
of the active substance was in fact low (so it was in sub – therapeutical levels, namely in lower levels
that it is needed to help) and also in
some cases the product contained lead,
a toxic heavy metal. Often, different
products had different amounts of the main substance.
Other times the products did not contain sufficient – effective dose of the substance (e.g. a herb root), but a part
of it (e.g. steams or leaves). Also, the effective
dose of most of the herbs/ dietary supplements hasn’t been established
for most of them!
The herbs/ dietary supplements
(including herbs) are not under
the full regulation of governmental authorities such as the
FDA (Food & Drug Administration) of
the USA and so the products aren’t regulated that strictly as
the medications – see chapter I. NOTES FROM OFFICIAL ORGANIZATIONS SUCH AS THE FDA
(US Food & Drug Administration)
That means that for many herbs/ dietary supplements
there is lack of safety and official scientific research (that
leads to guidelines) for their indications, their safe therapeutical
dose (that indeed treats a disease), their contraindications,
their interactions (with other drugs or herbs) and all their
side effects. Except perhaps fish oil, there aren’t any official medical guidelines for taking most
dietary supplements (including herbs). Also for many herbs/
dietary supplements there is efficient, conclusive and ‘evidence
based’ scientific proof that they help comparing to drugs (medicine)
or placebo.
As medications, herbs and dietary supplements
have specific indications, contraindications, interactions with
other drugs and side effects such as allergy, nausea and gastrointestinal disturbance
(5).
Herbalists have the specialty that can guide patients how to use sufficiently
and safely herb medications and generally dietary supplements.
A well qualified complementary medicine expert and also a doctor can also give herbs and dietary supplements
(if he/she is well trained to). However,
it is unacceptable for people to buy herbs on the supermarket
or on the internet without counselling an expert (doctor,
herbalist, complementary medicine expert etc).
About the question if there is evidence that
herbs and dietary supplements work better than medical drugs
or than placebo, generally for many herbs/dietary supplements
there is lack of sufficient data to support that they work better.
Today it is important
to check if a herb or a dietary supplement (or a medicine) really
helps a patient and there is a specific way of checking it: Evidence Based Medicine. Also several trials and research is published
at database such as the Medline.
Many
published studies have bias (one example is a medication that
is studied by a manufactory company). They may are poor designed.
They may have a small sample (e.g. it is different to involve 5 subjects
and different to involve 5 000 subjects) and they may have logistic problems and
inadequate publication of the statistic methods and results.
They may also have published insufficient data. They may not
be placebo controlled or double – blind and also may not be
randomized controlled. Also many meta-analysis involve just
a few RCTs (randomized controlled trials), for example they investigate just 3 – 4 studies
or even 1 – 2 studies, so
it is impossible to lead to a safe conclusion. Also a study
may have short duration and this may influence the results.
So the duration of a study is important.
In conclusion many studies are poor designed, so we need
to check first if the quality of a study is good or poor. Cochrane
meta-analysis are based on good designed studies that fulfil
the inclusion criteria.
Evidence Based Medicine analyzes
several trials (meta-analysis) and ends up to a safe conclusion
about if a dietary supplement or a medication really helps a
disease. A guideline is published
to guide the doctors and the scientists
in all over the word about its safe use (1),
(2), (3), (4).
We should not accept any article – trial
without References at the end of the publication. Of course many investigations are biased (e.g. if conducted
from a drug company), and
that’s why today scientists seek and analyze several trials
(meta-analysis). Also trials
are better if are randomized controlled and also double blind and
placebo – controlled. These
trials are analyzed by ‘Evidence
Based Medicine’ and
also the ‘Cochrane’ Library. The Cochrane
Library has meta-analysis that are more important than a single
study e.g. on pubMed. However, many meta-analysis involve just a few RCTs (randomized
controlled trials), for example
they investigate just 3 – 4 studies or even 1 – 2 studies, so it is impossible to lead to a safe conclusion.
So, we all need to search on the web about Evidence Based Guidelines.
Evidence Based Medicine (EBM) aims
to apply the best available evidence gained from the scientific
method to clinical decision making. It seeks to assess the strength
of evidence of the risks and benefits of treatments (including
lack of treatment) and diagnostic tests. Evidence quality can range from meta-analyses
and systematic reviews of double blind, placebo controlled
clinical trials. EBM recognizes that many aspects of health
care depend on individual factors such as quality and value
of life judgments, which are only partially subject to scientific
methods. EBP seeks
to clarify those parts of medical practice that are in principle
subject to scientific methods and to apply these methods to
ensure the best prediction of outcomes in medical treatment,
even as debate continues about which outcomes are desirable
(1).
Evidence based Medicine recommendations, according
to the US Preventive
Service Task Force, can be categorized to the following categories:
- Level A: there is good scientific evidence suggesting that the benefits of
the clinical service substantially outweigh the potential
risks. Clinicians should discuss the
service with eligible patients.
- Level B: there is at least fair scientific evidence suggesting that the benefits
of the clinical service outweigh the potential risks. Clinicians should discuss the
service with eligible patients.
- Level C: there is at least fair scientific evidence suggesting that there
are benefits provided by the clinical service, however the
balance between benefits and risks are very close for making
general recommendations. Clinicians need not offer it, unless
there are individual considerations.
- Level D: there is at least fair scientific evidence suggesting that the risks
of the clinical service outweigh the potential benefits. Clinicians
should not routinely offer the service to asymptomatic patients.
- Level I: scientific evidence is lacking, has poor quality, or is conflicting,
so that the risk against benefit balance can’t be assessed.
Clinicians should help patients understand the uncertainty
of surrounding the clinical service (1).
Always someone should
make his/her own research and check a herb or a dietary supplement
(by writing its name at the ‘search’ box) at the following sites:
1. Sites for Evidence Based
Medicine are many e.g. http://ebm.bmj.com and
http://www.dmoz.org/Health/Medicine/Evidence_Based_Medicine
2. Sites for Cochrane (it has matanalysis) are http://www.cochrane.org and
http://www.thecochranelibrary.com
3. Site for medline – PubMed
is http://www.ncbi.nlm.nih.gov/pubmed
and for MedlinePlus
http://www.nlm.nih.gov/medlineplus/healthtopics.html
For quick search write on a search engine
such as ‘google’ the keyword with the name of the supplement
and next the phrase ‘PubMed’.
For a classic encyclopaedia
go e.g. to Britannica
at http://www.britannica.com
Also for encyclopaedia go to http://en.wikipedia.org/wiki/Main_Page
OTHER SITES:
Clinical evidence:
• www.clinicalevidence.com
• http://highwire.stanford.edu
• www.eguidelines.co.uk
• www.medicine.ucsf.edu/recourses/guidelines
• www.guidelines.gov
•
http://www.nature.com/
For drugs (medications,
medicines)
• www.bnf.org
• www.medicines.org.uk
• www.ukmi.nhs.uk
• www.fda.gov
• http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm
• http://www.drugs.com/
-
Further information on internet about
herbs, dietary supplements and complementary medicine
you can find at the sites:
and
For a good dictionary
(that follows the ‘corpus’) go to
http://dictionary.cambridge.org
About buying medicine on
the internet please read the FDA’s
article:
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/BuyingMedicinesOvertheInternet/default.htm
It is strongly suggested to never stop a medication that a doctor prescribed or suggested in order
to replace it with a herb or a dietary supplement. Instead,
therapy with dietary supplements
(including herbs), may be combined with prescribed drugs
(guided by a specialist)
and that is why we call this kind of medicine as ‘complementary medicine’.
Of course this combination may occur only
if there aren’t any interactions between the dietary supplement
and the medication (that’s why an expert needs to guide someone who takes a dietary supplement).
Complementary medicine offers
a therapy (e.g. a herb/dietary supplement) that can help to
a specific medical problem, WITHOUT the need of stopping the
drugs (medications) of contemporary
(modern) medicine. It
is important especially for severe diseases such as cancer in
which the medication therapy should not be stopped in order
to be replaced by a herb/ dietary supplement in any way.
REFERENCE (LINKS)
1. http://en.wikipedia.org/wiki/Evidence_based_medicine
2. Simon C., Everitt
H., Kendrick T., Oxford
Handbook of General Practice, Oxford Medical Publications,
2nd edition, 2005.
3. Evidence Based Medicine, p. 668 – 669, Longmore
M., Wilkinson I.B, Davidson E.D., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine,
Oxford Medical Publications, 8th edition, 2010.
4. Evidence Based Medicine, p. 489, Collier J.,
Longmore M., Brinsden M., Oxford
Handbook of Clinical Specialties, Oxford Medical Publications,
7th edition, 2006.
5. Herbal Medicine, p. 148 – 149, C. Simon, H. Everitt, T. Kendrick, Oxford Handbook of General Practice,
Oxford Medical Publications, 2nd edition, 2005.
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