Setting the Herbal Supplement vs Prescription Drugs Straight

November 7, 2010 7:19 AM

Need some advanced advice on herbal supplements for both energy and rest for a semi-healthy person, but on prescription drugs too.

Okay here is the thing. I'm a nurse and a very experienced nurse at that. Probably 50% of doctors (and I'm speaking from experience, mind you) really don't know very much about herbal supplements, they are just beginning to learn; myself included.

That said, I am - as I write this - preparing for a trip out of town to help a close family member get back on her feet. She has seen many doctors, but her symptoms persist. I could go into a long explanation of her history (some of which I'll touch on in a moment) but the cause is likely a a result from very bad car accident (MVA), from many years ago. Her doctors have pretty much said nothing else can be done.

Her important medical history, outside of the MVA above:

# Rheumatoid arthritis (RA); moderate stage. She still works full time in a job that requires good dexterity.
# Hypertension (HTN); mild to moderate.
# Hypothyroidism

Right now, her RA is acting up because she went off her RA meds, thinking she was doing well and so now she is not. This is one of the reasons for my visit.

Her other problem is the question above. Lately she has had some energy issues and has trouble sleeping. I've established that this is not med related.

I take valerian and melatonin for sleep and I absolutely LOVE them. Unfortunately I'm not familiar with how herbal supplements interfere with prescriptions. I've tried googling it but I only find paranoid panic warnings which all basically say, "talk to your doctor." Well that just cracks me up because a lot of doctors really don't know!

I worked for a well-to-do, very educated plastic surgeon. He even admitted, "I just tell them don't take it." It's all about lawsuits and not about reality.

On the other hand, there really are not that many "studies" out there which say one way or another, however I'm sure that there is something that is helpful.

So! I'm not asking for any medical advice here. I'm just looking for an advanced reliable website with information on herbal supplements and prescription drugs AND suggestions on good herbal supplements for energy during the day and rest at night that I can check on.

Phew! Sorry this is long.

posted by magnoliasouth to health & fitness (19 answers total)

Well that just cracks me up because a lot of doctors really don't know!

This is simply not true. Nobody else is as well-trained as physicians in diagnosis and prescribing appropriate drugs. That physicians are reluctant to recommend "herbal supplements" that are almost universally ineffective and often unsafe points to the problems of the BS-pushing supplement industry and wishful thinking on the part of people that seek a "natural" solution to things, not to some lack of knowledge on behalf of the medical establishment. Plant-derived substances that have been confirmed safe and effective through the clinical trial process are already in widespread use.

It is irresponsible and stupid to attempt, without medical training, to "prescribe" any substances to a patient who has gone off her medicine and is not communicating with the prescribing doctor, especially in the context of a condition as complex as rheumatoid arthritis. This is the sort of thing that gets people sued and suspended or barred from medical pofessions. DO NOT DO IT.
posted by Inspector.Gadget at 7:34 AM on November 7, 2010 [7 favorites]

There are physicians who are also knowledgeable about CAM. She might be able to find a clinician through the American Holistic Medical Association or the American Board of Integrative Holistic Medicine.
posted by Wordwoman at 7:53 AM on November 7, 2010 [1 favorite]

Also, the University of Maryland Medical Center has good resources on herbs for different conditions.
posted by Wordwoman at 8:03 AM on November 7, 2010

I'd suggest referring to this and this. They are both reputable instutitions, survey a variety of peer-reviewed papers, and are thoroughly skeptical.
posted by astrochimp at 8:08 AM on November 7, 2010

Try taking gluten, rice, and grain-based carbs out of her diet. Replace with fruits and vegetables. Sometimes the issue is not adding something but removing something else.
posted by schroedinger at 8:13 AM on November 7, 2010

There's actually a PDR for herbal supplements which was used to great effect by a former doctor of mine.
posted by corey flood at 8:23 AM on November 7, 2010

From a previous thread (too lazy to look it up): SNAKEOIL? SCIENTIFIC EVIDENCE FOR HEALTH SUPPLEMENTS.
posted by sockpup at 8:24 AM on November 7, 2010

IANAD, IANYD, and I would not do this/but I do have relatives who do use supplements, have comorbid disorders, and when the day comes and they ask for "what I think," (and I know that regardless of what I say, they will use something) there are things that I would look up to hopefully increase the probability of safer use...but I'm only responding to point to some peer-reviewed references or to point to search terms.

My main concern would be potential drug-drug interactions, and if the potential supplement stimulates or inhibits the same liver enzymes (e.g. CYP3A4, etc.) that the medication for high blood pressure does, then as a consequence there may not be enough of the medication to treat the disorder or alternatively, the risk of adverse events increases.

Because the medications have already gone through many clinical trials, you should easily be able to find out the enzymes that are inhibited or stimulated on the most up-to-date prescribing information PDF for the particualr medication.

Now for the supplements. This small study with healthy subjects suggests Valierian does not act on those enzymes (I can only access the abstracts, sorry - but the data looks good from the abstract)

I think it would be a good idea to keep going through pubmed, using search terms like valerian and drug interactions, or valerian and CYP3A4, etc, or valerian and adverse events, etc...but that article there is a start. Go through all the enzymes that are strongly stimulated or inhibited by the medication.

Although this was extracted from a textbook (and you may want to double check their references), they did summarize this in a useful way with a chart and theoretical drug-drug interactions (in vitro? animals) to documented reports from clinical trials.

OP, you also mention this: "Right now, her RA is acting up because she went off her RA meds, thinking she was doing well and so now she is not. This is one of the reasons for my visit." This is probably where your training as a nurse can really help your relative; implement strategies to improve medication adherence.

Maybe start there before adding other medications? There are also medications that can be prescribed that do increase alertness, for example. Those medications have already gone through extensive cilnical trials and the drug-drug interactions should be reported by this point - the doctor could prescribe these if the patient reports her symptoms. I'm not going to put the name of the meds here because I think that this part should be done with a physician and it is probably a bit off label, but ...there are pharmacologic solutions to this, too,that is all I'm saying.
posted by Wolfster at 8:27 AM on November 7, 2010

My main concern would be potential drug-drug interactions, and if the potential supplement stimulates or inhibits the same liver enzymes (e.g. CYP3A4, etc.) that the medication for high blood pressure does, then as a consequence there may not be enough of the medication to treat the disorder or alternatively, the risk of adverse events increases.

Because the medications have already gone through many clinical trials, you should easily be able to find out the enzymes that are inhibited or stimulated on the most up-to-date prescribing information PDF for the particualr medication.

This is very true. My experience with this is that while some interactions pop up instantly, others take a long time to manifest as drug levels build up, or liver enzymes become unable to keep up.
posted by gjc at 8:42 AM on November 7, 2010

You say that 50% of doctors don't know much about herbal supplements. Why not go to one of the 50% of doctors who does know about herbal supplements?
posted by Salvor Hardin at 8:58 AM on November 7, 2010

Right now, her RA is acting up because she went off her RA meds, thinking she was doing well and so now she is not. This is one of the reasons for my visit.

Her other problem is the question above. Lately she has had some energy issues and has trouble sleeping. I've established that this is not med related.


IAAD but certainly not your or her doctor. Fatigue and malaise are incredibly common symptoms of poorly controlled rheumatoid arthritis. These days, there are well-proven disease-modifying agents that can control the progression of RA, which in many people, can lead to irreversible joint destruction and loss of function if left unchecked.

Here is the most recent thorough review of diet and RA, which is inconclusive. There is some promise with respect to omega-3 and Vitamin D. There are multiple other reviews of other herbal agents that may potentially have beneficial properties including this, this, and this. If you don't have access to full texts and want to read these, MeMail me.

Asking a practicing "well-to-do" plastic surgeon about the literature on supplements is like asking your mechanic to do your taxes. But a quality rheumatologist (particularly at an academic center) will and should know the data or lack there of -- equipoise on this subject isn't a matter of ignorance, it's a matter of the absence of research showing a demonstrable benefit. Alternatively, as Wordwoman noted, you might find a physician with specific additional expertise in CAM. If you wish to rely on anecdote, there are many people eagerly willing and ready to sell you something.

But the best advice I can give is for her to see a rheumatologist, and if she doesn't like the one she has, to get a new one she can trust. Supplements are not a substitute for proven therapies which may be necessary in her case, and delaying the latter in favor of the former is a disservice to her that may lead to irreversible impairment.
posted by drpynchon at 9:22 AM on November 7, 2010 [3 favorites]

You are a nurse. You can read the scientific literature, and it is actually getting to be quite large on the subject of herbal supplements.

And what it shows is that the entire business is 90 percent bullshit, 5 percent speculation, and the balance old wives tales. One by one, the claimed remedies fail to show any provable effects as they are studied.

There is no difference between any "nutritional supplement" and a pharmaceutical drug (many of which are based on natural substances and compounds) except that the latter has been proven to work, and the former has not. Calling something a "supplement" is a way to evade the need to prove claims of benefit while still making them. This was done to appease the supplement industry, not as good scientific policy, and as a result millions and millions of people take products every day that are either known or suspected to be ineffective, and in some cases dangerous, and always a waste of money.

You asked for a good website. Let me recommend quackwatch.com
posted by fourcheesemac at 10:01 AM on November 7, 2010 [2 favorites]

Herbal medications are not recommended by doctors due to lack of scientific basis as to safety, mechanisms of action, and quality control.
That said, stick with doctors and medications. Always research what you are going to put in your body and how it works. I find doctors are not always forthcoming with potential dangerous side effects when scripting medications. I'd know, I've been on the receiving end of ulcers from anti inflammatories and nerve pain from medications. Lesson learned, never put something in your body without knowing what it is.
Only herbal I recommend is cannabis, which I use for my arthritis. I've tried kava kava, but lack of safety and quality control made me discontinue it as it uses the same liver enzymes as other medication.
posted by handbanana at 10:50 AM on November 7, 2010

I'm also going to say: Do not do this.

Do not "prescribe".

I am also a very experienced nurse.

The problem is that, as a nurse, you are seen as more credible by people to whom you recommend things like supplements. ....whether you're qualified to make those recommendations or not.

There are altermative medicine databases out there for use by medical professionals. The one I use (through HealWA)is linked to my RN license. Evidence-based information is available on alt. therapies and nutritional supplements.

And what it shows is that the entire business is 90 percent bullshit, 5 percent speculation, and the balance old wives tales. One by one, the claimed remedies fail to show any provable effects as they are studied.

That is slightly exaggerated, but sadly, not by much.
posted by reflecked at 10:54 AM on November 7, 2010

If something has an actual physiological effect, it is not a supplement. It is a drug. If it is a drug that has not been through clinical testing, then there are unknown factors: dosage, drug interactions, and side effects. If it has actual physiological effects, then it has drug interactions and side effects.

"Herbal supplements" are, however, so poorly controlled that there's no guarantee you're getting *any* of the drug that supposed to be in it, in any individual pill. Some independent testing has shown that some supplement bottles don't have a single full dosage in all the pills in the bottle put together. Alternatively, individual pills may have many times the supposed dosage levels.

FDA approved medications are often derived from herbal sources, or originally discovered because a certain plant/mineral/whathaveyou had some effect. To make it a commercial product, testing was done and done and done until they figured out just what was in the whathaveyou that was effective. Sometimes they still derive the actual medication from the
all-natural" whathaveyou, sometimes they produce it synthetically but it is the exact same chemical that was otherwise effective before commercial testing. They have managed to remove all the other bits--things that may cause additional side effects or interactions--and made it a single medication as simple as possible.

Then they do extensive testing to see what dosages are safe, and what is okay to give to who and when, and what they shouldn't give in combination with it. All these are required before it can be cleared as a drug by the FDA.

...it baffles me that anyone would want to take untested chemicals, mixed in with who-knows-what other chemicals that may or may not have additional effects, at random dosages. Especially when they're already taking known chemicals that may have unknown interactions with these untested random dosages.
posted by galadriel at 10:59 AM on November 7, 2010

I'd get her up and about as much as possible, walking and doing whatever small productive chores she can, make sure she has a reliable schedule for taking her meds and a good system for remembering it, and then just be there for her so that she can vent about her situation.

That's really what I'd want a friend to do if she came to help me, not complicate my life by giving me *more* pills (herbal or otherwise) to remember to take.
posted by misha at 3:35 PM on November 7, 2010

I'm going to second schroedinger here. Arthritis is an 'itis', so in her body there is a systemic inflammation. Most likely her CRP levels will be high.
Anything she can do to lower her stress level and strengthen her immune system will help her.
There are links between CRP and low carbo diets, so that is something she could try, carefully and depending on her body type.
posted by Eltulipan at 12:09 AM on November 8, 2010

a-z guide to drug-herb-vitamin interactions
posted by InkaLomax at 4:05 PM on November 12, 2010

I've found The Natural Health Complete Guide to Safe Herbs to be an excellent reference guide. It's well-organized and densely packed with information on herbal interactions and side effects "for hundreds of drugs, supplements, and foods," as the subtitle indicates. Recommended.
posted by velvet winter at 10:03 PM on November 29, 2010