COMPLIMENTARY ALTERNATIVE MEDICINE

Jane D. Ricaforte-Campos, MDFPCP, FPSG, FPSDE

4th Post-graduate CourseAsian Hospital and Medical Center

Two widely believed but often false ideas…..

“If it’s natural, it’s safe”

“If a little of a drug is good for you, then more is better”

Complimentary Alternative Medicine (CAM)

Group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.

Concoction of various extracts, many of which are unidentified

NCCAM, 2010

Types of CAM

Natural Products (Dietary supplements) Herbal medicines (botanicals) Vitamins and minerals Probiotics

Mind-Body Medicine Meditation Yoga Acupuncture

Manipulative and Body-Based Practices Spinal manipulation Massage

Other CAM Movement therapies (e.g. , pilates) Biofields (magnet and light) Whole medical systems (Ayurvedic and TCM) Homeopathy and naturopathy

LIVER diseases………

• 65 % of patients take herbal preparations

• $180B in the US• $6B nutritional

supplements• $1B on herbs and

tea

Commonly Used CAM in Liver diseases…..HERBS

Herbal Products With Well-defined Chemical Formulations:

• Milk thistle• Glycyrrhizin• TJ-9• Phyllanthus amarus• St. John’s Wort

Herbal Products With a Mixture of Herbs or Partially Known Ingredients :

• Traditional Chinese Medicine• Plantago asiatic• Herbal Medicine 861• CH-100• Liv 52

Commonly Used CAMin Liver Diseases

Anti-oxidants, Immune Modulators, and

Dietary Supplements

Homeopathy

Acupuncture

MILK THISTLE (Silymarin)

Extract of Silybanum marianum Flavonoids, 80-90% is silibinin Mechanism of Action:

Anti-oxidant Anti-fibrotic Anti-inflammatory

Evidence of Efficacy of Silymarin in Acute Viral Hepatitis

Cavalieri S. 1974 Significantly shorter hospitalization and time to

development of immunity to HBV in patients who received Silymarin

Magliulo E et at. 1978 57 patients with HAV or HBV, 70mg TID x 3wks vs

placebo Lower liver enzymes at day 5 and 3 weeks No influence on HBeAg seroconversion

Bode J et al. 1977 No significant difference in liver tests or

coagulation profile in 151 patients

Evidence of Efficacy of Silymarinin Chronic Viral Hepatitis

No RCT’s for chronic HBV infection Anecdotal evidence on reduction of

transaminae levels without any impact on HCV-RNA levels

RCT of 117 patients (Silymarin vs Mvits) No difference in quality-of-life scores, liver

enzymes, hyaluronic acid and YKL-40

Seeff LB et al. Hepatol 2001;34:595-603Berkson B et al. Med Klin 1999;15(Suppl 3):84-89

Tanamly M et al. Dig Liver Dis 2004;36:752-759Huber R et al. Eur J Med Res 2005;10:68-70

Hepatotoxicity from CAM

1.1% of all cases seen by hepatologist 52% due to Traditional Chinese medicine

(TCM) 14% due to anti-TB drugs

62% hepatocellular 24% cholestatic 14% mixed

10% died and 3% underwent liver transplantCIOMS-Council for International Organization of Medical Sciences

CDC-Clinical Diagnostic Scores

Wai, CT. Sing Med J 2006;47(2):116-120

Hepatotoxicity from CAM

Prospective study in Singapore 31 cases of DILI in 2 years (22 definite/9

probable) 55% Chinese CAM 16% Malay CAM

Wai CT et al. Liver Intl 2007

Hepatotoxicity from CAM Adulterants in CAM

(29% Singapore; 27% Taiwan; 3% Saudi Arabia) Corticosteroids Phenylbutazone Codeine Berberine Metformin Glibenclamide

Wai CT et al. Liver Intl 2007Kim SJ et al. J Hepatol 2004;10:125-34Huang WF et al. J Clin Pharma 1997;37:344-50Bogusz MJ et al. Adv Drug React Toxico Rev 2002; 21219-29

Hepatotoxicity from CAM

Herbalife weight reducing food supplements Israel: 12 cases after 11 months on intake Switzerland: 10 cases after 5 months of intake

Ephedrine (Ma-Huang) N-nitroso-fenfluramine (Chaso or Onshido) Guarana (Paullinia cupana) Green tea (Camella sinensis)

Elinav E et al. J Hepatol 2007;47:514-520Schoepfer, AM et al. J Hepatol 2007;47:521-526

Hepatotoxicity from CAM

Weight loss and herbal supplements Contents:

Phenylpropanolaine Ephedra Kava Scutellaria (skullcap)

4/6 patients died; 2/6 underwent OLT (mean age, 37 years old)

Stolpman DR et al. Hepatol 2002;36:168A

ISONIAZID, major drug incriminated in Anti-TB D.I.L.I.

The overall mortality is less than 1%.

Hepatotoxicity from Anti-TB drugs

Boundi et al. Hepatol, 2002

Consider this as a ROUTINE…

Thank you for your kind attention…

Gee, have to come up with something or else…