Disclosures: No financial Herbs Commonly Used I will be discussing - PDF document

10/15/2018 Disclosures:  No financial Herbs Commonly Used  I will be discussing non-FDA approved supplements by Females and integrative treatments (the FDA oversees safety but does not approve efficacy for these) Molly Heublein, MD Assistant Professor UCSF Division of Internal Medicine Women’s Health Primary Care Goals of today’s talk: How should we think  Get a brief introduction to Ayurveda and Traditional about herbal medicine? Chinese Medicine (TCM)  Think about prescribing herbs and if/how that fits in a western medical system of thought  Discuss my 5 favorite supplements Molly Heublein, MD Assistant Professor UCSF Division of Internal Medicine Women’s Health Primary Care 1

10/15/2018 Western Medicine is Systems of Thought Incredibly New Ayurveda and TCM Western Biomedical - Seeks an isolatable - Sees a pattern of disharmony as a description of the patient’s disease separate from whole experience the patient - Balance and relationships (no - Cause and effect single part can be understood outside the whole) - Pathology focused - Symptom focused - Evidence based medicine - Ancient wisdom Basics of Ayurveda Tridosha Health defined as: “a state of equilibrium of the Dosha Vata Pitta Kapha Tridosha (fundamental physiological governing Element Ether + Air Fire + Water Earth + Water principles of the body), Agni (metabolic and digestive processes), and Dhatu (principles that Qualities Dry Hot Heavy uphold the formation of body tissues). Waste Light Slow Light products are excreted well. The sense organs, Cold Oily Liquid mind and the soul are in a state of bliss” Movement Sharp Cold Basisht. Ayu. 2014 Oct-Dec; 35 (4): 351-355. 2

10/15/2018 Doshas Diagnosis Vata Pitta Kapha  Digestion is highly important In Balance Movement in the body Digestion Cohesion of tissues Creativity Absorption of Joint lubrication  Listening to patient’s voice Flexibility nutrients skin moisture Imaginative Body temperature Immunity  Pulse taking Understanding Love Intelligence Calmness  Tongue inspection Shine of hair/eyes  Body habitus Out of Fear Rashes/acne Slowness Balance/ove Anxiety Sour stomach Weight gain ractive Abnormal movement Redness Congestion Delicate health Anger Water retention Infertility Jealousy Greed Malabsorption Inflammation Gas/bloating Picture from: http://www.drramaprasad.com/tongue-analysis- Constipation article.html Ayurvedic Treatment Basics of Chinese Medicine - Balance is the goal; disease is a situation of imbalance - Qi - Yin-Yang Photo from Flickr Creative Commons “yin yang grunge symbol” Nicolas Raymond Photos from Flikr Creative commons “yoga” by Paolo Reno; “sleepy man with clock” Vic Lawrence; “Spice Magic” by Atul T 3

10/15/2018 Evaluation 4 Examinations: 1. Looking: Appearance, facial color, tongue. 2. Listening/smelling: Voice, respiration, cough, body odors 3. Asking: Questions- heat/cold, perspiration, pain 4. Touching: Pulse Chart from Traditional Chinese Medicine World Foundation. https://www.tcmworld.org/what-is-tcm/the-five-major- organ-systems/ Diagnosis TCM- treatments Photo from: https://qiblog.emperors.edu/2012/10/stick-out-your-tongue/ 4

10/15/2018 Three 30 year old women present Chinese herbs c/o dysmenorrhea… - Over 5000 herbs described in a recent pharmacopeia - Start with a traditional formulation of 3-15 herbs with modifications made for individual patient - TCM providers aware of narrow therapeutic window for some herbs Photo from Flickr Creative commons **El-Len** “At the Market” Talking to our patients about supplements…  Check natural medicine database for safety, efficacy:  Safety? https://naturalmedicines.therapeuticresearch.com/  Memorial Sloan Kettering Cancer Center About Herbs: https://www.mskcc.org/cancer-care/diagnosis- treatment/symptom-management/integrative- medicine/herbs/search  Evidence?  The FDA regulates under the Dietary Supplement Health and Education Act of 1994  May not make unproven treatment claims  May not be adulterated with other substances 5

10/15/2018 Supplements I recommend the most…. Biotin  Boric acid  B7 or Vitamin H  2.5mg daily studied in  Red yeast rice several studies for nail  Cannabis strength and thickness  Biotin  No benefit in alopecia (not studied)  St Johns Wort  FDA warning: Can interfere with lab tests (ie TSH) Treatment of vulvovaginal candidiasis with boric acid powder. Van Slyke KK, Michel VP, Rein MF. Am J Obstet Gynecol. 1981 Sep 15;141(2):145-8. Photo from: https://www.medicalnewstoday.com/articles/318724.php Red Yeast Rice Boric Acid  For vaginal candidiasis, and possible benefit in BV and • Rice fermented by the yeast trichomaniasis monascus purpureus  natural  Multiple studies, including 2 RTCs statin show equivalent outcomes w nystatin or azoles • An analysis of RCTs reported LDL-c lowered by 27-32%,  Dose: 600mg gelatin capsule given triglycerides lowered by 27-38%, vaginally X1-2 weeks and HDL-c raised by 15-22% (Liu 2006) Photo from: https://commons.wikimedia.org/wiki/File:Hongqu_3.jpg Photo from: https://en.wikipedia.org/wiki/Boric_acid 6

10/15/2018 St John’s Wort Cannabis - don’t be afraid! • Limited but growing - More effective than placebo, research likely equally effective as SSRIs and TCAs for mild to moderate • proven benefit in depression (data less strong for neuropathic pain severe depression) • Nausea • May be opioid sparing - Drug interactions  ocps, warfarin, etc - 450mg BID or 300mg TID Photo from: https://commons.wikimedia.org/wiki/File:Saint_John%27s_wort_flowers.jpg Photo from: https://www.theroot.com/spelman-grad-bringing-pg-county-maryland-its-1st-medi-1820835987 Resources to learn more: References  Weil Integrative Medicine Library, Oxford University Press Burns, Beverly. “Traditional Chinese Medicine UCSF Osher Center.” Online Video. YouTube, 25 Mar 2013.  Kaptchuk, Ted. The Web that Has No Weaver: https://www.youtube.com/watch?v=uwdxzBxXsf8 Accessed 9/2018. Understanding Chinese Medicine . New York: McGraw-Hill, 2000. Basisht. “Exploring insights towards definition and laws of health in Ayurveda: Global health perspective.” Ayu . 2014 Oct-Dec; 35 (4): 351-355.  Natural Medicines database: Devries, Stephen et al. Integrative Cardiology . New York: Oxford University Press, 2011. https://naturalmedicines.therapeuticresearch.com/ FDA Warning: “The FDA Warns that Biotin May Interfere with Lab Tests: FDA Safety Communication” Date  Memorial Sloan Kettering Cancer Center About Herbs: Issued: November 28, 2017 https://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm586505.htm Accessed 9/2018. https://www.mskcc.org/cancer-care/diagnosis- treatment/symptom-management/integrative- Gokani T. “Ayurveda--the science of healing.” Headache. 2014 Jun;54(6):1103-6. doi: 10.1111/head.12363. Epub medicine/herbs/search 2014 Apr 25. Review. Kaptchuk, Ted. The Web that Has No Weaver: Understanding Chinese Medicine . New York: McGraw-Hill, 2000. 7

10/15/2018 Linde K, Berner MM, Kriston L. St John's wort for major depression. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD000448. DOI: 10.1002/14651858.CD000448.pubΩ Lipner SR. “Rethinking biotin therapy for hair, nail, and skin disorders.” J Am Acad Dermatol . 2018 Jun;78(6):1236-1238. doi: 10.1016/j.jaad.2018.02.018. Epub 2018 Feb 10. Lipner SR, Scher RK. “Biotin for the treatment of nail disease: what is the evidence?” J Dermatolog Treat. 2018 Jun;29(4):411-414. doi: 10.1080/09546634.2017.1395799. Epub 2017 Nov 9. Review. “Lysine, Professional Monograph” Natural Medicines Website. 4 Oct 2017. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs- supplements/professional.aspx?productid=237 Accessed 9/2018. Maizses, Victoria and Low Dog, Tieraona. Integrative Women’s Health, Second Edition . Oxford University Press, New York. 2015. Sharma H, Chandola HM, Singh G, Basisht G. “Utilization of Ayurveda in health care: an approach for prevention, health promotion, and treatment of disease. Part 1--Ayurveda, the science of life.” J Altern Complement Med. 2007 Nov;13(9):1011-9. Review. Soleymani T, Lo Sicco K, Shapiro J. “The Infatuation With Biotin Supplementation: Is There Truth Behind Its Rising Popularity? A Comparative Analysis of Clinical Efficacy versus Social Popularity.” J Drugs Dermatol. 2017 May 1;16(5):496-500. Review. “St Johns Wort, Professional Monograph” Natural Medicines Website. 31 July 2018. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs- supplements/professional.aspx?productid=329 Accessed 9/2018. 8