• Recognize the herbal medicine use is increasing among elderly patients.
• Recognize the most commonly used herbal remedies.
• Increase awareness of the potential for unwanted side effects and drug interactions seen with commonly used herbal preparations.
• Learn how to manage common side effects of alternative therapies.

William T. O'Byrne, MD
General Internist
Albuquerque, New Mexico

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

Few enterprises in modern history have experienced the proliferation and widespread use that has attended herbal medication and natural supplements. Advertisements for these products have inundated print, broadcast, and electronic media, tempting the consumer with (often exaggerated or even patently false) claims of restored youth and vigor, or as panaceas for nearly every ailment. In 1994, the U.S. government passed the Dietary Supplement and Health and Education Act (DSHEA), which provided the herbal medicine (also termed “nutraceutical”) industry with essentially unfettered license to market products without rigorous Food and Drug Administration (FDA) oversight.[1,2] Ephedra (also known as ma-huang) is perhaps the most notorious example of questionable marketing practices and anemic regulation. Serious questions about adverse cardiac events (including stroke and sudden cardiac death) caused by nutritional products containing edphedra arouse nearly a decade before the FDA banned the compound in the spring of 2004.[3,4] In 1998, the United States congress established the National Center for Complementary and Alternative medicine (NCCAM), whose mandate encompasses exploring “complementary and alternative healing practices in the context of rigorous science, training complementary and alternative medicine (CAM) researchers, and disseminating authoritative information to the public and professionals.” NCCAM provides information to health professionals and consumers about a broad range of alternative therapies (e.g., prayer, traditional Chinese medicine, herbal supplements), and supports evidence-based research on them.[5] Given the ever increasing costs of healthcare, particularly prescription medicines, it is not surprising that the elderly are turning to herbal medicines and other alternative therapies (commonly referred to as complementary and alternative medicine or CAM) to both help reduce their medical expenses and improve their wellbeing. Many compounds (such as garlic, used to treat hypercholesterolemia) are several orders of magnitude less expensive than prescription medication. Furthermore, many of the most commonly used supplements have (like garlic) been use for centuries, thus increasing their acceptance by consumers. Some studies have suggested that up to 50% of elderly persons have used non-traditional products.[6,7] Of increasing concern is the fact that most patients who use herbal preparations do not reveal it to their healthcare providers. This lapse may occur for a variety of reasons - some patients do not consider supplements true medications (e.g, garlic, flax seed oil), others may feel that their provider would not support their choice of CAM for treating serious medical conditions. Despite the fact that herbal supplement use is increasing at exponential rates, there is a lack of rigorous evidence to support their efficacy and many, like ephedra, have serious, sometimes devastating side effects. Thus, healthcare providers should be familiar with the most common herbal medicines, especially their potential for adverse effects and drug interactions.

The patient tells you that he has been searching the Internet for cheaper alternatives to his current medicines, and has considered acupuncture for treating his arthritis pain. He also reports that his BPH symptoms have improved somewhat in the past six months, which he attributes to changes he made in his medication regimen without your knowledge.

Current Medications

Felodipine, 2.5 mg QD
Temazepam, 15 mg QHS
Hydrocodone/APAP, 2.5mg/750 mg BID
Meclizine, 25 mg TID
Celecoxib, 200 mg BID
Gabapentin, 600 mg TID
Venlafaxine HCL, XR, 75 mg QD
Clonazepam, 0.5 mg TID
Sumatriptan, 50 mg for migraine

The patient also brings with him a “list of things I take that I read about on the Internet”:

The patient tells you that his orthopedic surgeon has asked him to see you for a preoperative evaluation. He is eager to have his hip replaced because of increasingly limited mobility and severe pain.