Alternative Therapies

Conventional Medicine

Disease focused

Ex: medications

Alternative Medicine

Used in place of conventional medicine

Ex: herbal supplements

Complementary Medicine

Conventional and alternative medicine put together

Ex: acupuncture for pain

Integrative Medicine

Conventional and complementary medicine

Combines all elements of a person (mind, body, and spirit)

Ex: Whole person health-patient focused

Nutritional Approaches

Dietary supplements, vitamins and minerals, aromatherapy, diet

Aromatherapy

Definition: use of natural fragrances from essential oils, hydrosols, and carrier oils to improve well-being

Methods of application: Inhalation, topical application

Clinical uses: Relaxation, stress reduction, pain relief, strengthen immunity, improve mood

Safety: Increased risk of skin irritation and contact dermatitis with topical application

Highlights: Avoid contact with eyes, store oils in cool, dry place away from children, avoid essential oil use during 1st trimester of pregnancy. Oils containing citrus may be photosensitizing.

Physical Approaches

Massage, chiropractic medicine, magnet therapy

Massage

Definition: Adjustment of muscles and connective tissue promoting relaxation

Massage techniques: Most common-Swedish, Others-Massage with essential oils, hot stone, deep tissue, sport, shiatsu, Thai, prenatal, reflexology

Clinical uses: release stress/tension, pain relief

Safety: Generally safe, avoid intense massage in patients with bleeding disorders, PVD, thrombocytopenia, or those on antiplatelet/anticoagulant therapy

Highlights: Rarely covered by insurance-generally is out-of-pocket cost. Studied in a variety of pain conditions including neck/shoulder/low back pain, knee OA and HA. Pregnant individuals should consult their OB prior to starting therapy.

Chiropractic Medicine

Definition: Focuses on relationship between spine and body function

Clinical Uses: Neuromusculoskeletal disorders and pain relief

Safety: Generally safe, Safety concerns arise with excessive force or inappropriate techniques, Caution should be used in patients with: OP, bleeding disorders, tumors, bone metastases, etc.

Highlights: Rarely covered by insurance-generally is out-of-pocket cost, Spinal manipulation for the following conditions: back/neck/shoulder pain, asthma, carpal tunnel syndrome, fibromyalgia, and HA have shown varying degrees of effectiveness

Magnet Therapy

Clinical uses: Pain relief, other conditions-respiratory problems, HTN, circulatory issues, arthritis, stress and HA

Safety: Relatively safe, Localized skin reactions have been noted, avoid in patients using medical devices (i.e: pacemaker, defibrillator, insulin pump, etc.)

Highlights: Magnets of different metals/materials allow for differences in potency, Two types of magnets: static (no charge, weaker magnets) and electromagnetic (electrical current present to charge metal, stronger magnets), not usually covered by insurance-may be covered by HSA

Psychological Approaches

Meditation, Mindfulness Activities: biofeedback, mindful breathing, and forest bathing

Meditation

Definition: Quieting the mind and minimizing unnecessary thoughts to help improve focus and understanding

Meditation Styles: Guided, walking, focused, compassion, etc.

Clinical uses: Relaxation, well-being, improved health

Safety: Minimal risk

Highlights: Low out-of-pocket cost, 4 key elements to meditation: quiet location, comfortable posture, focused attention, open mindset

Mindfulness Activities

Definitions: Biofeedback: learning to change or regulate body functions with the use of electronic devices for feedback (provider-led technique), Mindful breathing: consciously focusing on breathing, Forest bathing: taking in the forest atmosphere

Clinical uses: focus, relaxation, and improve well-being

Safety: Generally safe, some reports of increased anxiety, intrusive thoughts, fear, etc.

Highlights: minimal out-of-pocket cost, goal for forest bathing: 20 minutes/day or 2hrs/wk in a quiet area outdoors, recommended that high-risk patients work with trained professionals to observe/manage worsening symptoms

Psychological and Physical Approaches

Yoga, Tai Chi, Reiki, Acupuncture, Healing Touch

Yoga

Definition: Combines exercise and body posture, breathing and meditation to balance and improve the connection between the mind, body and spirit

Yoga styles: Hatha (most basic), Kundalini (most traditional), Anusara, Ashtanga, lyenga, Power, Bikram, Restorative, Vinyasa, Jivamukti, Yin, Prenatal

Clinical uses: increase fitness and flexibility, improve blood circulation, alertness

Safety: Generally safe, may causes temporary muscle pain/soreness

Highlights: Out-of-pocket cost for yoga session will vary based on location-may be able to use HSA, prenatal yoga is considered safe in all trimesters, yoga is associated with numerous health benefits and may assist with smoking cessation and improving immune health

Tai Chi

Definition: Exercise that originated as an internal style of martial arts for self-defense. Slow, rhythmic, circular body movements and deep breathing techniques

Clinical uses: improve balance/coordination, generate internal energy, and promote body healing, may improve cardiovascular function and muscle strength

Safety: safe (when done correctly)

Highlights: May be a good option for older adults (improve balance → decreased risk of falls)

Reiki

Definition: Spiritual energy (passed from a provider to the patient) who heals patient’s spirit and body

Clinical uses: stress reduction, relaxation, improve physical and emotional wellbeing, pain relief, and improve mental health

Safety: no significant risks or adverse effects, patients may experience a healing crisis (HA, stomach issues, weakness)

Highlights: Out-of-pocket cost depends on location, 30-90 minute sessions, self-treatment is possible when the patient receives technique instructions, management of healing crisis: increase fluid intake, sleep, and eating a light meal

Acupuncture

Definition: Placement of needles through the skin to stimulate anatomical meridian points (acupoints) and manipulated to areas where it is believed they will open channels allowing for improved energy flow and balance.

Approaches: Manual acupuncture (traditional), Electroacupuncture

Clinical Uses: Pain relief, OA, cancer-related fatigue, alternative anesthetic treatment prior to some surgical procedures, other efficacy: GI complaints, smoking cessation dermatologic conditions and chronic fatigue

Safety: safe with few complications (burning/electrical sensations, drowsiness, fainting), improper needle insertion may cause: pain, bruising, swelling, etc.

Highlights: Possibly an out-of-pocket coat—however, some insurance companies may cover a limited number of sessions. Believed to affect both nervous system and body tissues, Type of acupuncture: full body (traditional), scalp, auricular

Healing Touch

Definition: gentle, intentional touch that helps balance physical, emotional, mental and spiritual well-being. Supports body’s natural self healing abilities

Clinical Uses: Anxiety/depression, cancer care, immune system health, pain, stress reduction, surgery recovery, spirituality, and palliative care

Safety: Safe, noninvasive modality

Highlights: similar out-of-pocket cost to massage therapy, not usually covered by insurance-however, may be able to us HSA

Other Approaches

Homeopathic medicine, Naturopathic medicine, traditional Chinese medicine, ayurvedic medicine, hydrotherapy or balneotherapy

Homeopathic Medicine

Definition: Likes cure likes-disease can be cured by a substance that produces similar symptoms, law of minimum dose—lower dose=greater efficacy

Safety: low risk of toxicity

Highlights: Efficacy depends on both dilution factor and trituration, Variety of delivery forms: solid forms (sugar pallets, etc.) and topical forms (gels, lotions, etc.), most products are available without a prescription, generally out-of-pocket cost, rarely covered by insurance

Standards and regulation: Homeopathic pharmacopeia of the US = official compendium of manufacturing standards, Homeopathic product approval is different from Rx medications, Per the FDA: compliance with requirements of HPUS, USP or NF does not establish that it has been shown bby appropriate means to be safe, effective and not misbranded for its intended use.

Naturopathic Medicine

Definition: Focused on establishing, restoring, and maintaining whole body health in order for the body to heal itself

7 principles of healing: first do no harm, the healing power of nature, treat the causes, treat the whole person, doctor as teacher, disease prevention and health promotion, well-being

Safety: Generally safe-however safety depends on treatments and conditions being treated, should not be used in place of conventional medicine for serious medical conditions

Highlights: out-of-pocket cost varies by location, providers can’t prescribe prescription drugs, order imaging, etc.

Traditional Chinese Medicine

Definition: Combination of historical ideals/methods and modern research findings

Methods: herbology, acupuncture, moxibustion, tui na (Chinese massage), and qigong

Safety: Chinese herbs can be associated with AEs, similar to dietary supplements - concerns related to product quality and drug interactions with Chinese herbs

Highlights: TCM balances total energy, Chinese herbs are selected based on their restorative qualities, Out-of-pocket cost varies by location and treatment type, Treatments are usually not covered under insurance but may be covered by HSA

Ayurvedic Medicine

Definition: Uses natural and holistic approach to treat physical and mental health

Goal: Prolong life and support perfect health by eradicating disease and body dysfunction

Basic elements: Space (Akasha), Wind (Vayu), Fire (Tajas), Water (Jala), Earth (Prithvil)

Safety: Not regulated by the FDA, Use cautiously as quality control is inconsistent

Highlights: Similar focus as TCM and naturopathy — whole person health, Out-of-pocket cost — may be covered by HSA, Foods are described in terms of energetic qualities: sweet —nourishment, coolness, and weight gain; sour—warmth and weight gain; salty—warmth, stimulate sense, and weight gain; bitter—coolness and weight loss; pungent—weight loss, warmth and stimulation

Hydrotherapy or Balneotherapy

Definition: Water therapy—utilizing soaking strategies to promote health, hydrotherapy uses tap water/low levels of minerals, balneotherapy uses natural thermal mineral waters

Clinical use: pain relief, improve joint mobility (OA), improve funtionality

Safety: increased risk of cardiac arrhythmias, skin irritation, infection, muscle weakness and changes in BP

Highlights: May remain stationary or move through the water, traditional treatment: 20-30 minutes (5-7 days/wk), out-of-pocket cost varies—potentially able to use HAS, pregnant women should avoid using hot water baths

Nonprescription Products

OTC Medications, Dietary Supplements, Vitamins and Minerals

Dietary Supplements

The safety is the manufacturer’s responsibility

Available on the market (Supplement AE’s can be reported to FDA’s Safety Reporting Portal) → FDA must prove the product is unsafe → Removed from the market by the FDA

Prescriptions/Non-prescription drugs

Demonstrated safety/efficacy data → FDA approval → Available on the market

Regulation: Required by Law

Good manufacturing practices (GMPs), Serious AE reporting by manufacturers

Regulation: Not Required by Law

Proof of efficacy, proof of safetyR

Regulation: Health Claims

Disease claims are not permitted, Structure/function claims are permitted

Labeling Requirements

Name of the product and the word dietary supplement

Net quantity of contents

Manufacturer’s, packer’s, or distributor’s name and place of business

Directions for use

Supplement facts panel

Appropriate Claims for Dietary Supplements: Health Claims

Describer a relationship between a substance and reduced risk of a disease or health-related condition

Requires FDA approval

Appropriate Claims for Dietary Supplements: Structure/function claims

Describes how a product may maintain the normal, healthy structure or function of the body

Required disclaimer: this statement has not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent disease

Appropriate Claims for Dietary Supplements: Nutrient content claims

Describe the relative amount of a nutrient in a product

Requires FDA approval

Inappropriate Claims for Dietary Supplement

Manufacturers are not allowed to make health claims that their product will diagnose, cure, mitigate, treat, or prevent disease

Fraudulent or Misleading Claims

Lists specific disease states or alludes to products use for a disease typically treated with RX therapy

States only benefits and no harmful effects

Uses exaggerated terms (i.e; miraculous discovery) suggesting superior efficacy to standard of care

Promises quick relief of health condition

Provides “money back guarantee” or “satisfaction guarantee”

Suggests that the product is more expensive because it works better than other products

Seal of Approval Quality Assurance

Purpose: assures compliance with cGMP, it ensures product was properly made, contains what is on the label, and is free of contaminants

Limitation: does not address product quality between lots

Cardiovascular System

Coenzyme Q10, Omega-3 Fatty Acids, Garlic, Red Yeast Rice

Coenzyme Q10 (Ubiquinone)

Common uses: primary CV conditions, antioxidant, reduction of statin-associated AEs, secondary antiaging effects, migraine prevention, dyslipidemia, PD, reduction of chemotherapy-associated AEs

Proposed mechanisms: essential cofactor in mitochondrial ATP formation, regeneration of antioxidants, stabilizes membranes, vasodilatory and inotropic effects

Side effects: N, GI distress, anorexia, HA, irritability and dizziness

Highlights: taking supplement with food helps increase absorption, GI side effects (minimized by dividing large doses), Avoid in pregnancy and lactation — due to no safety data

Omeg-3 Fatty Acids

Common uses: lower triglycerides, improve cardiac health, aid in treatment of depression, relieve inflammatory conditions (RA, psoriasis)

Proposed mechanisms: May decrease intestinal absorption of cholesterol, inhibit enzymes involved in synthesis, excretion, and degradation of VLDL → decreases levels of other lipoproteins (LDL), increases levels of noninflammatory cytokines, decreases proinflammatory cytokines

Side effects: most common is a fishy burp and GI distress, possibility to increase LDL, increased risk of bleeding

Highlights: Sources: Eicosapentsenoic acid (EPA) and Docosahexaenoic acid (DHA), RX products: lovaza, vascepa, recommend EC capsules be taken with meals or at bedtime to minimize AEs, use caution with high dose fish oil in patients taking antithrombotic agents

Garlic

Common uses: HLD, HTN, T2DM, increasing immune function, preventing cancers

Proposed mechanisms: Antiplatelet properties, anti-infective properties, increases levels of vasodilator hydrogen sulfide. enhances nitric oxide product, may inhibit ACE

Side effects: Well-tolerated — however may cause GI AEs (N, reflux, V, and heartburn), Garlic breath, body odor, rare — allergic reactions

Drug interactions: Warfarin - increased INR, Saquinavir - 50% decrease in levels, OCPs - decreased effectiveness, Isoniezid - significantly decreased levels

Highlights: Should only use products similar to those used in clinical trials - powdered garlic or aged garlic extracts, EC products may help decrease garlic breath, GI AEs more common with therapy initiation or with higher doses, stop 10-13 days before surgery to avoid excessive bleeding, use caution in patients taking antithrombotic agents

Red Yeast Rice

Common uses: lower lipid concentrations

Proposed mechanisms: Similar to statins HMG-CoA reductase inhibitors (monacolin K - is structurally identical to lovastatin), increased bile acid excretion

Side effects: Generally well-tolerated, allergic reactions, HA, mild GI symptoms (bloating, flatulence, and heartburn), increased levels of LFTs, risk of hepatotoxicity

Drug interactions: Statins - additive activity and increased risk of AEs

Highlights: Some products have been declared illegal by FDA due to containing unauthorized drug (lovastatin), patients with daily EtOH intake of > 2 drinks should avoid use, contraindicated in pregnancy, only use products that are free of citrinin, avoid use in patients with kidney disease, potential option for patients unable to tolerate statin therapy

Central Nervous System

Butterbur, Feverfew, Ginkgo, Melatonin, St. John’s Wort, Valerian

Butterbur

Common uses: primary - migraine prevention, allergic rhinitis, asthma

Proposed mechanisms: Vasodilation by inhibiting calcium channels, COX-2 inhibition → decrease prostaglandin synthesis and leukotriene synthesis → anti-inflammatory effects, decreased mast cell activation, decrease in macrophages, eosinophils, and lymphocytes

Side effects: GI symptoms (most common), skin changes, dizziness, Hepatotoxicity and carcinogenesis (due to toxic pyrrolizidine alkaloids PAs)

Highlights: Recommend products labeled as PA-free or alkaloid free, Patients with ragweed (and related plants) allergy - should avoid butterbur, avoid during pregnancy and lactation

Feverfew

Common uses: primary—migraine prevention, conditions related to inflammation

Proposed mechanisms: anti-inflammatory effects, effect on prostaglandin synthesis, platelet aggregation, serotonin release, histamine release, vascular smooth muscle contraction

Side effects: generally well tolerated, GI effects, post-feverfew syndrome — anxiety, HA, insomnia, and muscle stiffness after abrupt withdrawal

Highlights: not effective for tx of acute migraine attacks, avoid if allergic to plants in Asteraceae/Compositae family, avoid during pregnancy and lactation, use caution if taking antithrombotic agents

Ginkgo

Common uses: Primary — alzheimer disease/vascular dementia, ADHA, tardive dyskinesia, intermittent claudication, tinnitus, acute mountain sickness, age-related macular degermation

Proposed mechanism: antagonism of platelet-activating factor promoting vascular perfusion, neuroprotective antioxidant effect

Side effects: generally well tolerated, mild GI AEs, HA, dizziness, and allergic skin reaction, increased bleeding risk

Drug interactions: antithrombotic agents, atorvastatin, efavirenz, omeprazole, trazodone

Highlights: avoid during pregnancy and lactation, use caution if taking antithrombotic agents

Melatonin

Common uses: primary—insomnia, prevention of jet lag, shift work sleep issues

Proposed mechanisms: stimulates sleep regulation, regulatory effects on sexual development and ovulation, effects on bone regulation

Side effects: generally well-tolerated, Rare AEs: N, V, HA, irritability, morning grogginess, worsening of depression symptoms

Drug interactions: Nifedipine - reduced delivery by GI system, Fluvoxamine, MAOIs, TCAs - increase melatonin, BZDs, sodium valproate, beta blockers - decrease nighttime levels

Highlights: Ramelteon is an available FDA product, majority of supplements are synthetic - avoid melatonin extracted from bovine pineal glands, avoid use during pregnancy or breastfeeding, for children in or around the age of puberty - discuss with PCP before use, variable effects on cancer treatments - discuss melatonin with oncologist before use

St. John’s Wort (SJW)

Common uses: primary — depression, anxiety, other — pain, OCD, menopause symptoms, premenstrual syndrome

Proposed mechanisms: modulate serotonin, dopamine, and norepinephrine, activate GABA and glutamate receptors, potentially inhibit monoamine oxidase

Side effects: most common — N, fatigue, and skin reactions, photosensitivity, sexual dysfunction, withdrawal symptoms (after abrupt d/c)

Drug interactions: lots of drug interactions, CYP3A4 substrates, antidepressants, cyclosporine, OCPs and hormone therapy

Highlights: should be taken in 3 divided doses with meals, weeks to therapeutic efficacy, depression is not a self-diagnosed/self-treated disease, avoid in patients with bipolar disorder or schizophrenia, limited evidence to assess safety in pregnancy and lactation

Valerian

Common use: primary — insomnia

Proposed mechanism: interact with GABA receptors in the brain → producing sedation

Side effects: generally well-tolerated, rare — HA, excitability, paradoxical insomnia, BZD-like withdrawal symptoms (after d/c of valerian), residual daytime sedation (with higher doses-900mg), hepatotoxicity, induction of uterine contractions

Highlights: valerian root can have an unpleasant taste and smell, avoid concomitant use with other CNS depressants, avoid in pregnancy!!!

Gastrointestinal system

Ginger, Milk thistle

Ginger

Common uses: primary — N/V related to pregnancy, motion sickness, chemotherapy, and surgery, other — indigestion, colic, hyperlipidemia, and osteoarthritis

Proposed mechanisms: anti-5HT effect in GI tract → antiemetic effect, COX and lipoxygenase pathway inhibition → anti-inflammatory effect and potential inhibition of thromboxane A2

Side effects: heartburn, belching, increased risk of hypoglycemia, increased risk of bleeding

Drug reactions: antithrombotic agents - possible additive effect, nifedipine - decreased platelet aggregation

Highlights: avoid doses > 4g/day, caution use in patients taking antiplatelets or anticoagulants

Milk thistle

Common uses: liver disease, diabetes, liver-protective agent for exposure to EtOH, acetaminophen and caron tetrachloride

Proposed mechanisms: antioxidant effects, antifibrotic effects, immunostimulant effects, anti-inflammatory effects, regulation of cell permeability and inhibits mitochondrial injury, stimulation of polymerase 1 → liver regeneration/formation of new hepatocytes

Side effects: generally well tolerated

Highlights: avoid use in pregnancy, avoid use in patients with allergy to ragweed and other members of Asteraceae/Compositae family, product may stimulate lactation, should not be used in place of antiviral therapyE

Endocrine system

Alpha-lipoic acid, bitter melon, cinnamon

Alpha-lipoic acid

Common uses: diabetes, peripheral neuropathy

Proposed mechanism: stimulates glucose uptake through effects on GLUT-1 and GLUT-4, improves nerve conduction and blood flow, improvement in insulin and oral glucose tolerance tests

Side effects: mild AEs - HA, N, D, and rash, potential additive hypoglycemic effects

Drug interactions: valproate - increased bioavailability

Highlights: food decreases absorption - take on an empty stomach, avoid antacids or other mineral containing supplements within 2-3 hours of alpha-lipoic acid, if wanting to take supplement for diabetes - discuss with PCP prior to starting, avoid in patients with thyroid conditions

Bitter melon

Common uses: lower blood glucose levels, lower cholesterol

Side effects: generally well-tolerated, common AEs - N, anorexia, abdominal discomfort, C, D, and flatulence

Highlights: main component for hypoglycemia are charantin, insulin-like polypeptide, and vicine, treatment duration - 4 to 16 weeks

Cinnamon

Common uses: lowering blood sugars

Proposed mechanisms: triggers autophosphorylation of insulin receptors → increases insulin sensitivity, stimulates GLUT-1 and GLUT-4 receptors → increases cell glucose uptake, activates PPAR-alpha and PPAR-gamma, displays inhibition of amylase and sucrose, inhibits inactivation of insulin receptors, anti-inflammatory actions, delayed gastric emptying (whole cinnamon) → reduced postprandial glucose spikes

Side effects: generally well tolerated - except if completing cinnamon challenge, medication-induced hepatitis

Highlights: aqueous extracts may be more effective

Immune modulators

Echinacea, elderberry

Echinacea

Common uses: immune support (colds/other respiratory infections), prevention or treatment

Proposed mechanisms: increased cytokine secretion, lymphocyte activity, phagocytosis, leukocyte mobility, direct inactivation of viruses, bacteria, fungi, anti-inflammatory activity and decreased mucin production

Side effects: allergic reactions, mild GI discomfort, HA, more serious reactions are possible after taking echinacea root product for 5+ days while ill

Drug interactions: caffeine - increased levels

Highlights: take at first sign of cold for greatest efficacy, avoid in patients with history of asthma, atopy, or severe allergy to Asteraceae/Compositae family, avoid in patients with severe systemic illness, autoimmune disorders, concurrent immunosuppressant use, review of use during pregnancy found no differences in rates of major malformations

Elderberry

Common causes: immune support

Proposed mechanisms: inhibition of virus replication, increased production of anti-inflammatory and inflammatory cytokines, strong antioxidant capacity, increased number of antibodies, inhibition of hemagglutination of influenza-virus blocking viral entry into cell, inhibited growth of gram-positive and gram-negative bacteria

Side effects: commercial products - well tolerated, home-prepared juices/extracts - N, V, dizziness, weakness, stupor

Genitourinary System

Cranberry, Saw palmetto

Cranberry

Common uses: urinary tract infections

Proposed mechanisms: blocks bacteria

Drug interactions: atorvastatin - increased risk of AEs from concomitant daily cranberry juice

Highlights: encapsulated formulations may be preferred to avoid sugar found in juice, avoid in patients at risk of kidney stones, mixed results for cranberry’s usefulness in prevention of UTIs in LTC patients at high risk, AUA guidelines for recurrent uncomplicated UTIs include cranberry as an option with conditional recommendations to prevent infections

Saw palmetto

Common uses: primary - BPH symptoms, other - supports hair growth

Proposed mechanisms: inhibits 5-alpha reductase and cytosolic androgen receptor, anti-estrogenic and anti-inflammatory effects

Side effects: most common - mild GI complaints, fatigue, HA, other - significant bleeding

Highlights: avoid use in patients taking antithrombotic agents, recommend evaluation by PCP before starting saw palmetto to rule out cancer, does not reduce PSA levels, occasionally used in multi-ingredient products intended for women, contraindicated in pregnancy and should avoid in lactation

Musculoskeletal System

Glucosamine and chondroitin, SAMe, Turmeric

Glucosamine and Chondroitin

Common uses: OA/joint health

Proposed mechanisms: Glucosamine — stimulates chondrocytes and synoviocytes, increase production of cartilage, synovial fluid, and hyaluronic acid, inhibitors matrix metalloproteinase, modulates activity of inflammatory cytokines, Chondroitin — inhibits leukocyte elastase → inhibits cartilage degradation and bone resorption, stimulates chondrocytes → reduced inflammation, donates sulfur

Side effects: GI upset, N, D, C, uncommon AEs — glucosamine: drowsiness, HA, and skin reaction, chondroitin: allergic reactions, edema, hair loss

Drug interactions: warfarin - increased bleeding risk in individuals with variant CYP2C0 alleles

Highlights: can take 4-6 months to see effects, if not benefit after 6 months - d/c supplements, glucosamine monotherapy should be the sulfate salt vs. HCl, take with food if causing GI side effects, avoid use of glucosamine in patients with severe shellfish allergies, instead use bovine or porcine chondroitin monotherapy, avoid in pregnancy or lactation due to lack of safety data, use caution if taking antithrombotic agents

S-adenosyl-L-Methionine (SAMe)

Common uses: OA, depression

Proposed mechanisms: OA — stimulate chondrocytes → producing proteoglycans, reduces cartilage degradation enzymes, maintains synovial fluid, and has anti-inflammatory effects, depression — donates methyl groups to neurotransmitters and catecholamines → increase brain NT levels (NE, dopamine, 5-HT)

Side effects: N, D, heartburn, less common AEs — xerostomia, HA, dizziness, nervousness, insomnia, cognitive impairment, switch to mania in pts with bipolar disorder

Drug interactions: antidepressants and 5-HT1 - significantly increased risk of serotonin syndrome

Highlights: liver disease and low B12/folate levels may decrease SAMe concentrations, CNS effects may be dose-related, avoid use in pregnancy or lactation

Turmeric/Curcumin

Common uses: arthritis, inflammatory conditions

Proposed mechanisms: Inhibits arachidonic acid metabolism, lipoxygenase, COX, TNF-alpha and interleukins → anti-inflammatory effects, others — antihyperlipidemic, antitumor, antibacterial, antioxidant, and antidiabetic effects

Side effects: GI discomfort, N, increased risk of bleeding due to platelet aggregation inhibition

Drug interactions: Sulfasalazine and tacrolimus — significantly increased blood levels, sulfonylureas — decreased postprandial glucose

Highlights: use caution if taking antithrombotic agents

Women’s Health

Black cohosh

Black cohosh

Common uses: premenstrual syndrome, menopause, and RA symptoms

Proposed mechanism: regulates serotonin, may exhibit estrogenic-like activity/acting as a selective estrogen receptor modulator

Side effects: GI upset and rash, V, dizziness, tiredness, CVD, bradycardia, hepatotoxicity