Biochem 4/25: Homeopathy, Supplements, and Herbals

CPR Course Announcement (APHA)

• Mira from APHA is announcing a CPR course on the Worcester and Manchester campuses.
• Registration via QR code (available at the end).
• Dates:
  • Worcester: Four dates
    • Sunday, 8 AM - 12 PM (right after break)
    • Tuesday (contingency block): 3:15 PM - 7:15 PM (after class)
    • May 31st: 8 AM - 12 PM and 1 PM - 5 PM
  • Manchester: June 3rd, 3:15 PM - 7:15 PM
• Cost: $65 per student (non-refundable), payable via PayPal.
• Registration deadline: This Sunday at 11:59 PM (not extended).
• Contact: Mira's email (provided) or Ms. Baker's email.
• Other payment: Cash App may be possible.
• CPR Requirement: CPR certification is required for IPI rotations.
  • Not required to do it through APHA; it's just a convenient option.
• Non-refundable reminder.
• Location Flexibility: Worcester students can attend Manchester sessions, and vice versa.

Dietary Supplements and Herbals

• Focus: Herbal dietary supplements (following vitamins and minerals).
• Objective: Cover supplements relevant to the NAPLEX exam.
• NAPLEX Prep: Questions will involve identifying uses and counseling points for dietary supplements.
• Content Source: NAPLEX prep book and Natural Medicines Database.
• Internet Caution: Avoid using general internet information for exam preparation.
• Lectures: Information presented in lectures is most important for the exam.
• Natural Medicines Database (MCPHS Library).
  • Gold standard resource for dietary supplements.
  • Level of evidence rankings, drug interaction checker, effectiveness for conditions, adverse events.
  • Summarized information will be provided on slides.
• Goal: Word association approach with supplements, similar to vitamins and minerals.
• Focus: Pay attention to circled items and pictures.
• Study guides: Will be posted

Common Dietary Supplements

• Focus will be on common supplements per NAPLEX book (not necessarily common in real life)
• Emphasis on "possibly or likely effective" supplements (color-coded in orange and green).
• Supplements with little to no evidence will be discussed, too.

Immune System: Echinacea

• Related to the ragweed family.
• Thought to have anti-inflammatory properties.
• Use: Common cold.
  • Vitamin C: Treats the common cold (minor clinical significance).
  • Echinacea: Can prevent the common cold (take before symptoms develop).
• Tolerance: Well-tolerated.

Cardiovascular System: CoQ10 (Coenzyme Q10)

• Endogenous: Naturally occurring in the body.
• Location: Mitochondria (powerhouse of the cell).
• Best Evidence: Mitochondrial disorders (genetic conditions with CoQ10 deficiency).
  • CoQ10 enables mitochondria to function properly in these cases.
• Cardiovascular Conditions:
  • Possible effectiveness in heart failure and preventing MIs.
  • No strong evidence when used alone; helpful in combination with prescription heart failure treatments.
• Regulation: Dietary supplements are not intended to treat, prevent, or cure any disease.
• Approach: Combine Western and Eastern medicine
• Dosage form: Large capsule

Cardiovascular System: Garlic

• Benefits: Helpful in cardiovascular conditions.
• Consumption: Encourage adding garlic to food.
• Active Ingredient: Allicin (responsible for cardiovascular benefits and garlic's odor).
  • Odor-free garlic supplements are generally ineffective.
• Effectiveness:
  • Hypertension: Lowers blood pressure up to 8 mmHg systolic and 5 mmHg diastolic.
    • Modest effect; consider in combination with prescription treatments or for patients close to goal.
    • Recommendation: Use garlic instead of salt to spice food.
  • Hyperlipidemia: Statistically significant reductions in LDL and total cholesterol (not always clinically significant).
• Study Contradictions: Common due to lack of regulation and consistency in products.
• Effective Garlic Type: Kauai (not available in the United States).
• Garlic Types:
  • Aged/odorless: Not recommended.
  • Enteric-coated: Good (allicin present, less garlic breath).
• Five Gs: Garlic is one of the "five Gs" that increase bleeding risk (important for NAPLEX).
• Drug Interactions: Caution when combining with drugs that increase bleeding risk.
  • Warfarin (Coumadin), antiplatelets (Plavix/clopidogrel, aspirin).
  • Food consumption: Usually not a concern.

Cardiovascular System: Fish Oil

• Large capsules that can be difficult to swallow.
• Omega-3 polyunsaturated fatty acids (good fats).
• Active Components: EPA and DHA.
  • EPA: Helps with triglycerides.
  • DHA: Important for fetal brain development (pregnant patients).
• Effectiveness: Shown to effectively reduce triglyceride levels (20-50%).
• Prescription Version: Lovaza (icosapent ethyl).
  • Modified EPA, FDA-approved.
  • Reduces triglycerides and cardiovascular risk.
  • OTC fish oil will reduce triglycerides, but only Lovaza has shown to reduce cardiovascular events.
• Dosage: Important to take enough to get the effect.
  • Labels show serving size, not necessarily the therapeutic dose.
  • Need more than 4 grams a day of fish oil.
  • Example: 8 capsules of 500mg or 4 capsules of 1000mg.
  • Most people take 1000mg twice a day (2 capsules each time)
• Tolerability: Side effects increase above 4 grams/day.
• Side Effect: Fishy burp
  • Animal-based fish oils only (krill, etc.).
  • Plant-based/vegan fish oils are not shown to be effective.
  • Freezing capsules can help reduce fishy burps.
• Bleeding Risk: Increased bleeding risk at higher doses.

Cardiovascular System: Red Yeast Rice

• Prescription counter part: Statins.
• Mechanism: Same chemical structure as lovastatin (Mevacor).
• Low Potency: Equivalent to 10mg lovastatin.
• Use: Hyperlipidemia (lowering cholesterol).
• Comparison to Statins: Statins are more effective at reducing cardiovascular events.
• Side Effects:
  • Increased LFTs: Liver function tests (transaminitis).
    • Safe until 3-5 times the upper limit of normal.
  • Myopathy: Muscle pain.
  • Rhabdomyolysis: Muscle breakdown (severe, possibly fatal).
• Drug Interactions:
  • CYP3A4: Metabolized through CYP3A4 (inducers and inhibitors).
  • Inhibitors: Increase statin levels (toxicity, rhabdomyolysis).
  • Inducers: Decrease statin levels (decreased efficacy).
  • Other Cholesterol Meds: Gemfibrazole, niacin (synergistic side effects).
• Pregnancy: Category X. Should not be used.
• Quality: USP seal needed, as products that aren't fermented appropriately.
• Dosage Variance: Great variation that has been observed (0.1mg-10mg).

Neurological System: Ginkgo

• Source: Tree.
• Uses: Neurological improvement in dementia and stroke.
  • Mild improvements in quality of life, mentation, and ADLs.
  • Not shown to prevent dementia in healthy patients.
• Adverse Event: Bleeding (one of the "five Gs").
• Tolerance: Typically well-tolerated.
• Quality: Raw plant material in supplement can be toxic.
• Drug Interactions: Warfarin, clopidogrel (Plavix), aspirin.

Neurological System: Ginseng

• Benefits: CNS and sexual health.
• Cognitive Function: Helps with cognitive function in healthy middle-aged people (simple tasks like math).
• Combination: Often combined with ginkgo.
• Adverse Event: Bleeding (one of the "five Gs").
• Drug Interactions: Warfarin, clopidogrel (Plavix), aspirin.

Neurological System: St. John's Wort

• Mechanism: Modulates serotonin, dopamine, norepinephrine, GABA, glutamate, MAO.
• Effectiveness: Effective for depression (similar to low-dose SSRIs).
• Tolerance: Well-tolerated (better than SSRIs).
• Drug Interactions: Potent inducer of almost every CYP enzyme.
• Drug interactions: Should not be taken with other pharmacotherapy.
• Mnemonic: St. John's Wort - Inducer.

Neurological System: Melatonin

• Source: Tryptophan is converted to serotonin and then melatonin.
• Production: Natural hormone in brain, regulated by circadian rhythm.
• Effectiveness: Best for people lacking natural circadian rhythm (blind patients).
• Insomnia: Reduces time to fall asleep (7-12 minutes) and increases sleep duration (8-20 minutes).
• Jet Lag: Helps reset circadian rhythm.
• Dose: 3-5mg (higher doses not more effective).
• Timing: Take multiple hours before bedtime.

Neurological System: Valerian

• Use: Insomnia.
• Onset: Takes up to 4 weeks to work.
• Duration: Studied for only 6 weeks (withdrawal after that).