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Flashcards in CAM e-book Deck (38)
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1
Q

What conditions is St John’s Wort used for?

A

There is only evidence for depression and low mood use.

2
Q

Are there any other interactions with St Johns Wort?

A
  • Antidepressants (can cause serotonin syndrome)
  • Sleeping pills and anaesthetics
  • Antipsychotics
  • Anticoagulants
  • Immunosuppressants
  • Antihistamines

It can also reduce the effectiveness of common medications to treat cholesterol, heart disease, high blood pressure, migraines, epilepsy, cancer, hepatitus C, HIV and AIDS. Eg. Ciclosporin, digoxin, warfarin, simvastatin, triptans

3
Q

Mrs Jones then tells you that she has just started taking Microgynon 30. Can she still use St. Johns Wort?

A

St John’s wort can reduce the level of contraceptives in the blood and make them less effective, increasing the risk of pregnancy and breakthrough bleeding.

St Johns wort is an enzyme inducer so will interact with CYP450 substrates. MHRA guidance states these should not be used in combination.

4
Q

Therapies can be classified as:

A
  • Medicine based therapies such as herbalism, naturopathy, homeopathy, aromatherapy
  • Traditional medicine such as Traditional Chinese Medicine (TCM), Ayurveda
  • Manipulative therapies such as Alexander technique, reflexology, massage
  • Mind-body therapies such as Reiki, Yoga.
5
Q

Cochrane Collaboration defines CAM as:

A
“Complementary medicine includes all such practices and ideas which are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well-being. These practices complement mainstream
medicine by (1) contributing to a common whole; (2) satisfying a demand not met by conventional practices; and (3) diversifying the conceptual framework of medicine.”

The World Health Organisation’s definition is: “[CAM] refer to a broad set of health care practices that are not part of
that country’s own tradition and are not integrated into the dominant health care system.”

6
Q

There are many reasons why people choose to use CAM. These may include:

A
  • The impression that CAM is safer than orthodox medicine / therapy
  • Disenchantment with orthodox medicine as a system and the consultation process
  • Perception that prescribed or purchased CAM is good value for money
  • Effect of opinion leaders endorsing e.g. royalty (HM the Queen Mother was Patron of the British Homeopathic Association), celebrities etc.
  • The environmental association – using ‘natural’ therapies
  • Encouragement by the media
  • Traditional to their culture e.g. TCM, Ayurveda
7
Q

There are also many reasons why people choose not to use CAM. These include:

A
  • Lack of scientific evidence
  • Believe strongly in ‘scientific medicine’
  • Orthodox medicine is working for them so they do not feel the need to look elsewhere
  • No belief in CAM – ‘old wives tales’
  • Fear of CAM interfering with orthodox medicine
  • Fear of poor quality and safety claims
8
Q

There are many reasons why studies into CAM have been hampered. These include:

A
  • Financial resources and lack of funding from funding bodies
  • Lack of research skills in CAM practitioners
  • Poor research design in previous studies such as lack of hypothesis to test
  • Difficulties designing placebo-controlled trials due to the nature of CAM
  • Wide variety within forms of CAM e.g. there are many different ways of practising acupuncture
  • Inappropriate extrapolation of results has happened in the past due to small size of studies
  • Standardisation is difficult to achieve as patients are treated in different ways due to a holistic approach, even if they present with the same symptoms
  • Lack of patients to test
9
Q

Examples of CAM
As mentioned previously, there are over 700 CAM therapies currently being practised worldwide. Some of the most common forms are:

A
• Acupuncture
• Homeopathy
• Herbal medicine / Herbalism
• Traditional Chinese Medicine (TCM)
• Ayuveda
• Chiropratic and osteopathy
• Massage 
 Electromagnetic therapy
• Kinesiology
• Reiki
• Qigong
10
Q

Acupuncture

A

Acupuncture is a technique involving the insertion of fine needles into the skin at specific points on the body. There are two main forms of discipline: traditional Chinese medicine and Western acupuncture.

11
Q

TCM acupuncture

A

The meridian system, or channel network, in TCM, is a path through which life-energy, or qi, flows. Physical or emotion ill health is thought to cause a disruption in the flow of this life energy. In order to correct the disruption the TCM practitioner will stimulate ‘acupoints’ on the meridians using fine needles, applying pressure or using other means. There are 365 acupoints situated on the meridians and another 1000 special use points on the hand, ear and scalp.

The practitioner, or acupuncturist, uses approximately 15-20 3cm solid, sterile disposable needles to stimulate the acupoints (although longer needles may be used in different sites of the body) whilst the patient is lying down. Initially the needles are inserted superficially but then they are inserted deeper into the muscle and are rotated between the practitioners finger and thumb to stimulate
qi and blood flow. Some practitioners may also connect the needles to electrical equipment (battery operated). This is known as electroacupuncture. Once the needles are in place the patient lies back and relaxes for approx 20 minutes. Occasionally a needle, usually located in the ear, will be left in for several days.

A single course of treatment usually involves 10-12 sessions of TCM acupuncture. It is often given with other forms of TCM such as traditional Chinese herbalism or dietary control.

12
Q

Western acupuncture

A

Western acupuncture is also known as minimal acupuncture as it involves very brief needling (for no more than a few seconds) with very few needles. The traditional concepts of meridians and acupoints are ignored and trigger points, small hyperirritable areas in injured skeletal muscle known as nodules, are used or they are used to stimulate nerve endings.

13
Q

Sham acupuncture

A

Sham acupuncture is where needles are inserted outside of the acupuncture points or trigger points and with a minimal amount of interaction between the patient and practitioner. It is most often used as the control in a randomised controlled trial.

14
Q

Acupressure

A

Acupressure is a form of acupuncture where instead of inserting needles pressure is applied, using fingers, thumbs and elbows, to the acupoints. It is claimed to relieve muscular tension, and increase blood flow within the body.
Many community pharmacies will sell elasticated travel bands.
These use acupressure to combat motion sickness by pressing on the wrist acupressure point with a small raised bead.

15
Q

Homeopathy

A

“A holistic complementary and alternative therapy based on the concept of ‘like to treat like’ and involves the administration of dilute and ultradilute products prepared according to methods given in homeopathic pharmacopoeias.”

16
Q

The founder of homeopathy was Samuel Hahnemann, a German doctor who lived from 1755 to 1855. He based homeopathy on three basic principles:

A
  1. Like cures like
  2. Minimum dose
  3. Single medicine
17
Q

Like cures like

A

Homeopaths believe in order to treat an illness they must use a substance which causes similar symptoms to the illness in a healthy human e.g. to treat someone with nausea the practitioner would prescribe a substance which causes emesis. This concept is the ‘law of similars’.

18
Q

Minimal dose

A

When Hahnemann first began practicing homeopathy he often prescribed substantial doses. This caused severe toxic reactions and even death. Because of this he developed a method of ‘potentisation’ whereby he diluted
out the toxic effects whilst retaining the therapeutic efficacy. Today Hahnemannian method of potentisation is still the most popular method. It has two scales of dilution: the centesimal scale and the decimal scale.

19
Q

The centesimal scale

A

The centesimal scale involves taking one drop of mother tincture (the liquid preparation resulting from the extraction of suitable source material, either natural or synthetic, with alcohol/water mixtures) and added to 99 drops of diluent (a triple distilled alcohol and water mixture varying in strength from 20-60%) in a new clean screwcap glass vial. The vial is then vigorously shaked.
After this initial dilution, dilutions are repeated, using fresh glass vials each time, until the solution reaches 12C, 30C, 200C and so on. The number e.g. 12 refer to the number of successive 1-in-100 dilutions and the ‘c’ indicates the
centesimal method.

20
Q

The decimal scale

A

The decimal scale involves taking one drop of mother tincture and adding to nine drops of diluent, shaking and repeating the dilutions. This is indicated by a number to represent the number of successive 1-in-10 dilutions and the letter X to indicate the decimal method.

21
Q

Single medicine

A

e.g. Aconite, Belladonna and Chamomilla (ABC) in homeopathic teething powders.

22
Q

How to take homeopathic medicines

A

Homeopathic medicines require special handling as they can easily deteriorate due to chemical and bacterial contamination.
• Tablets should not be handled and should be tipped into the container cap and from there into the mouth. If it is dropped then it must be discarded
• Tablets should be allowed to dissolve in the mouth (do not chew or swallow whole)
• Liquid medicines should be held in the mouth for 20-30 minutes before swallowing
• Homeopathic medicines should be taken half an hour before or after food, drink or tobacco. Ideally peppermint flavoured toothpaste should be avoided but if not possible leave 30-60 minutes after cleaning teeth and the mouth should be rinsed thoroughly. Aromatic flavours can denature homeopathic medicines.
• Medication should be stored in original packaging and in a cool dry place
• Existing orthodox medicines should not be stopped without the original prescriber’s permission

23
Q

Safety of homeopathy

A

Homeopaths consider homeopathic medicines to be non-toxic and safe for administration to both adults (including women who are pregnant or breastfeeding) and children, particularly if they are highly diluted. There have been no reported side effects and interactions in high dilution products.
Some non-dilute and mother tinctures do contain a measurable amount of active material so should be treated with caution. These may have interactions, side effects and may not be suitable for women who are pregnant or breastfeeding.

24
Q

Evidence base for homeopathy

A

The Royal Pharmaceutical Society (RPS) and British Medical Association (BMA) do not recommend the use of homeopathy.

25
Q

Regulation of homeopathy

A

Homeopathic medicines are regulated in the UK for human use by the MHRA. Prior to September 2006 there were two ways medicinal products were regulated:
1. Product Licence of Right
This was for products on the market before the Medicines Act 1968. The product licence of right allowed these products to have indications for minor conditions suitable for self-treatment
2. Simplified registration scheme
This was for products on the market since the Medicines Act 1968. It meant that they only had to provide safety and quality data (not efficacy). They could not make claims of effectiveness.

26
Q

National Rules Scheme for homeopathic medicinal products

A

In 1 September 2006 National Rules Scheme for homeopathic medicinal products was introduced. It allowed Indications for the relief or treatment of minor (not major) symptoms and conditions e.g. colds and flu and hayfever.
To make such as claim, the manufacturers need to show that their product has been used to treat those particular conditions within the homeopathic industry.
Manufacturers still need a Marketing Authorisation (issued under national rules scheme for homeopathic medicinal products), and manufacturer’s licence, wholesale dealer’s licence and if applicable, a wholesale dealer’s (importer) licence. They still need to provide evidence of quality and safety. The marketing authorisation number will have the prefix NR instead of MA

27
Q

Herbal medicine

A

Herbal remedies are derived from plants, parts of plants or extracts of plants.
Herbal medication may cause side effects and Pharmacists are encouraged to report any ADRs with herbal medicines to the MHRA using the yellow card scheme

Herbal medicines can also potentially interact with orthodox medicines and are recommended to be avoided or used with caution in women who are pregnant or breastfeeding

28
Q

Herbal medicine interactions

A
  • Gingseng and Warfarin –reduced anticoagulant effect
  • St Johns Wort and SSRI antidepressants – increased risk of serotonin syndrome
  • St John Wort and MAOI antidepressants – increased risk of hypertensive crisis
  • St Johns Wort and Hormonal Contraception (inc. Emergency Hormonal Contraception) – reduced contraceptive effect
  • Feverfew and Warfarin – Increased effect of warfarin
  • Glucosamine and Warfarin- Increased effect of warfarin
29
Q

Regulation of herbal medicines

A

There are two pieces of legislation which affect the regulation of herbal medicines by the MHRA: the European Traditional Herbal Medicinal
Products Directive (THMPD) 2004/24/EC which came into effect on 30 April 2011 and The Human Medicines Regulations 2012. Before they can be sold (whether to consumers, herbal practitioners, retailers or wholesalers) in the UK manufactured human medicines are required to have either:
• a marketing authorisation (MA) or
• a certificate of registration under the Traditional Herbal Products Registration Scheme (THR)
If a product does not have either of these it is not a licensed herbal product.
These are mostly sold as food supplements and are controlled under food legislation. No medicinal claims are permitted to be made. They may also be sold as cosmetics.

Directive 2004 /24/EC on Traditional Herbal Medicinal Products (THMP) had three key requirements:
• Traditional herbal medicines will have to meet specific and appropriate standards for safety and quality
• The product must be accompanied by necessary information for the product to be used safely
• The product must demonstrate ‘Traditional use’
To show traditional use the product must have been in use for at least 30 years in the EU or 15years in the EU and 15 years elsewhere. If these 3 key requirements can be met a certificate of registration under the Traditional
Herbal Products Registration Scheme (THR) may be issued. Traditional Herbal Products Registration Scheme (THR) regulates all manufactured, finished, OTC traditional herbal medicines. All registered products will be given a registration number (THR) similar to a MA number and will display the following symbol: THR

30
Q

Directive 2004 /24/EC on Traditional Herbal Medicinal Products (THMP) also
stated that:

A

All manufacturers of THMP will require a Manufacturers Licence
• All wholesalers dealing with THMP will require a Wholesalers Licence
• Any company which imports THMP from a non EU country will need a wholesalers (import) licence
• Any advertisement for THMP will require the statement:
• Traditional herbal product for use in specified indication(s) exclusively based on long-standing use

31
Q

True or False:
1. Some homeopathic products are made from synthetic material.

  1. Homeopathic products are safe to use in pregnancy and breastfeeding.
  2. Some homeopathic products can interact with some conventional medicines.
  3. In homeopathy, something that causes vomiting may be used to treat vomiting.
  4. Homeopathic practitioners believe that increasing the dose will increase the effect.
A
  1. Some homeopathic products are made from synthetic material. = True
  2. Homeopathic products are safe to use in pregnancy and breastfeeding. = True – although mother tinctures and non-dilute preparations should be avoided or used with caution.
  3. Some homeopathic products can interact with some conventional medicines. = False - although mother tinctures and non-dilute preparations may possibly interact.
  4. In homeopathy, something that causes vomiting may be used to treat vomiting. = True
  5. Homeopathic practitioners believe that increasing the dose will increase the effect. = False -In homeopathy increasing the dilution will increase the effect.
32
Q

True or False
1. Different brands of the same herbal product are equivalent in composition.

  1. Herbal products are safe to use in pregnancy and breastfeeding.
  2. Some herbal products can interact with some conventional medicines.
A
  1. Different brands of the same herbal product are equivalent in composition. = True
  2. Herbal products are safe to use in pregnancy and breastfeeding. = False
  3. Some herbal products can interact with some conventional medicines. = True
33
Q

When are 30C remedies used

A

30C remedies are used for acute conditions for a short time only and

34
Q

When are 6C remedies used

A

6C are used for chronic conditions over a longer period of time.

35
Q

Clinical pharmacokinetic study interactions

A

Garlic and saquinavir
Gingko and omeprazole
Ginseng and warfarin

36
Q

case reports only interactions

A

Acidophilus and immunosuppresants
Ginkgo and aspirin or clopidogrel
Glucosamine and warfarin

37
Q

Animal evidence only interactions

A

Turmeric and midazolam

38
Q

Theoretical evidence only interactions

A

Gingko and warfarin