| Moderator:
Welcome to today's chat! Our topic is "Complementary and Alternative Medicine" (CAM), and our guests are Ethan Basch, M.D., and Catherine (Kate) Ulbricht, Pharm.D.
Ethan Basch, M.D., is chief editor of the Natural Standard Research Collaboration, which provides high-level complementary and alternative medicine content for health-care institutions. He has served as a faculty member at Harvard Medical School and as an attending physician at Massachusetts General Hospital in the Department of Medicine. He also is on the editorial board of the Journal of Herbal Pharmacotherapy. Catherine (Kate) Ulbricht, Pharm.D., is a senior attending pharmacist at Massachusetts General Hospital, and an assistant professor at Massachusetts College of Pharmacy, Northeastern University, and the University of Rhode Island, among others. She is a founder of Natural Standard Research Collaboration, which provides high-level complementary and alternative medicine content for health-care institutions. She also is a member of the board of directors of the Integrative Medicine Alliance, and chief editor of the Journal of Herbal Pharmacotherapy. Question:
How should I approach my doctor about using complementary and alternative medicine?
Dr. Basch:
More and more these days, physicians and health-care practitioners of all types are becoming aware of the importance of discussing complementary and alternative medicine (CAM) with their patients. This is based on growing knowledge that the use of complementary therapies such as herbs, supplements and modalities (for example, acupuncture and chiropractic) are quite widespread in the United States. Therefore, perhaps more than many patients expect, their health-care practitioners are open to discussing these topics. As a physician, I often suggest that patients be very open with their practitioners. For example, when discussing their prescription medications, they should also mention any herbs or supplements they are taking. Although patients may find that their health-care practitioners do not have an immediate answer to their questions, there are many resources that clinicians can review to try to answer specific questions. It is very important to stress that patients should not hide therapies they are using from their practitioners, because we know that there are many possible, even dangerous, interactions that can occur. Dr. Ulbricht:
A current goal of high-quality health-care information providers such as Aetna InteliHealth and Natural Standard is to ensure that health-care providers and consumers have a resource they can trust. From a pharmacist's perspective, in order to be able to properly assess a medication regimen, it is important that we are aware of over-the-counter preparations that a patient is taking, including vitamins, minerals, herbs, and supplements, plus agents like ibuprofen and aspirin. This is not only to avoid interactions and side effects, but also to help patients choose the most cost-effective and potentially effective regimen for their condition. In some cases, it may be necessary to monitor lab results and follow symptoms to see if they actually do improve or if doses need to be adjusted. Perhaps there is also a physical therapy, diet or lifestyle intervention that could help. The take-home message is that we strongly encourage patients to speak up about therapies they are using, even if they are not sure of what the doctor may think. It is critical to your health that your health-care providers know what you are taking. Like Dr. Basch said, don't be put off if a provider does not have an answer right away. A lot of these therapies are new, and the doctor may be taking the extra step to do the needed research to give you a good answer. Your doctor may be taking the time to tap in to his or her colleagues' knowledge as well. Question:
Given the amount of advertising and promotion of products, what criteria do you use to advise people who are interested in trying a product or type of therapy? Dr. Basch:
Great question. Just as with any product, ads about medical therapies must be viewed with awareness that these are promotional advertisements and not necessarily objective accounts of scientific research. Therefore, it is always our recommendation that patients discuss therapies with their health-care providers and consider doing some research themselves. When doing research as a consumer, it is important to note the possible bias of the source. Therefore, we usually recommend referring to authoritative textbooks or databases for more scientifically based information. There are several examples. For example, on the Internet, one can consult this very informative resource — Aetna InteliHealth. In addition, the Natural Standard website with which Kate Ulbricht and I are involved is specifically designed for this purpose. There are also a number of good books. However, I would caution consumers that alternative medicine is an area that is notorious for misinformation and misleading advertisements, so marketing materials should be viewed with a critical eye. Dr. Ulbricht:
So, in summary, you want to speak with your doctor, pharmacist, and any other health-care providers you are seeing, conduct research on Web databases, and consult reputable textbooks. Some consumers may wish to look at scientific research first-hand by searching for research publications at www.pubmed.org, a free government site that you can search. You should consider the scientific evidence and the safety profile of these therapies and weigh the benefits versus the risks, as well as cost effectiveness. After doing all of this, if you want to try a new therapy, you should be monitored by your health-care provider. Work together to assure that you've made the best choice for your body. Choose a product that has been standardized and tested for quality and purity. Some groups that test products for accuracy of labeling and constituents are www.consumerreports.com and www.consumerlabs.com, as well as the United States Pharmacopoeia (USP) and NSF. Question:
Please describe the difference between ephedra and Xenadrine and the problems that have been associated with each of these products. Dr. Basch:
Xenadrine is the name of a product that contains both ephedra and caffeine. Xenadrine and many other commercial products are popularly used in the United States for weight loss — up to 14 percent of people using nonprescription weight-loss products in the United States have taken an ephedra- or ephedrine-containing product. Ephedra also has been used for many other health-related problems such as asthma, sexual arousal, and athletic performance enhancement. Ephedra sinica is a species of the ephedra plant and is also called Ma Huang. Ephedra contains the alkaloids ephedrine and pseudoephedrine, which stimulate the central nervous system, cause relaxation of the airways, and tightening of blood vessels. There are major safety concerns associated with ephedrine, particularly when used in combination with caffeine, as it is in many commercial weight-loss products. In the past, there has been a great amount of publicity about adverse effects linked to ephedrine due to the death of a Baltimore Orioles pitcher who was found to have an ephedrine product in his system. In addition, the U.S. Department of Health and Human Services recently released a report in which more than 1,500 adverse event reports to the U.S. Food and Drug Administration were reviewed. The report identified at least three deaths, two heart attacks, two strokes, one seizure and three severe psychiatric events strongly tied to ephedra use. A prior review in 2002 found at least 22 deaths that were felt to be related to ephedra. On February 6, 2004, the U.S. Food and Drug Administration (FDA) issued a final ruling prohibiting the sale of dietary supplements containing ephedrine alkaloids (ephedra) because such supplements present an unreasonable risk of illness or injury. The rule became effective 60 days from the date of publication. Question:
Are there any natural alternatives to hormone-replacement therapy (HRT)? Dr. Ulbricht:
There are several other therapies that have been researched, but to date have yielded unclear or conflicting evidence. These include black cohosh, soy, dong quai, flax seed, red clover, wild yam, St. John's wort and relaxation therapy. The long-term risk/benefit analysis has not been conducted. We are not sure whether these agents, some which contain estrogen-like molecules called phytoestrogens, carry the same risk as traditional estrogen therapies. If you have or are at high risk of developing an estrogen-sensitive cancer such as breast cancer, ovarian cancer, or endometrial (uterine) cancer, you should speak with your physician before starting any of these therapies. These agents, like other herbs and supplements, also carry with them their own unique side effects. Basically, anything that has a therapeutic effect may have a side effect as well. Question:
Glucosamine with chondroitin has gotten a lot of attention regarding its ability to relieve joint pain. What can you tell me about this product? Dr. Basch:
There is scientific evidence supporting the use of glucosamine sulfate in the treatment of mild to moderate knee osteoarthritis. The evidence is suggestive that glucosamine may be helpful in other parts of the body as well, although further research is needed before firm conclusions can be made. Chondroitin is structurally related to glucosamine, and the two are often combined in commercially available products. However, the evidence in support of chondroitin is not as convincing. For other causes of joint pain, such as rheumatoid arthritis, there is inconclusive evidence and it is not known if there are any benefits. Question:
Do you have any advice for a newly diagnosed diabetic (type 2) who is interested in controlling the diabetes without having to use insulin injections? It is being controlled by diet right now, and I am interested in knowing if there are any vitamins or alternative therapies available to help keep the disease from progressing. Dr. Basch:
It's very important for patients with type 2 diabetes to control their blood-sugar levels tightly. Therefore, they should be closely followed by their health-care practitioner. Patients with type 2 diabetes (sometimes also called adult-onset diabetes or non-insulin-dependent diabetes) can often benefit from dietary changes and exercise. There are a few herbs that have been used traditionally in the management of diabetes. However, these have not been compared to prescription treatments, and safety or dosing is not well established. Question:
How do you know which Web sites are the best for alternative medicine information? Dr. Ulbricht:
Look for a site that is unbiased, does not sell products, is not financially supported by a manufacturer, and is peer reviewed. Each piece of information should disclose information about the author and the date of the last update. References to source materials (such as scientific articles) and substantiation of proposed health benefits should be provided. Since alternative therapies may be a little new to conventional practitioners, it is important that the contributors to the Web site come from a variety of health-care backgrounds — for example, nurses, medical doctors, pharmacists, herbalists, naturopathic physicians, acupuncturists, chiropractors, etc., to get a well-rounded viewpoint. There should be full disclosure of any potential conflict of interest by those contributing to the Web site. Question:
Are there many alternative-medicine Web sites that meet the criteria that you just discussed? Dr. Ulbricht:
Unfortunately, there are not. Information with which we are editorially involved, and which meet these criteria, include the glossary of information on herbs and supplements in Aetna InteliHealth and Natural Standard. I also would recommend www.mdanderson.org/cimer at the University of Texas. Information on many sites, including health information sites, has not been updated for some time, despite many developments in this area. Other sites are not comprehensive, and therefore users get an incomplete picture of the scientific evidence or historical context of these agents and are at greater risk for incomplete reporting of potential adverse effects and interactions. Question:
What kind of training, if any, do health-care providers receive that prepares them for questions regarding CAM? Dr. Ulbricht:
Most medical doctors in their original training were not taught in this area. But there has been a recent push in curricula for physicians and pharmacists in this area. Many schools have CAM rotations and include CAM courses in their curricula, including Harvard Medical School; the University of California, San Francisco; the University of Arizona. Natural Standard, based in Cambridge, Mass., runs rotations for multiple universities to educate practitioners-in-training about CAM and evidence-based medicine. Moderator:
Well, our time is up. We had a lot of great questions, and I'm sorry that we couldn't get to them all. I'd like to thank our experts for taking time out of their busy schedules to join us this afternoon. | 
