Complementary medicines can be herbal medicines, traditional medicines, vitamins and minerals, nutritional supplements, homeopathic medicines and aromatherapy products. Under the Therapeutic Goods Act, complementary medicines are either registered or listed. An AUST R number on the label shows the medicine is registered and has been individually assessed for quality, safety and efficacy, whereas listed (AUST L) products have been tested only for quality and safety, but not efficacy. The role of complementary medicines as part of the holistic treatment of a patient, can be from the establishment of the regimen, or following the patient’s treatment with conventional medicines first, using complementary medicines in an integrative manner to maintain remission or reduce relapse of disease.
Complementary medicines with established roles in therapy include:
This is a soluble fibre which passes through the intestine without being absorbed. It is used for constipation and irritable bowel syndrome. The average Australian has around 20g of fibre daily, where the target should be 30g, and psyllium husk can be added in doses of 7–40g per day in 2 to 4 divided doses. Psyllium husk can reduce absorption of some drugs like iron and carbamazepine, hence it should be given at least two hours before or after other prescribed medicines, and it can also reduce blood glucose levels in patients with type 2 diabetes.
Probiotics are live, non-pathogenic yeast or bacteria that are found in a range of products (e.g. fermented milks, powders and capsules). Probiotics work as immunomodulators and stimulate lymphocyte and macrophage activity, cytokine production by mononuclear cells, and increase immunoglobulin A in the intestines. Studies have demonstrated that the gut microflora modulate intestinal inflammation, reduce colonic permeability and enhance barrier function. Used alongside rehydration therapy, probiotics shorten the duration and reduce stool frequency in acute infectious diarrhoea and Crohn’s disease. They can prevent increases in pathogenic bacteria and relapses of ulcerative colitis. Saccharomyces boulardii is a particularly beneficial yeast strain and can be given with antibiotics, especially in long-term antibiotic therapy, in doses of 1000mg daily. It is best taken with meals to prevent acid killing the probiotic.
St John’s Wort
The aerial parts of the plant Hypericum perforatum contain hypericin and hyperforin, the active ingredients with antidepressant and anti-inflammatory effects, which act by rebalancing serotonin levels in the brain. St John’s Wort has been shown to be as effective as standard antidepressants in mild to moderate depression. Its preparation has been standardised to a content of 0.3% hypericin and is available as 300mg tablets with a recommended dose of one tablet three times daily. Maximum effects are seen after two weeks of continuous therapy. Adverse effects include gastrointestinal symptoms such as abdominal discomfort, bloating and nausea.
St John’s Wort induces hepatic cytochrome P450 isoenzymes, mainly CYP3A4, CYP2E1 and CYP2C19, and therefore it reduces plasma concentrations of drugs metabolised by this route. Clinically important interactions have been reported with anticonvulsants, cyclosporin, HIV drugs, warfarin, digoxin, oral contraceptives, verapamil, and theophylline. St John’s Wort also increases serotonin levels and hence the risk of serotonin toxicity when used in combination with selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, triptans, opioid analgesics, tramadol and some recreational drugs (ecstasy, cocaine and LSD).
The therapeutic valepotriates and valerenic acid are obtained from the rhizome of Valeriana officinale. Valerian has both hypnotic and anxiolytic effects and works by stimulating the release of gamma aminobutyric acid and inhibiting its reuptake. A dose of 600mg of valerian extract has comparable effects to 10mg of oxazepam with less somnolence. It works best after one to two weeks of regular use and adverse effects include gastrointestinal problems and headache.
Fish Oil (Omega 3)
Fish oil is used as a supplement to relieve the symptoms of arthritis, improve cardiovascular health (help to maintain normal cholesterol levels in healthy individuals) and support healthy cognitive function. Fish oil helps increase serum high-density lipoproteins (good cholesterol) and lowers triglycerides while increasing joint mobility and reducing inflammation in arthritis. Fish oil is indicated for rheumatoid arthritis and although it has not been specifically tested for treatment of osteoarthritis, it is possible that an anti-inflammatory dose of fish oil may be of benefit to patients with osteoarthritis. However, more direct studies are required to clarify dosing specifically for osteoarthritis.
The dose of fish oil is measured by the content of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) with a standard 1000mg fish oil capsule having 180mg of EPA and 120mg DHA. Dosage of fish oil is 40mg/kg body weight/day with a dietary fatty acid intake of 10g per day in the background. Monitoring is recommended for signs and symptoms of increased bleeding in patients taking fish oil, especially if used in combination with aspirin or other antiplatelet drugs (such as clopidogrel and dipyridamole), or anticoagulants (such as warfarin, heparin and low molecular weight heparin).
Cranberry has bacteriostatic and antioxidant effects. Its role in the prevention of urinary tract infection is currently under scrutiny. There is some evidence for cranberry’s use in prevention of urinary tract infections (UTIs) over a 12-month period for women with recurrent UTIs. Cranberry prevents Escherichia coli from adhering to the urethra, relieves symptoms of cystitis (e.g. pain or burning on urination) and masks urinary odour associated with incontinence.
However cranberry is not effective in treatment of UTIs and, if symptoms appear, conventional treatment should be applied. Adverse effects associated with high doses include gastrointestinal discomfort, nausea and increased blood glucose, which requires monitoring in diabetic patients especially if the fruit juice is used.
In conclusion the role of complementary medicines should be acknowledged rather than dismissed and patients who choose to use these products and treatments should be assisted in making informed (evidence-based) decisions rather than be categorised as being superstitious. Medical professionals who have embraced complementary medicines should be commended and these practitioners’ role should be enhanced.
- Mapp G, Tiralongo E. Short Course in Integrative Medicine [course notes]. Griffith University School of Pharmacy; 2011 May 14–24; Melbourne, Victoria.
- Rossi S. ed. Australian Medicine Handbook 2011. Adelaide: Australian Medicines Handbook Pty Ltd; 2011.
- eTG complete (Internet). Melbourne: Therapeutic Guidelines Limited; 2011 Jul. Available from www.tg.org.au. Accessed 19 December 2012.