Popular Natural Remedies, Part XII

This will be the 12th in a series of articles that I have written on natural products. As a pharmacist, I'm aware that a number of our patients take natural products, whether it be a multivitamin, herbal supplement, or nutritional drink. The purpose of these articles is to discuss natural products that generally have possible recognized medical benefit or, in some cases, to put the brakes on one's enthusiasm for products that are widely discussed in the lay press, but for which documented medical efficacy is lacking. It is my hope that these articles will help the Wright State community, perhaps more wisely choose natural products with at least some documented efficacy and value. The previous 11 articles may be viewed at our website at www.wright.edu/admin/fredwhite/pharmacy/.

Passion flower was introduced into medicine in 1840 by Dr. Al Phares of Mississippi. Thereafter, it was buried in obscurity for about 50 years until it was reintroduced by professor I.J.M. Goth of Atlanta, Georgia, around 1900. Passion flower had an official listing in the National Formulary of the United States from 1916 to 1936. Per Tyler's Honest Herbal, this product is used extensively in Europe to treat diabetic disorders and help with inducing sleep. Per the German Commission E List, the medicinal part of this plant involves the above ground parts of the plant. Officially, under the German Commission E List, passion flower is paid for on the national health insurance as a product to reduce general restlessness. Per The Lawrence Review of Natural Products, animal studies have shown that passion flower extracts have a complex action on the nervous system, including dose dependent stimulation and depression. Again, per The Lawrence Review of Natural Products, the pharmacological activity of passion flower is thought primarily due to its alkaloids and flavonoids. The harurala alkaloids in passion flower have been found to inhibit monoamine oxidase in the brain. This may count for part of passion flower's pharmacological effects. Two other ingredients of passion flower with medicinal properties are maltol and ethylmaltol. When mice were injected with 400 mg/kg of these substances, they showed spontaneous bradycardia, hypothermia, relaxation of skeletal muscles, and diminished pinea, corneal, and isolateral flexor muscles. Passion flower's ability to reduce anxiety makes it useful for asthma, heart palpitations, high blood pressure, insomnia, nervousness, pain relief, and other related conditions, where it is used widely in Europe. Adverse reactions of passion flower can include dizziness, confusion, and ataxia in some patients. Vasculitis and altered consciousness have been reported with use of passion flower; this per the Pharmacist's Letter. In theory, passion flower can effect blood coagulation, and should not be used in patients taking blood thinners. Neither should passion flower be used with natural or pharmaceutical products which may have sedative properties. Theoretically, the drugs that passion flower can interact with are: barbiturates, monoamine oxidase inhibitors, sedatives, and tranquilizers. There are no known interactions with food, lab tests, or other disease states.

For the most part, I believe that most people drink grapefruit juice as part of their daily routine, rather than for any particular health benefit. With regard to health benefits, grapefruit pectin has been found to reduce cholesterol, and to promote the regression of arteriosclerosis. Grapefruit was first introduced to the Western world in 1750 as the forbidden fruit of Barbados. In 1823, grapefruit was introduced in Florida by a French count, Odette Fillipe, but did not gain popularity until the end of the 19th Century. During the 1930s, one of the original Hollywood fad diets was known as the Grapefruit Diet and, although it was very popular, however, it was extremely unhealthy. One of the more common questions that we get at the Pharmacy over the years, has been whether grapefruit juice will interfere with a patient's medication. Per The Lawrence Review of Natural Products, grapefruit juice has been found to increase the bioavailability of certain drugs by inhibition of cytochrome P-450 3A4 (CYP 3A4) isozyme found in the liver and gut wall. However the effects of grapefruit juice are primarily on the isozyme found in the gut wall. As a result of this inhibition, more of a drug is absorbed and the plasma concentration increases. It has been reported that grapefruit juice can increase the plasma concentrations of the benzodiazepines (Xanax, Ativan, and others), which are antianxiety agents. However the clinical significance of this is expected to be low. Perhaps one of the most significant drug interactions occurs with the calcium channel blockers, which are used to treat hypertension. The dihydropyridine subgroup of calcium channel blockers, which include Norvasc, Plendil, and Procardia, are most affected by grapefruit juice. Again, per The Lawrence Review of Natural Products, plasma concentrations of Plendil increased by 300% when grapefruit juice is ingested. The plasma increases of Norvasc were about 15%, and the plasma increases of Procardia were approximately 35% with the resultant further reduction in blood pressure and potential side effects. Interestingly, the calcium channel blocker, diltiazem, was not affected by grapefruit juice, but it is from a different subgroup of calcium channel blockers. Another class of drug affected by grapefruit juice are the HMG-COA reductase inhibitors. Grapefruit juice increases the absorption and concentration of lovastin (Mevacor), simvastatin (Zocor), and atorvastatin (Lipitor). This would increase the likelihood of adverse reactions. It does not affect pravastatin. Other drugs affected by grapefruit juice: Tegretol (carbamazepine) - treats epilepsy - ç blood levels; Coreg (carvedilol) - cardiac patients - ç blood levels; Anafranil (clomipramine) - obsessive compulsive behavior; Neoral, Sandimmune (cyclosporin) - organ transplant; Sporanox (itraconazole) - fungus infections in the nails; Cozaar (losartan) - hypertension.

About two and a half years ago in the fourth series about natural products, I wrote about MSM, which is methylsulfonylmethane. It has gained much popularity in the intervening 2_ years in the natural product market. It is promoted heavily and sold both in oral and topical form, often in combination with glucosamine/chondroitin. At the time that I wrote the article, there was not much scientific data one way or the other about the efficacy of MSM, and I stated that at some time in the future I would report if there was any change. Unfortunately, since I know how widely this product is used, there is no change with the product in any of the four reference books that I use, which are Tyler's Honest Herbal, 4th edition, the most current version of the English translation of The German Commission E List, The Lawrence Review of Natural Products, and lastly, Natural Medicine's Comprehensive Data Base compiled by the editors of The Pharmacist's Letter. In the 2003 edition of The Pharmacist's Letter, it states that there is insufficient reliable information about the effectiveness of MSM in treating ANY medical condition. This means that in the intervening two and half years, there have been no credible studies published anywhere that MSM is effective. I'm merely pointing this out because, as a pharmacist, I see many ads for natural products that have MSM listed in them. MSM is pretty much touted as a cure all in these ads.. I would caution those of you who are spending your money, that MSM has not been found to benefit any medical condition.

In the treatment of elevated cholesterol, there are developments with a product that has been purported for years to be beneficial to people with elevated cholesterol. Per The Lawrence Review of Natural Products, as well as The Pharmacist's Letter, avocado is a natural product that can have a beneficial effect for people with elevated cholesterol. Per The Pharmacist's Letter, avocado is likely effective for reducing total serum cholesterol, LDL cholesterol, apolipoprotein B, and increasing HDL cholesterol. It is the fruit of the avocado plant that is being used to reduce serum cholesterol levels. Per The Pharmacist's Letter, at this point in time the mechanism of action of this plant is not fully understood, but it could possibly be due to the high content of unsaturated fatty acids and other compounds (oleic acid, tocopherols, vitamin E, sterols, and volatile oils). The only drug interaction known at this time would be warfarin. There is one reported case of this. However, I would note that reports of the use of this plant in lowering cholesterol levels are so recent that a patient should discuss with their doctor whether avocados are appropriate for them.

Most of us reading this article, some time in the next year, will have some sort of GI discomfort. An agent that has been used in Europe for hundreds of years, and also in this country to treat GI discomfort, is fennel seed. Per Tyler's Honest Herbal, fennel has been recommended for the treatment of a variety of ailments, but chiefly as an agent which helps to expel flatulence (gas). Per The German Commission E List, fennel is used for mild, spastic gastrointestinal afflictions, fullness, and flatulence. Like most natural products, fennel has over a dozen other purported uses, but none of the others have been proven at this time. The Pharmacist's Letter lists fennel as possibly effective when taken orally for treating mild GI symptoms, fullness, and flatulence. Fennel contains a number of chemicals. Per The Pharmacist's Letter, it is a rich in beta-carotene, vitamin C, and its volatile oil is composed largely of trans-anethole, with lesser amounts of fenchone, estragole, and other constituents. Unfortunately, at this time it is unknown which of these chemical constituents actually affects the GI tract. Side effects, per The German Commission E List, include allergic reactions of the skin and respiratory tract. There are no known interactions with other herbs or dietary supplements. Per The Pharmacist's Letter, the only known drug interaction is with the antibiotic, Cipro - fennel seed can decrease the absorption by up to 50%. Patients with allergies to celery, carrot, or mugwert are cautioned in taking fennel, as there could be a cross sensitivity. Orally, a typical dose of fennel is five to seven grams of the dried fruit or seed per day in a cup of tea, one to three times a day. The tea is prepared by steeping one to two grams of the crushed or ground fruit or seed into 150 mls of boiling water for 10 minutes, and then straining. I have also seen this preparation used in infants with colic in a product called gripe water. In this product, a teaspoon of fennel seed is combined with a tablespoon of light Karo Syrup and a thousand milliliters of water. It is boiled for approximately 20 minutes. The seeds are strained off, and two ounce bottles are made for the infants. The same product that is homemade in this country is sold commercially other countries.

Alan C. McKelvey, R.Ph.
Pharmacist, Frederick A. White Health Center