What do commercial ginseng preparations contain?

Clinically proven natural products, vitamins and mineral in boosting up immunity: A comprehensive review

BACKGROUND

and Purposes: The terminology "immune boost-up" was the talk of the topic in this Covid-19 pandemic. A significant number of the people took initiative to increase the body's defense capacity through boosting up immunity worldwide. Considering this, the study was designed to explain the natural products, vitamins and mineral that were proved by clinical trail as immunity enhancer.

METHODS

Information was retrieved from SciVerse Scopus ® (Elsevier Properties S. A, USA), Web of Science® (Thomson Reuters, USA), and PubMed based on immunity, nutrients, natural products in boosting up immunity, minerals and vitamins in boosting up immunity, and immune booster agents.

RESULT

A well-defined immune cells response provide a-well functioning defense system for the human physiological system. Cells of the immune system must require adequate stimulation so that these cells can prepare themselves competent enough to fight against any unintended onslaught. Several pharmacologically active medicinal plants and plants derived probiotics or micronutrients have played a pivotal role in enhancing the immune boost-up process. Their role has been well established from the previous study. Immune stimulating cells, especially cells of acquired immunity are closely associated with the immune-boosting up process because all the immunological reactions and mechanisms are mediated through these cells.

CONCLUSION

This article highlighted the mechanism of action of different natural products, vitamins and mineral in boosting up the immunity of the human body and strengthening the body's defense system. Therefore, it is recommended that until the specific immune-boosting drugs are available in pharma markets, anyone can consider the mentioned products as dietary supplements to boost up the immunity.

Integrating herbal medicine into oncology care delivery: development, implementation, and evaluation of a novel program

OBJECTIVE

To evaluate the feasibility of a novel program facilitating patient-provider communication about appropriate use of herbal medicine at a large academic cancer center and its impact on patient wellbeing.

METHODS

In the Herbal Oncology Program (HOP), integrative medicine providers counseled patients about unmet symptom needs and prescribed traditional Chinese medicine (TCM) herbs when indicated, taking into consideration the clinical context, patient preference, and research evidence. To evaluate the feasibility and outcomes, we performed a retrospective analysis using medical record data (symptoms and other concerns that motivated patients to seek herbal products, types and numbers of dispensed TCM herbs, and demographic characteristics). We also conducted a survey to assess patient experience and satisfaction.

RESULTS

All 851 participants were outpatients, with 712 (84%) in active treatment. HOP dispensed 1266 herbal prescriptions for a range of symptoms, most commonly GI symptoms (467, 37%); pain (353, 28%); and treatment-related fatigue, sleep, and mood disorders (346, 27%). Of 269 patients invited to the survey, 107 (40%) completed it. A majority of respondents 70.9% (73/103) were satisfied with the effectiveness of dispensed herbs in relieving their symptoms, and few 6.7% (7/104) had experienced mild adverse events that resolved after discontinuing herbal use.

CONCLUSIONS

The study's findings support the feasibility of integrating herbal medicine into an academic oncology setting. Patient satisfaction with HOP was high, with limited adverse events. The patterns of herbal prescriptions in HOP suggest future areas for clinical research to strengthen the evidence base around safe and effective use.

A Review of Authenticity and Authentication of Commercial Ginseng Herbal Medicines and Food Supplements

Ginseng traditional medicines and food supplements are the globally top selling herbal products. Panax ginseng, Panax quinquefolius and Panax notoginseng are the main commercial ginseng species in herbal medicine. Prices of ginseng products vary widely based on the species, quality, and purity of the used ginseng, and this provides a strong driver for intentional adulteration. Our systematic literature search has reviewed the authenticity results of 507 ginseng-containing commercial herbal products sold in 12 countries scattered across six continents. The analysis of the botanical and chemical identity of all these products shows that 76% are authentic while 24% were reported as adulterated. The number of commercial products as well as the percentage of adulteration varies significantly between continents, being highest in South America (100%) and Australia (75%), and lower in Europe (35%), North America (23%), Asia (21%) and Africa (0%). At a national level, from the five countries for which more than 10 products have been successfully authenticated, the highest percentage of adulterated ginseng products were purchased from Taiwan (49%), followed by Italy (37%), China (21%), and USA (12%), while all products bought in South Korea were reported to be authentic. In most cases, labeled Panax species were substituted with other Panax species, but substitution of ginseng root, the medicinally recommended plant part, with leaves, stems or flowers was also reported. Efficient and practical authentication using biomarkers to distinguish the main ginseng varieties and secondary metabolite spectra for age determination are essential to combat adulteration in the global marketplace.

Exploring Herbal Medicine Use during Palliative Cancer Care: The Integrative Physician as a Facilitator of Pharmacist-Patient-Oncologist Communication

Oncology patients frequently use herbal and other forms of complementary medicine, often without the knowledge of oncologists, pharmacists, and other healthcare professionals responsible for their care. Oncology healthcare professionals may lack the knowledge needed to guide their patients on the safe and effective use of herbal medicinal products, a number of which have potentially harmful effects, which include direct toxicity and negative herb–drug interactions. The current review addresses the prevalence and expectations of oncology patients from herbal medicine, as well as evidence for the beneficial or harmful effects of this practice (potential and actual), especially when the herbal products are used in conjunction with anticancer agents. Models of integrative oncology care are described, in which open and effective communication among oncologists, pharmacists, and integrative physicians on the use of herbal medicine by their patients occurs. This collaboration provides patients with a nonjudgmental and multidisciplinary approach to integrative medicine, echoing their own health-belief models of care during conventional cancer treatments. The role of the integrative physician is to facilitate this process, working with oncologists and pharmacists in the fostering of patient-centered palliative care, while ensuring a safe and effective treatment environment. Case scenario: W. is a 56 year old female artist who was recently diagnosed with localized hormone receptor-positive breast cancer. Following lumpectomy and sentinel node dissection, she is scheduled to begin adjuvant chemotherapy with a regimen which will include adriamycin, cyclophosphamide, and paclitaxel (AC-T protocol). She is worried about developing peripheral neuropathy and its impact on her ability to paint, and she asks about a number of dietary supplements which she heard could prevent this from happening: omega-3, vitamin E, alpha-lipoic acid, and acetyl-l-carnithine. She is concerned, however, that the supplements may negatively interact with her chemotherapy regimen.

The ‘Natural Health Service’: natural does not mean safe

Plants have been used for medicinal purposes for centuries, treating everything from non-specific ailments such as backache and colds to serious conditions, including depression and cancer. In this review, a few commonly known plants with psychotropic effects (St John's wort, Ginkgo biloba, kava, ginseng and valerian) are discussed by way of illustration. The readers' attention is brought to important interactions between herbal remedies and conventional drugs. A background to the constituents of herbs, possible mechanisms of action and an explanation of their antioxidant properties is given.

Survey of Preoperative Patients' Use of Herbal Products and Other Selected Dietary Supplements

Purpose

This study was designed to determine the prevalence of herbal and selected dietary product use among preoperative patients.

Methods

A questionnaire listing 26 herbal/dietary supplements was given to 979 preoperative patients in the anesthesia assessment unit. Subjects were asked to indicate the amounts and durations of products taken. Demographic data and proposed surgical procedures were noted.

Results

One hundred and seventy surgical patients (17.4%) reported taking herbal or dietary supplements. Neurosurgical, gynecological, and orthopedic surgical patients reported the highest incidences of use at 21%, 21%, and 20%, respectively. Of patients taking these agents, 34.7% took only one product, 23.5% took two products, 11.2% took three products, and 10.6% took four or more products. The most commonly used herbals, in descending order of frequency, were ginkgo, garlic, ginseng, St. John's wort, and echinacea. Glucosamine, chondroitin, and chromium were the surveyed dietary supplements most widely used. More than 40 herbs were taken occasionally. The median age of users and nonusers was 62 years. Orthopedic patients took glucosamine and chondroitin most commonly, ophthalmic patients took ginkgo most commonly, and urology patients took saw palmetto most commonly.

Conclusion

The adverse effects of herbals and dietary products during surgical procedures and the interactions between these products and anesthetic drugs warrant further research. The use of herbal or dietary supplements may indicate alteration of patients' perioperative regimens.

Safety Assessment of Panax spp Root-Derived Ingredients as Used in Cosmetics

The Cosmetic Ingredient Review Expert Panel (Panel) reviewed the safety of 13 Panax spp root-derived ingredients as used in cosmetics. Panax "spp" indicates that multiple species within the genus are used in cosmetics, but not all species within that genus. Four species are being considered in this safety assessment. These ingredients function mostly as skin-conditioning agents-miscellaneous, fragrance ingredients, skin-conditioning agents-humectant, skin-conditioning agents-emollient, and cosmetic astringents. The Panel reviewed available data related to these ingredients and addressed the issue of pulegone, a constituent of these ingredients and other ingredients, such as peppermint oil. The Panel concluded that these Panax spp root-derived ingredients are safe in the practices of use and concentration as given in this safety assessment.

Safety Issues in the Interaction of Conventional, Complementary, and Alternative Health Care

This article reviews issues of safety in health care, applied particularly to the interface between conventional medicine and complementary and alternative medicine. These issues include errors in treatment and medical management, adverse effects of pharmaceuticals, and defining risk for patients. For complementary and alternative medicine, especially dietary supplements, problems of quality control, licensing, regulation, and misrepresentation are discussed. An important issue is the interface between conventional and complementary therapies, in terms of drug/herb interactions, laboratory diagnosis, and lack of communication between clinicians about patients. Improvements in safety and quality will come from a commitment to better education and understanding between both types of care.

Safety Assessment of Panax Ginseng

Since the 1994 Dietary Supplement Health and Education Act, the consumption of botanical supplements has increased to the point where ginseng is the third best selling herbal supplement in the United States and it is now also being used as a flavoring agent in foods. The predominant pharmacologically active constituents of Panax are ginsenosides, at least 25 of which have been identified and are present in variable amounts and ratios to one another, depending on the particular species, variety, and conditions of growth. The toxicological profile of ginseng indicates it to be of rather low acute oral toxicity (LD50 > 5000 mg/kg for rats and mice, approximating 200 mg ginsenoside/kg.) No toxicological effects were identified in mini pigs at a dose of 2000 mg/kg (80 mg ginsenoside/kg). As concluded from a 90-day dog study and in reproduction studies in rats and mice, 15 mg/kg (∼ 0.6 mg ginsenoside/kg) was without effect. No effect was seen in rats administered 4000 mg/kg (160 mg ginsenoside/kg) for 20 days. There was no mutagenic activity observed in Salmonella typhimurium TM677 system with the use of ginseng in the presence or absence of metabolic activation. The no-observed-adverse-effectlevel (NOAEL) in rodents is likely within the range of 50 to 100 mg ginsenoside/kg. There are no confirmed reports of adverse reactions in humans attributed to ginseng alone. Importantly, no consistent symptomology or findings have been attributed to, or identified as being associated with, ginseng consumption. Ginseng extracts standardized at a concentration of 4 mg ginsenosides/100 mg capsule and given at a dose of up to 114 θ g ginsenoside/kg have not resulted in untoward effects when administered to humans for periods of up to 12 weeks.

Thyroxine and triiodothyronine content in commercially available thyroid health supplements

BACKGROUND

As defined by the Dietary Supplement Health and Education Act 1997, such substances as herbs and dietary supplements fall under general Food and Drug Administration supervision but have not been closely regulated to date. We examined the thyroid hormone content in readily available dietary health supplements marketed for "thyroid support."

METHODS

Ten commercially available thyroid dietary supplements were purchased. Thyroid supplements were dissolved in 10 mL of acetonitrile and water with 0.1% trifloroacetic acid and analyzed using high-performance liquid chromatography for the presence of both thyroxine (T4) and triiodothyronine (T3) using levothyroxine and liothyronine as a positive controls and standards.

RESULTS

The amount of T4 and T3 was measured separately for each supplement sample. Nine out of 10 supplements revealed a detectable amount of T3 (1.3-25.4 μg/tablet) and 5 of 10 contained T4 (5.77-22.9 μg/tablet). Taken at the recommended dose, 5 supplements delivered T3 quantities of greater than 10 μg/day, and 4 delivered T4 quantities ranging from 8.57 to 91.6 μg/day.

CONCLUSIONS

The majority of dietary thyroid supplements studied contained clinically relevant amounts of T4 and T3, some of which exceeded common treatment doses for hypothyroidism. These amounts of thyroid hormone, found in easily accessible dietary supplements, potentially expose patients to the risk of alterations in thyroid levels even to the point of developing iatrogenic thyrotoxicosis. The current study results emphasize the importance of patient and provider education regarding the use of dietary supplements and highlight the need for greater regulation of these products, which hold potential danger to public health.

Ginseng, the 'Immunity Boost': The Effects of Panax ginseng on Immune System

Thousands of literatures have described the diverse role of ginseng in physiological processes such as cancer, neurodegenerative disorders, insulin resistance, and hypertension. In particular, ginseng has been extensively reported to maintain homeostasis of the immune system and to enhance resistance to illness or microbial attacks through the regulation of immune system. Immune system comprises of different types of cells fulfilling their own specialized functions, and each type of the immune cells is differentially influenced and may be simultaneously controlled by ginseng treatment. This review summarizes the current knowledge on the effects of ginseng on immune system. We discuss how ginseng regulates each type of immune cells including macrophages, natural killer cells, dendritic cells, T cells, and B cells. We also describe how ginseng exhibits beneficial effects on controlling inflammatory diseases and microbial infections.

Use of non-vitamin, non-mineral (NVNM) supplements by hospitalized internal medicine patients and doctor-patient communication

OBJECTIVE

To study non-vitamin, non-mineral (NVNM) supplements use and disclosure of among hospitalized internal medicine patients.

METHODS

A convenience sample of patients completed an interviewer-administered questionnaire examining use of and perceptions regarding NVNM supplements, and disclosure to medical personnel.

RESULTS

280 patients were interviewed (54% female), 15.4% reporting NVNM supplement use. This practice was more prevalent among female patients (p=0.045), more educated (p<0.001) and patients with more impaired quality-of-life, measured by the SF-12 tool (p<0.020). The most common factor influencing NVNM supplement use was a physician's recommendation. Most (74%) patients using NVNM supplements reported having disclosed this practice to community-based physicians, with only 23.7% disclosing to hospital staff. Six patients reported using supplements at the exclusion of conventional medication, with potentially serious implications.

CONCLUSION

While the majority of patients using NVNM supplements are sharing this information with their primary-care physicians, there is little disclosure of this practice to hospital staff. This may be due to a perceived negative attitude of medical professionals to complementary medicine, and a lack of awareness by hospital staff regarding such practices.

PRACTICE IMPLICATIONS

Hospital-based medical professionals need to be aware of the use of NVNM supplements and the resulting implications by their internal medicine patients.

The Quality of Commercially Available Herbal Products

Herbal products are believed to be safe as they are naturally occurring, however, this is a misconception. Currently, there are many herbal products which are not manufactured under the Good Manufacturing Practice (GMP) guidelines and hence the quality of the product is not controlled. Quality can be assessed by evaluation of data on levels of either active constituent(s) or chemical markers indicative of origin of plant material. Assessment of published data on levels of quality of herbal medicinal products revealed that only a percentage of the total number of products investigated were found to contain the levels of markers as stated on the label, and others had widely varying levels of constituents. Thus few products complied with acceptable quality control standards. Herbal products are increasingly self-prescribed for the treatment of minor ailments. Patients relying on herbal products for therapeutic effects may expose themselves to either low doses of active constituents causing insufficient effects or alternatively take higher levels than expected, with the increased risk of toxicity or adverse effects, or be affected by the inadvertent inclusion of unexpected components with associated potential health risks.

Over the counter (OTC) oral remedies for arthritis and rheumatism: how effective are they?

BACKGROUND

Increasingly patients resort to alternative remedies for arthritis and rheumatism, perhaps partly impelled by reports of toxicities from prescribed non-steroid anti-inflammatory drugs (NSAID). There is uncertainty about whether the most common alternative treatments provide relief or may cause adverse reactions.

AIM

To ascertain the validity of manufacturers' claims permitted by the Therapeutic Goods Administration (TGA) in Australia for a range of self-medication products to treat the pain and inflammation of arthritis, available in local pharmacies, supermarkets or by mail order and in other countries.

METHODS

OTC products were administered orally to rats in standard assays for suppressing experimental arthritis and fever and for determining potential gastrotoxicity.

RESULTS

The three NSAIDs available OTC were efficacious but gastrotoxic. Of the 37 herbal formulations examined, seven were as effective as ibuprofen in the anti-arthritic assay without causing gastric bleeding. Five of the 10 animal-sourced products tested were also effective without evident toxicity. Within a certain class of product, e.g. celery seed extracts or dried mussel preparations, efficacies ranged from almost zero to highly effective.

CONCLUSIONS

Consumers currently have no guide to the likely efficacy of TGA-approved remedies. Quality control is urgently needed to justify the veracity of TGA-permitted and other claims on product labels.

Drug-induced hepatotoxicity or drug-induced liver injury

Drug-induced hepatotoxicity is underreported and underestimated in the United States. It is an important cause of acute liver failure. Common classes of drugs causing drug-induced hepatotoxicity include antibiotics, lipid lowering agents, oral hypoglycemics, psychotropics, antiretrovirals, acetaminophen, and complementary and alternative medications. Hepatotoxic drugs often have a signature or pattern of liver injury including patterns of liver test abnormalities, latency of symptom onset, presence or absence of immune hypersensitivity, and the course of the reaction after drug withdrawal.

Hot topics and landmark studies from the 43rd annual meeting of the American Society of Clinical Oncology

The results of several preclinical and clinical studies were reported by oncology professionals at the 43rd American Society of Clinical Oncology (ASCO) meeting, the largest international forum in which the latest achievements in cancer research are annually presented. The central theme this year was 'Translating Research into Practice', emphasizing the goal of forging stronger links between basic research and clinical practice. This review offers a critical, summarized selection of several of the foremost studies presented at the meeting. The focus is on the findings from randomized phase III trials that, in the authors' opinion, are most likely to have an immediate effect on clinical practice.

Herbal medicine and epilepsy: proconvulsive effects and interactions with antiepileptic drugs

The use of complementary and alternative medicine is on the rise, including among patients with epilepsy. Herbal medicine, one of the most popular forms of CAM, is considered to be both safe and effective by most consumers. Yet many herbs may increase the risk for seizures, through intrinsic proconvulsant properties or contamination by heavy metals, as well as via effects on the cytochrome P450 enzymes and P-glycoproteins, altering antiepileptic drug (AED) disposition. Herb-drug interactions may be difficult to predict, especially since the quality and quantity of active ingredients are often unknown. Since most patients do not inform their physicians that they are taking herbal medicines, health care professionals must initiate a dialogue in order to prevent complications with the combined regimen. At the same time, further research is required regarding the effect of herbs on seizure activity and interactions with AED treatment.

The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004

OBJECTIVE

To survey the use, cost, beliefs and quality of life of users of complementary and alternative medicine (CAM).

DESIGN

A representative population survey conducted in 2004 with longitudinal comparison to similar 1993 and 2000 surveys.

PARTICIPANTS

3015 South Australian respondents over the age of 15 years (71.7% participation).

RESULTS

In 2004, CAMs were used by 52.2% of the population. Greatest use was in women aged 25-34 years, with higher income and education levels. CAM therapists had been visited by 26.5% of the population. In those with children, 29.9% administered CAMs to them and 17.5% of the children had visited CAM therapists. The total extrapolated cost in Australia of CAMs and CAM therapists in 2004 was AUD$1.8 billion, which was a decrease from AUD$2.3 billion in 2000. CAMs were used mostly to maintain general health. The users of CAM had lower quality-of-life scores than non-users. Among CAM users, 49.7% used conventional medicines on the same day and 57.2% did not report the use of CAMs to their doctor. About half of the respondents assumed that CAMs were independently tested by a government agency; of these, 74.8% believed they were tested for quality and safety, 21.8% for what they claimed, and 17.9% for efficacy.

CONCLUSIONS

Australians continue to use high levels of CAMs and CAM therapists. The public is often unaware that CAMs are not tested by the Therapeutic Goods Administration for efficacy or safety.

Herbal supplements

Herbal dietary supplements are taken by many individuals, often without the knowledge of their clinicians. Herbals have many pharmacologic and medicinal properties but are unregulated with respect to manufacturing purity, safety, and efficacy. Although clinicians often dismiss the utility of herbal therapy, many randomized controlled trials of herbal use in gastrointestinal and liver diseases have been conducted. There is no evidence for benefit from herbal supplements in the treatment of liver disease, but sufficient evidence exists for their use in functional gastrointestinal symptoms to warrant further investigation.

Immune system effects of echinacea, ginseng, and astragalus: a review

Traditional herbal medicine provides several remedies for strengthening the body's resistance to illness through effects on immune system components. This review article examines 3 popular herbal immune stimulants that are often of interest to cancer patients. Echinacea, a native of North America, is widely used to prevent, or provide early treatment for, colds. Preclinical studies lend biological plausibility to the idea that echinacea works through immune mechanisms. Numerous clinical trials have been carried out on echinacea preparations: it appears that the extracts shorten the duration and severity of colds and other upper respiratory infections (URIs) when given as soon as symptoms become evident. However, trials of long-term use of echinacea as a preventive have not shown positive results. Ginseng has been studied in some depth as an antifatigue agent, but studies of immune mechanisms have not proceeded so far. Preclinical evidence shows some immune-stimulating activity. There have been several clinical trials in a variety of different diseases. Astragalus is the least-studied agent. There are some preclinical trials that show intriguing immune activity. The herbs discussed appear to have satisfactory safety profiles. Cancer patients may wish to use these botanicals to inhibit tumor growth or to boost resistance to infections. However, passive immunotherapy with herbs, with no mechanism to expose tumor antigens, is unlikely to be effective in inhibiting tumor growth. Although the margin of safety for these herbs is large, more research is needed to demonstrate the clear value of using herbs to improve resistance to infections.

Quality assessment programs for dietary supplements

BACKGROUND

In the US, consumers and healthcare professionals have been forced to depend on self-regulation by the dietary supplement industry for product quality, consistency, potency, and purity, a system that has yielded mixed results at best.

OBJECTIVE

To characterize the current state of product quality verification in the dietary supplement industry and review recent developments and future plans to improve supplement safety and regulation.

METHODS

Studies describing the quality of dietary supplements are reviewed, along with recent Food and Drug Administration (FDA) plans to improve supplement regulation. Several independent dietary supplement quality certification programs are described and evaluated.

RESULTS

Quality control standards for dietary supplements run the gamut from good to nonexistent. Contamination, false labeling, and incomplete labeling are not uncommon problems--as are significant discrepancies in disintegration, dissolution, and in vitro release characteristics of various dietary supplements. The need for improved regulation has led to plans for increased FDA involvement through enforcement of good manufacturing practices and truths in labeling. Meanwhile, independent product certification companies have emerged and provide some reassurances; however, they possess several limitations as well.

CONCLUSIONS

Until proposed FDA initiatives are finalized and implemented, certification programs can help provide assurances of safety and assist in product selection. Although they do not testify to effectiveness (and may even inadvertently mislead some consumers), certification programs may help curb what has been called "the Wild West nature of the dietary supplement industry."

The use and safety of non-allopathic Indian medicines

Non-allopathic Indian medicines, referred to elsewhere in the world as complementary and alternative medicine have gathered increasing recognition in recent years with regard to both treatment options and health hazards. Ayurveda, Siddha, Unani and homeopathy are practiced in India as non-allopathic systems. These systems comprise a wide range of therapeutic approaches that include diet, herbs, metals, minerals, precious stones and their combinations as well as non-drug therapies. Ayurveda is the oldest system of medicine in the world and by far the most commonly practiced form of non-allopathic medicine in India, particularly in rural India, where 70% of the population lives. The difference between modern medicine and these systems stems from the fact that the knowledge base of many of the above systems, unlike Western medicine, is based on years of experience, observations, empiricism and intuition and has been handed down generations both through word of mouth and treatises. The focus on non-allopathic systems of medicine in India can be attributed to various causes including a need to revive a rich tradition, the dependency of 80% of the country's population on these drugs, their easy availability, increasing worldwide use of these medicines, the lack of focused concerted scientific research and the abuse of these systems by quacks. Elsewhere, the increasing use of herbal products worldwide and the growth of the herbal product industry has led to increasing concern regarding their safety. The challenges in these non-allopathic systems relate to the patient, physician, regulatory authorities, the abuse/misuse of these medicines, quality and purity issues. Safety monitoring is mandated by a changing ecological environment, the use of insecticides, new manufacturing techniques, an as yet unregulated pharmaceutical industry, the availability of combinations of herbs over the counter and not mentioned in ancient Ayurvedic texts, and the need to look at the active principles of these medicines as potential chemotherapeutic agents. The Indian traditional medicine industry has come a long way from the times when it was considered unnecessary to test these formulations prior to use, to the introduction of Good Manufacturing Practice guidelines for the industry. However, we still have a long way to go. The conflict between the traditional practitioners and the purists demanding evidence of safety and efficacy needs to be addressed. There is an urgent need for the practitioners of the allopathic and non-allopathic systems to work together to optimise the risk-benefit profile of these medicines.

Influence of pharmaceutical quality on the bioavailability of active components from Ginkgo biloba preparations

To be effective, herbal medicinal products are expected to meet comparable standards concerning the assessment of efficacy, safety and biopharmaceutical quality as chemically defined synthetic drugs as food supplements. However, these requirements are often not fulfilled, particularly regarding the characterization of biopharmaceutical properties such as in-vitro dissolution and in-vivo bioavailability. With respect to the relevance of biopharmaceutical quality of herbal medicinal products, two different Ginkgo biloba brands (test product: Ginkgo biloba capsules; reference product: Ginkgold) were analysed for dissolution rates and bioavailability of the most relevant active ingredients. Dissolution rates at pH 1 and 4.5 were determined according to the USP 23. The relative bioavailability of ginkgolide A, ginkgolide B and bilobalide was investigated after single oral administration of 120 mg Ginkgo biloba extract as tablets or capsules. Bioavailability data (area under the curve and peak concentration in plasma) were clearly different and did not show bioequivalence of test and reference products. The slow in-vitro dissolution of the test product resulted in a large decrease in bioavailability. These results indicate for the first time that the pharmaceutical properties of a herbal medicinal product have a significant impact on the rate and extent of drug absorption, and very likely on efficacy in humans.

When food becomes a drug: nonanabolic nutritional supplement use in athletes

The use of nonanabolic nutritional supplements for the sake of improving athletic performance is common, and the types of supplements used can have significant implications for the medical care of athletes. This review will address the most common and most controversial nonanabolic nutritional supplements, including recommendations regarding their use. Many supplements are marketed and promoted based on various theoretical benefits, often derived from limited animal studies, without any basis for recommending their human use. Physicians are trained to not recommend a nutritional supplement unless it is known to be effective, whereas athletes are oriented toward trying any supplement or ergogenic aid as long as it is safe, with the hope that it may be effective. The built-in error in most study designs is larger than the difference between winning and not qualifying at elite levels of competition, such that research may not always answer the questions raised by athletes. An honest discussion of the limitations of most supplements, and acknowledgment that some supplements may work some of the time in some athletes, may lead the physician to be more credible and useful to athletes in providing medical care and guidance that support their desire to improve their performance.

Pharmaceutical quality of different Ginkgo biloba brands

Ginkgo biloba-containing brands are one of the top sellers within the growing market for herbal remedies in many European countries as well as in the USA. In the consumers' interest, these brands should feature a certain quality and should be transparent in quality claims. In this investigation, a variety of products on the USA market was studied with respect to pharmaceutical quality, such as quantity of constituents and in-vitro dissolution. In terms of the content of active substances, flavone glycosides ranged from 24% to 36% and terpene lactones from 4% to 11%. With ginkgolic acids, there was a very large range, from < 500 ppm to about 90000 ppm. Comparing the dissolution rates of terpene lactones and flavone glycosides within the single products, most were approximately the same. Thus, terpene lactones and flavone glycosides were released from these products and dissolved at the same rate in most cases. Furthermore, most of the products investigated released more than the required 75% of the content of both components within 30 min. However, several products showed clear and relevant differences in dissolution rates to the rest (e.g. < 75% within 30 min or even less than 25% after 60 min in one case, indicating much poorer pharmaceutical quality). Beside the comparability respectively standardisation of the extracts used, the in-vitro dissolution of the relevant constituents should be similar to other drugs to guarantee comparable in-vivo performance of herbal products. An important step in standardising pharmaceutical quality is the pharmacopoeial monograph for Ginkgo biloba extract in Germany, standardising the content of pharmacologically relevant substances (flavone glycosides 22-27% and terpenlactones 5-7%, 2.8-3.4% ginkgolides A, B, C and 2.6-3.2% bilobalide thereof). Many of the investigated products, which refer to the German Commission E (of the Federal Institute for Drugs and Medicinal Devices) monograph, are not in accordance with this specification. Thus, they can not be considered to be pharmaceutically equivalent.

Benefits, adverse effects and drug interactions of herbal therapies with cardiovascular effects

Because the use of herbal therapies in the U.S. is escalating, it is essential to be aware of clinical and adverse effects, doses and potential drug-herb interactions. A consumer poll in 1998 indicated that one-third of respondents use botanical remedies, and nearly one in five taking prescription medications also used herbs, high-dose dietary supplements or both. An estimated 15 million adults are at risk for potential adverse interactions involving prescription medications and herbs or vitamin supplements, yet most practicing physicians have little knowledge of herbal remedies or their effects. Herbal products are marketed without the proof of efficacy and safety that the Food and Drug Administration (FDA) requires of drugs. The Dietary Supplement and Health Education Act of 1994 allocates responsibility to manufacturers for ensuring safety and efficacy with no specific requirements to submit documentation. Manufacturers may state a product's physiologic effects but may not make claims for the treatment or cure of specific diseases. Consumers and practitioners have little information about product safety, contraindications, interactions or effectiveness and are reliant on manufacturers to provide accurate labeling. Recently, the growing number of foods with herbs has raised concerns at the FDA, which requires evidence that food additives are safe. Considering that the growing appeal of herbal remedies is likely to continue, physicians, particularly cardiologists, must become familiar with the available cardiovascular information on herbs. This review highlights the existing data on the efficacy, adverse effects and interactions for herbal therapies that impact on the cardiovascular system.

Dietary supplement safety information in magazines popular among older readers

Dietary supplements are extensively used in the United States, especially by people age 50 and over. Surveys have shown that magazines and other news media are an important source of information about nutrition and dietary supplements for the American public. It is uncertain, however, whether magazines provide their readers with adequate information about the safety aspects of supplement use. This report presents an analysis of supplement safety information in articles published during 1994-1998 in 10 major magazines popular among older readers. This time period was chosen to allow the impact of the 1994 Dietary Supplement Health and Education Act (DSHEA) to be assessed. The evaluation included 254 magazine articles. More than two-thirds of the articles did not include comprehensive information about the safety aspects of the dietary supplements that were discussed. Information about safety issues such as maximum safe doses and drug-supplement interactions was often lacking even in otherwise informative and well-researched articles. A total of 2,983 advertisements for more than 130 different types of supplements were published in the magazines surveyed. The number of advertisements per year increased between 1995 and 1998. Supplements of particular interest to older adults (such as antioxidants, calcium, garlic, ginkgo biloba, joint health products, liquid oral supplements, and multivitamins) were among the most frequently advertised products. Although magazines popular among older readers contain extensive information about dietary supplements, these publications cannot be relied upon to provide readers with all of the information that they need in order to use supplements safely.

Selected physical and chemical properties of commercial Hypericum perforatum extracts relevant for formulated product quality and performance

OBJECTIVE

The complex composition-activity relationship of botanicals such as St John's Wort (SJW) presents a major challenge to product development, manufacture, and establishment of appropriate quality and performance standards for the formulated products. As part of a larger study aimed at addressing that challenge, the goals of the present study are to (1) determine and compare the phytochemical profiles of 3 commercial SJW extracts; (2) assess the possible impact of humidity, temperature, and light on their stability; and (3) evaluate several physical properties important to the development of solid dosage forms for these extracts.

METHODS

An adapted analytical method was developed and validated to determine phytochemical profiles and assess their stability. The extract physical properties measured were particle size (Malvern Mastersizer), flow (Carr's compressibility index; minimum orifice diameter), hygroscopicity (method of Callahan et al), and low-pressure compression physics (method of Heda et al).

RESULTS

The phytochemical properties differed greatly among the extracts and were extremely sensitive to changes in storage conditions, with marked instability under conditions of elevated humidity. All extracts exhibited moderate to free-flow properties and were very hygroscopic. Compression properties varied among the extracts and differed from a common use excipient, microcrystalline cellulose.

CONCLUSIONS

Three commercial sources of SJW extracts exhibited different physical and chemical properties. Standardization to 1 or 2 marker compounds does not ensure chemical equivalence nor necessarily equivalent pharmacological activity. Flow and compression properties appear suitable for automatic capsule-filling machines, but hygroscopicity and the moisture sensitivity of the phytochemical profile are concerns.

Analysis of over-the-counter dietary supplements

OBJECTIVE

To determine if steroids containing over-the-counter (OTC) dietary supplements conform to the labeling requirements of the 1994 Dietary Supplement Health and Education Act (DSHEA).

DESIGN

12 brands of OTC supplements containing 8 different steroids were randomly selected for purchase in stores that cater to athletes. There are two androstenediones (4- and 5-androstene-3,17-dione), two androstenediols (4- and 5-androstene-3beta, 17beta-diol), and 4 more are 19-nor cogeners (19-nor-4- and 5-androstene-3,17-dione and 19-nor-4- and 5-androstene-3beta, 17beta-diol).

MAIN OUTCOME MEASURES

12 brands of OTC anabolic-androgenic supplements were analyzed by high-pressure liquid chromatography.

RESULTS

We found that 11 of 12 brands tested did not meet the labeling requirements set out in the 1994 Dietary Supplement Health and Education Act. One brand contained 10 mg of testosterone, a controlled steroid, another contained 77% more than the label stated, and 11 of 12 contained less than the amount stated on the label.

CONCLUSIONS

These mislabeling problems show that the labels of the dietary steroid supplements studied herein cannot be trusted for content and purity information. In addition, many sport organizations prohibit OTC steroids; thus, athletes who use them are at risk for positive urine test results. In this article we provide the details of the analyses, a summary of the steroids by name and structure, and information on the nature of the positive test results. Athletes and their physicians need this information because of the potential medical consequences and positive urine test results.

The prevalence and predictors of the use of alternative medicine in presurgical patients in five California hospitals

We measured the prevalence and predictors of the use of alternative medicine supplements in surgical patients by way of a self-administered questionnaire in consecutive patients > or = 18 yr old awaiting elective noncardiac surgery at five San Francisco Bay Area Hospitals. A total of 2560 patients completed the study survey (60% response rate). Of these patients, 39.2% admitted to using some form of alternative medicine supplements, of which herbal medicine was the most common type (67.6%). Of those who admitted to taking alternative medicine supplements, 44.4% did not consult with their primary physicians, and 56.4% did not inform the anesthesiologists before surgery regarding their use of these products; 53% of the patients ceased the use of these products before surgery. Multivariate logistic regression analysis revealed the following variables to be associated with the preoperative use of herbal medicine: female sex (odds radio [OR] 1.42, confidence interval [CI] 1.17-1.72), age 35-49 yr (OR 1.25, CI 1.02-1.53), higher income levels (OR 1.85, CI 1.50-2.27), Caucasian race (OR 1.34, CI 1.07-1.67), higher level of education (OR 1.35, CI 1.10-1.65), problems with sleep (OR 1.32, CI 1.05-1.66), problems with joints or back (OR 1.27, CI 1.04-1.56), allergies (OR 1.48, CI 1.21-1.82), problems with addiction (OR 1.90, CI 1.25-2.89), and a history of general surgery (OR 1.25, CI 1.03-1.52). In contrast, diabetes mellitus (OR 0.55, CI 0.36-0.86) and the use of antithrombotic medications (OR 0.57, CI 0.38-0.87) were associated with decreased odds of the use of herbal medicines. We concluded that the use of alternative medicine supplements by surgical patients is prevalent. Documentation of the use of these products is critical to determine the potential of drug or anesthetic interactions in the perioperative period.

IMPLICATIONS

The use of alternative medicine supplements by presurgical patients is prevalent. Documentation of the use of these products is critical to determine the potential of drug or anesthetic interactions in the perioperative period.

Effect of American ginseng extract (Panax quinquefolius) on formalin-induced nociception in mice

Twenty-three ICR mice were force fed orally with American ginseng extract, Panax quinquefolius, (Cold FX) for 4 days. Another 20 mice were fed with water as placebo in a similar fashion. Formalin tests which yield typically two phases of pain behavior were done in both groups. Although there was no difference in the first phase between groups, mice treated with Cold FX spent significantly less time in licking and biting of the injured paws in the second phase. The data indicate that American ginseng may have analgesic effect in this chronic pain model.

Drug interactions update: drugs, herbs, and oral anticoagulation

Management of warfarin drug interactions is often complicated by lack of information regarding interactions with new drugs and with herbal medicinals. The pharmaceutical industry has increased both the number and quality of drug interaction studies prior to marketing new agents. Interactions may still occur in patients, however, despite negative pre-marketing studies in healthy volunteers. The clinical significance and intensity of warfarin interactions with prescription drugs (e.g., celecoxib, proton pump inhibitors, and selective serotonin reuptake inhibitors) can often be predicted on the basis of known metabolic characteristics of the drugs and warfarin enantiomers. Drug interactions with herbal medicinals are much more difficult to characterize and predict because of the lack of federal regulations regarding safety, efficacy, and manufacturing standards. Published case reports of interactions between warfarin and even the most widely used herbal medicinals are limited. Practitioners are encouraged to report such interactions through the FDA MedWatch program.