Shunichi Homma, MD
- MM Hatch Professor of Medicine
- Department of Medicine?ardiology
- Columbia University College of Physicians and Surgeons
- Attending Physician
- Department of Medicine?ardiology
- New York Presbyterian Hospital
- Columbia University Medical Center
- New York, New York
This interact in their own right heart attack 1d order triamterene, but which are prevalent in a nomenclature is not meant to imply any preference blood pressure 88 over 60 generic triamterene 75 mg line, it is just number of herbal medicines blood pressure ratio purchase genuine triamterene on line, the most common example of simply a way of being clear about which preparation we are this being the flavonoids pulse pressure 71 cheap 75 mg triamterene amex. Because so many herbs contain a multitude of synthetic coumarins used as anticoagulants blood pressure bottom number 90 discount triamterene 75mg visa. The best information comes from clinical studies significance of some reported cases cannot be accurately carried out on large numbers of patients under scrupulously evaluated due to the variation in the nature of the herb itself controlled conditions; however blood pressure 40 over 70 buy discount triamterene 75mg line, with herbal medicines these and products made from it. What this publicabut there is also the possibility that many herbal medicines tion attempts to do is assess the wealth of data from animal have a generally safe profile and do not interact significantly and in vitro studies, which would not normally be considered with drugs. Although these interactions, but we have attempted to put their results and remarks were made in the context of drug interactions, they recommendations in perspective. These have to be evaluated very carefully before interaction reports associated them. While many publications uncritically use Every care has been taken to correctly identify the herbal theoretical evidence to advise on this issue, it risks the medicine involved in interactions. Obviously the best answer to this problem is for prescriptions, with a total value of $196 million, and, in good and reliable evidence to become available, and for the 2003, German health insurance paid $283 million in reimimportance of reports to be based on the nature of the bursements for prescribed herbal products including ginkgo, evidence that they provide. Some knowledge of not cines,6 and of course the cost at consumer level would be only who, but how and why people are taking herbal very much higher. Trends in alternative medicine use in the United States, 1990-1997: results of a followup national survey. Utilization of complementary and alternative medicine by United States adults: results from the 1999 national health interview survey. However, there is no doubt that the issue of groups people taking herbal and nutritional products at the same (a) Cancer patients time as conventional medicines is significant, and the purpose of this publication is to provide information so Certain groups of patients are known, or thought to have, a that this practice can be carried out as safely as possible. Vitamins and herbal it is logical to assume that in the patient population usage medicines were used by 62. Of these patients only 57% 4 General considerations discussed the use of at least one of these therapies with their 7. Use of nonprescription dietary supplements for weight loss is common healthcare provider. The highest level of use seems to be among 67%), whereas curative patients used herbal remedies much Asians (48. Women aged 18 to It is also apparent that, in the elderly, the use of herbal 34 years used weight-loss supplements the most (16. More worryingly, many adults were longinteractions was assessed in a Medicare population, using a term users and most did not discuss this practice with their retrospective analysis of Cardiovascular Health Study interdoctor. Of 5052 participants, the median age at the beginning of the study was 75 years, 60. From 1994 to 1999 the number using A study of herbal medicine use during perioperative care herbal medicines increased from 6. The authors suggested that most patients are elderly are those concerned with ameliorating degenerative not asked specifically about herbal consumption by their or age-related conditions. The prevalence of complementary/alternative medicine in cancer: each year from 1994 to 1999 for an average of 359 male a systematic review. Trends in complementary/alternative medicine use by breast cancer survivors: comparing survey data from 1998 and 2005. Complementary/ (non-vitamin, non-mineral) supplement followed by ginkgo, alternative medicine use in a comprehensive cancer center and the implications for chondroitin and garlic. Prevalence of complementary and alternative medicine use in evening primrose oil, flaxseed oil, chondroitin, prasterone cancer patients during treatment. The use of complementary/alternative (dehydroepiandrosterone), garlic, ginkgo, glucosamine, medicine bycancer patientsin aNew Zealand regional cancertreatment centre. Herbal use among cancer patients during alpha-lipoic acid, ginkgo and grapeseed extract showed a palliative or curative chemotherapy treatment in Norway. Herbal medicines were taken with conventional paediatric emergency department in Toronto, Canada. Conmedicines by 80% of respondents and 87% of these did not ventional and herbal medicines or supplements were being tell their healthcare provider. In the rural community 92% used concurrently in 20% of the patients and 15% were took herbal medicines with conventional medicines, compared with 70% of the urban community. Potential interactions between complementary/alternative products and conventional medicines in a Medicare Studies usually show that herbal medicine use is higher in population. Herbal therapy use in a pediatric take more supplements; women tend to be the primary carers emergency department population: expect the unexpected. Potential interactions of drug-natural everyday remedies used in the home; and women take more health products and natural health products-natural health products among children. Nonvitamin, nonmineral supplement use over a 12-month period by adult members of a large health maintenance suggested that women are at least twice as likely to take organization. Complementary/ alternative medicine use in a comprehensive cancer center and the implications for oncology. Prevalence of complementary and alternative medicine use in cancer patients during treatment. Use of nonprescription dietary supplements for weight loss is take herbal and nutritional supplements. Recent suggest that usage is similar across most education levels, trends in use of herbal and other natural products. Complementary and alternative generally high levels of education, it is of great concern that medicines versus prescription drugs: perceptions of emergency department patients. High use of complementary therapies in a New South knowledge about the products that they are consuming. The practice of polypharmacy involving herbal and prescription medicines in the treatment of diabetes product, 88% had at least 1 year of college education. However, 77% of the participants in the study did not believe, or were uncertain, if herbal medicines had any adverse effects; only 27% could name a potential adverse Attitudes to the use of herbal medicines effect and 66% were unsure, or thought that herbal People who use herbal medicines and nutritional supplemedicines did not interact with other medications. This serious under-reporting by patients may probably be this definition is obviously as true for conventional because they consider herbal medicines safe, even if taken at medicines as it is for herbal medicines. A potential example of this is the experimental cines can cause adverse effects and the tendency to report increase in toxicity seen when amikacin is given with their usage to the family physician. A the disapproval of the physician and, since they consider the reduction in efficacy due to an interaction can sometimes medicines to be safe, see no reason for inviting problems by be just as harmful as an increase. Physicians usually underestimate As with any publication detailing the adverse effects of the extent to which their patients use these remedies and drug use it would be very easy to conclude after browsing often do not ask for information from the patient. Worse still, through this publication that it is extremely risky to treat in one survey 51% of doctors believed that herbal medicines patients with conventional drugs and herbal medicines, but have no or only mild adverse effects and 75% admitted that this would be an over-reaction. Many One of the reasons that it is often difficult to detect an pharmacists (like many doctors) do not feel that they have interaction is that, as already mentioned, patient variability is enough basic knowledge themselves, or information readily considerable. Herbal therapy use in a pediatric Variability of herbal medicines emergency department population: expect the unexpected. J Am Diet Assoc (2005) 105, includes evaluating their possible interactions with drugs. Use of nonprescription dietary supplements for weight loss is and, even when standardised to one of more of their common among Americans. The use of complementary/alternative constituents, there can still be differences in the numerous medicine by cancer patients in a New Zealand regional cancer treatment centre. Consumption of herbal remedies and dietary supplements amongst patients hospitalized in medical wards. Herbal use among cancer patients during palliative or curative chemotherapy treatment in Norway. The practice of polypharmacy involving herbal and prescription medicines in the treatment of diabetes Echinacea purpurea extract mildly inhibited the cytochrome mellitus, hypertension and gastrointestinal disorders in Jamaica. However, when this and a medicines versus prescription drugs: perceptions of emergency department patients. For example, a mixture General considerations 7 of dietary soya isoflavones containing genistein was found to dealt with here as though they occur in isolation. These brief examples start to illustrate that the mechanAlthough all these mechanisms are undoubtedly relevant to isms of drug interactions with herbal medicines bear a great interactions with herbal medicines, this discussion will relationship to those of conventional drugs. Although a few drugs are cleared from the body simply by being excreted unchanged in the urine, most are chemically Mechanisms of drug interactions altered within the body to less lipid-soluble compounds, Some drugs interact together in totally unique ways, but, as which are more easily excreted by the kidneys. If this were the many examples in this publication amply illustrate, there not so, many drugs would persist in the body and continue to are certain mechanisms of interaction that are encountered exert their effects for a long time. Some of these common mechanisms are goes on in the serum, the kidneys, the skin and the intestines, discussed here in greater detail than space will allow in the but the greatest proportion is carried out by enzymes that are individual monographs, so that only the briefest reference found in the liver, mainly cytochrome P450. This discussion is restricted to those P450 is not a single entity, but is in fact a very large family mechanisms that have been extensively investigated with of related isoenzymes, about 30 of which have been found in herbal medicines. Some of these isoenzymes concert, although for clarity most of the mechanisms are are also found in the gut wall. Note inhibition also Lidocaine oral, Propafenone, Quinidine) greatly between products) reported) Ginkgo (in vitro studies supported by clinical data, Anticholinesterases, centrally acting Bitter orange (juice known to have clinically but any effect modest. Note induction also reported) Azoles (Itraconazole, Voriconazole) Feverfew (in vitro evidence only) Benzodiazepines and related drugs Garlic (effects in vitro are probably not clinically (Alprazolam, Triazolam, Midazolam; Buspirone, relevant) Zolpidem, Zopiclone) Calcium-channel blockers (Diltiazem, Ginkgo (in vitro studies supported by clinical data, Felodipine, Lercanidipine) but any effect modest. General considerations 9 (a) Enzyme induction therapeutic range the interaction may not be clinically important. Some herbal medicines can have a marked effect on the extent of first-pass metabolism of conventional drugs by (c) Predicting interactions involving cytochrome P450 inducing the cytochrome P450 isoenzymes in the gut wall or in the liver. A number of herbs have been studied specifically It is interesting to know which particular isoenzyme is for their effects on these isoenzymes. Those that appear to responsible for the metabolism of drugs because by doing in cause clinically relevant induction of specific isoenzymes are vitro tests with human liver enzymes it is often possible to grouped in a series of tables, along with the conventional explain why and how some drugs interact. What is very much more important than retrospectively the extent of the enzyme induction depends on the herbal finding out why drugs and herbal medicines interact is the medicine, its dosage, and even the specific extract used (see knowledge that such in vitro tests can provide about Variability of herbal medicines, page 6). However, at present such prediction is not always simply by raising the dosage of the drug affected, but this accurate because all of the many variables that can come into requires good monitoring, and there are obvious hazards if play are not known (such as how much of the enzyme is the inducing drug is eventually stopped without rememberavailable, the concentration of the drug at the site of ing to reduce the dosage again. The raised drug dosage may metabolism and the affinity of the drug for the enzyme). With so many factors possibly impinging on the outcome of giving two or more drugs together, it is (b) Enzyme inhibition very easy to lose sight of one of the factors (or not even More common than enzyme induction is the inhibition of know about it) so that the sum of 2 plus 2 may not turn out to enzymes. Unlike enzyme induction, which Drug transporter proteins may take several days or even weeks to develop fully, Drugs and endogenous substances are known to cross enzyme inhibition can occur within 2 to 3 days, resulting in biological membranes, not just by passive diffusion, but also the rapid development of toxicity.
In foods blood pressure 9860 quality 75 mg triamterene, aniseed is used as a spice and actions of natural coumarin-containing herbs arrhythmia chest pain cheap triamterene online master card. Effects of the naturally occurring alkenylbenzenes eugenol and trans-anethole on drug-metabolizing enzymes in the rat Pharmacokinetics liver blood pressure medication zestril purchase triamterene now. Aniseed oil increases glucose Studies in rats suggested that trans-anethole did not alter absorption and reduces urine output in the rat hypertension erectile dysfunction generic 75 mg triamterene visa. Importance and management Aniseed + Oestrogens these experimental studies provide limited evidence of the possible oestrogenic activity of aniseed hypertension va disability 75 mg triamterene mastercard. Because of the nature of the evidence blood pressure vitamins supplements discount triamterene online visa, applying these results in a clinical setting is extremely the interaction between aniseed and oestrogens is based on difficult and, until more is known, it would be unwise to advise experimental evidence only. Estrogenic activity of isolated compounds and essential oils of Pimpinella species No interactions found. A risto lo chia Aristolochia species (Aristolochiaceae) Synonym(s) and related species Constituents the nomenclature of these and related plants has given rise All species contain a range of toxic aristolochic acids and to confusion with other, non-toxic plants. Use and indications Birthwort has been used as a collective name for the Aristolochia species, but it has also been used for one of the Aristolochic acids and aristolactams are nephrotoxic, carspecies, Aristolochia clematitis L. Numerous deaths have resulted Tong has been used to refer to some of the Aristolochia from aristolochic acid nephropathy and associated urothelial species. All plants of the family most common species used in herbal medicines, but many Aristolochiaceae are banned in Europe and elsewhere, and others are also used. Constituents the main constituents of the bark are triterpenoid saponins including arjunic acid, arjunolic acid, arjungenin and arjunglycosides, and high levels of flavonoids, such as arjunone, arjunolone, luteolin and quercetin. Polyphenols, Interactions overview particularly gallic acid, ellagic acid and oligomeric proanArjuna appears to have some effects on cardiovascular thocyanidins, are also present. Use and indications For information on the interactions of individual flavoArjuna is widely used in Ayurvedic medicine for the noids present in arjuna, see under flavonoids, page 186. Clinical evidence the effect of arjuna on angina pectoris, congestive heart failure, left ventricular mass and hyperlipidaemia has been investigated in a number of small studies in patients with various cardiovascular Arjuna + Herbal medicines disorders (these have been the subject of a review). This the interaction between arjuna and thyroid or antithyroid improvement was maintained over long-term evaluation in an open drugs is based on experimental evidence only. The only notable adverse effect was a rise in serum potassium (from Clinical evidence about 3. Giving levothyroxine increased the level of thyroid hormones, increased the heart to body weight ratio, as well as Experimental evidence increasing cardiac and hepatic lipid peroxidation. When the plant Numerous pharmacological studies in animals (which have been the extract was given simultaneously, the level of thyroid hormones, and subject of a review) have shown that arjuna has cardiotonic activity,1 also the cardiac lipid peroxidation, were decreased. These effects positive or negative inotropic effects (depending on the type of were comparable to those of a standard antithyroid drug, propylextract), causes bradycardia, and has hypotensive effects, antioxidant thiouracil. When arjuna bark extract was given to euthyroid activity and lipid-lowering effects. Arjuna is purported to have inotropic and hypotensive effects, as well as lipid-lowering effects. These effects might be Mechanism additive with those of conventional cardiovascular drugs. Although the evidence is experimental, until more is known, it might be prudent to avoid the use of arjuna in patients requiring Importance and management levothyroxine (or any thyroid hormone), because of the possibility Arjuna has been used in small numbers of patients taking a variety of of reduced efficacy. If patients want to try arjuna, their thyroid conventional cardiovascular drugs, apparently without particular function should be monitored more frequently. Efficacy of Terminalia arjuna and hepatic lipid peroxidation was increased, the authors suggest in chronic stable angina: a double-blind, placebo-controlled, crossover study comparing that high amounts of this plant extract should not be consumed, as Terminalia arjuna with isosorbide mononitrate. Salutary effect of Terminalia Arjuna in patients hepatotoxicity as well as hypothyroidism may occur. Cardio-protective role of Terminalia arjuna bark effects of Terminalia arjuna tree-bark powder: a randomised placebo-controlled trial. Artichoke flowers are also used as food Pharmacopoeias and artichoke extracts are used as flavouring agents. For information on Artichoke leaf is usually standardised to the caffeoylquinic the pharmacokinetics of individual flavonoids present in acid derivative, chlorogenic acid. For information on the Use and indications interactions of individual flavonoids present in artichoke, see the leaf extract has been traditionally used for liver and under flavonoids, page 186. Asafoetida is used for its carminative, antispasmodic and Asafoetida is obtained from various Ferula species, the expectorant properties in chronic bronchitis, pertussis, and main sources being Ferula asafoetida L. Studies in rats fed with distinct from asafoetida and will not be dealt with in this asafoetida suggest that, it did not stimulate levels of monograph. The sesquiterpene dienones, fetidones A asafoetida may interact with anticoagulants, the available and B, samarcandin and galbanic acid are also present. In a study in rats, asafoetida gum extract significantly reduced mean arterial blood pressure. Importance and management Because of the nature of the evidence, applying these results in a clinical setting is extremely difficult and, until more is known, it Mechanism would be unwise to advise anything other than general caution. Antispasmodic and hypotensive effects of natural coumarins, but these are not thought to have the Ferula asafoetida gum extract. For more information, see Natural coumarins + Warfarin and related drugs, page 301. There appears to be no evidence to support the prediction of an interaction between warfarin and asafoetida, and some data do suggest that an interaction is unlikely to occur. No special precautions therefore appear to be needed if patients Asafoetida + Herbal medicines taking warfarin or related anticoagulants also wish to take asafoetida. The extract Interactions overview also contains phytosterols and alkaloids such as ashwagandAlthough ashwagandha may have blood-glucose-lowering hine, ashwagandhinine, anahygrine, withasomnine, witheffects, these seem to be mild, and would not generally be aninine and others. Ashwagandha may affect the reliability of Use and indications digoxin assays, and interfere with the control of hypoand Use of ashwagandha root originates in Ayurvedic medicine, hyperthyroidism. A Clinical evidence Limited evidence suggests that ashwagandha has blood-glucoseNo interactions found. Experimental evidence Clinical evidence (a) Digoxin In 6 subjects with mild type 2 diabetes, giving powdered root of In a study, mice fed two ashwagandha extracts (in quantities that ashwagandha 1g three times daily after meals for 30days reduced equated to human doses) developed apparent serum digoxin levels of blood-glucose levels by 12% (from 11. A further ashwagandha extract did subjects continued treatment with glibenclamide. This study is detected for any of the three extracts using a monoclonal antibodydifficult to interpret, because there was no placebo group. Importance and management (b) Other drugs the limited evidence suggests that ashwagandha might have bloodIn in vitro tests, ashwagandha extract had no effect on immunoglucose-lowering effects. Until further information is available, if a assays (Roche) for carbamazepine, gentamicin, paracetamol, phepatient taking antidiabetic drugs wants to take ashwagandha it may nytoin, phenobarbital, procainamide, salicylate, theophylline, be prudent to discuss these potential additive effects, and advise an tobramycin or valproic acid. However, bear in mind that, although ashwagandha has Mechanism been used for a wide number of complaints, it does not appear to be Some withanolides (major constituents of ashwagandha) are strucused for diabetes, suggesting that any effects are mild, and probably turally similar to digoxin, and might therefore interfere with the not clinically relevant. Hypoglycemic,diuretic and hypocholesterolemic effectof winter cherry (Withania somnifera, Dunal) root. Importance and management the animal data available suggest that, in patients taking digoxin and ashwagandha, digoxin levels might be spuriously elevated when assayed using a fluorescence polarisation immunoassay. Effect of Indian Ayurvedic medicine ashwagandha on measurement of serum digoxin and 11 commonly monitored drugs using immunoassays: study of protein binding and interaction with Digibind. Interference of Asian, American, and Indian (Ashwagandha) ginsengs in serum digoxin measurements by a fluorescence tests below. Effect of Brazilian, Indian, Siberian, Asian, and North American ginseng on serum digoxin measurement by immunoassays and binding of digoxin-like immunoreactive components of ginseng with Fab fragment of antidigoxin antibody (Digibind). Ashwagandha + Thyroid and Antithyroid Ashwagandha + Herbal medicines drugs No interactions found. Limited evidence suggests that ashwagandha increases thyroid hormone levels and therefore interferes with the control of hypoand hyperthyroidism. Clinical evidence Ashwagandha + Laboratory tests A 32-year-old healthy woman developed clinical symptoms of thyrotoxicosis, and was found to have elevated levels of thyroid Digoxin levels might be spuriously elevated when assayed using hormones when she increased the dose of capsules containing a fluorescence polarisation immunoassay in patients taking ashwagandha herbal extract that she had been taking for chronic ashwagandha. The symptoms and raised thyroid hormone levels resolved assays for carbamazepine, gentamicin, paracetamol, phenytoin, on stopping the product. Furthermore, on the basis of this evidence, ashwagandha may be expected to antagonise the effects of hormones, triiodothyronine and thyroxine, by 18% and 111%, respectively. In both cases it may be prudent to consider monitoring thyroid function tests if symptoms of Mechanism hypoor hyperthyroidism begin to emerge. Changes in thyroid hormone concentrations after administration of ashwagandha root extract to adult male mice. For Constituents information on the pharmacokinetics of individual flavoAsparagus contains saponins called asparagosides, steroidal noids present in asparagus, see flavonoids, page 186. Asparagus is also a source No interactions with asparagus found; however, note that of folic acid, vitamin K1 and other vitamins. For the root and green parts of asparagus have been used as a information on the interactions of individual flavonoids diuretic, laxative, cardiac tonic and sedative. Evidence, mechanism, importance and management Asparagus1 contains a moderate amount of vitamin K1, which reduces the effect of coumarin and indanedione anticoagulants, which are vitamin K antagonists. Patients taking these anticoagulants are advised to maintain a regular amount of vitamin Asparagus + Herbal medicines K from the diet. A stragalus Astragalus membranaceus Bunge (Fabaceae) Synonym(s) and related species a variety of other conditions such as cardiovascular disease Huang qi. Not to be confused with the pharmaceutical excipient, Pharmacokinetics tragacanth (Astragalus gummifer). These data, Constituents and data from in vitro studies, demonstrate that the the key constituents are triterpene saponins, which include isoflavones in astragalus could be absorbed and metabolised by the intestine. Isoflavones are also present, mainly glycosides of calycosin and formononetin, with astrapterocarpan, kumataInteractions overview kenin and numerous hydroxyl and methoxyl derivatives of Astragalus appears to alter the immune response, but the pterocarpan and isoflavan, and a series of polysaccharides effect this has on treatment with interleukins, interferons, known as astragaloglucans. For information about the interactions of individual isoflavones present in astragalus, see under Astragalus is traditionally used in Chinese medicine as a isoflavones, page 258. Absorption and metabolism of Astragali radix decoction: in silico, in vitro, and a case study in vivo. Forty patients receiving the herbs had a significantly greater decline in viral load than 20 patients receiving placebo. No serious adverse experimental data suggest that astragalus may diminish the events were reported in either of the two groups. Clinical evidence Experimental evidence In one small randomised clinical study in Chinese patients with No relevant data found. This zidovudine or zalcitabine no major adverse interaction would be suggests that astragalus reversed the immunosuppressant effect of 2 expected, and efficacy should not be compromised. Conversely, in a similar study, astragalus herbal product used contained three different herbs, a beneficial appeared to prolong the life of bone marrow cells transplanted effect for a combination of astragalus and antiretroviral drugs is still into mice pretreated with cyclophosphamide, as well as promoting 3 far from proven. Furthermore, in another study in rats, pretreatment with astragalus and Ligustrum lucidium (glossy privet) 1. Mechanism Unknown, although many in vitro studies have shown that astragalus has immunostimulating effects. Importance and management Astragalus + Cytokines the preclinical and preliminary clinical evidence suggests that astragalus might have immunomodulating activity and effects on Preliminary evidence suggests that astragalus may be beneficial blood cell production, and might therefore have beneficial effects if when given with interferon-alfa or interleukin-2. Some have interpreted the preclinical data showing increased rejection of a xenograft2 as suggesting that astragalus might decrease the effects of immunosuppressive therapy, Clinical evidence and recommend caution with the combination. Local application especially in those given immunosuppressant treatment for lifeof astragalus extract plus interferon was similar in efficacy to twice threatening conditions. Experimental evidence Reversal of cyclophosphamide-induced immune suppression by administration of Various in vitro studies have found that astragalus extract potentiates fractionated Astragalus membranaceus in vivo. Mechanisms by which Astragalus membranaceus injection the cytotoxic effect of interleukin-2 against renal cell carcinoma by regulates hematopoiesis in myelosuppressed mice. Extract of astragalus membranaceus and ligustrum lucidum does not prevent cyclophosphamide-induced myelosuppression. Mechanism Unknown, although many in vitro studies have found that astragalus has immunostimulating effects. Astragalus + Antiretrovirals Importance and management the above preliminary evidence suggests that astragalus might have immunomodulating activity and might therefore be beneficial when Long-term astragalus use does not appear to reduce the efficacy given with interferons or interleukin-2. Qian Z-W, Mao S-J, Cai X-C, Zhang X-L, Gao F-X, Lu M-F, Shao X-S, Li Y-Y, Yang Clinical evidence X-K, Zhuo Y, Shi L-Y, Duan S-M, Hou Y-D. Viral etiology of chronic cervicitis and its therapeutic response to a recombinant interferon. Phytochemicals potentiate interleukin2generated lymphokine-activated killer cell cytotoxicity against murine renal cell Artemisia capillaris Thunb. Avens has been used as an astringent in diarrhoea, a haemostatic and an anti-inflammatory. Constituents the main actives found in the whole plant are the tannins, Pharmacokinetics gallotannins and ellagitannins, including sanguiin H6, No relevant pharmacokinetic data found. Other polyphenols include gallic, caffeic and chlorogenic acids, gein (a phenolic glycoside of eugenol), flavonoids and Interactions overview volatile oil containing eugenol.
Weight loss improves 319 hypertension nutrition cheap 75 mg triamterene amex,320 asthma control heart attack cafe menu quality 75mg triamterene, lung function and health status blood pressure healthy range purchase 75 mg triamterene free shipping, and reduces medication needs in obese patients with asthma hypertension jokes generic 75 mg triamterene mastercard. In one study of obese patients with asthma blood pressure medication name brands order triamterene on line, a weight loss program plus twice-weekly aerobic and strength exercises improved symptom control heart attack photo order triamterene 75 mg with amex, lung function and inflammatory markers compared with weight loss alone (Evidence B). Breathing exercises A systematic review of studies of breathing and/or relaxation exercises for asthma and/or dysfunctional breathing, including the Buteyko method and the Papworth method, reported improvements in symptoms, quality of life and/or 325 psychological measures, but not in physiological outcomes or risk of exacerbations. A subsequent large pragmatic study of breathing training in patients with impaired asthma-related quality of life showed significant but small improvements in quality of life, but no difference in asthma symptom control or risk of exacerbations. In order for studies of non-pharmacological strategies such as breathing exercises to be considered high quality, control groups should be appropriately matched for level of contact with health professionals and for asthma education. This suggests that perceived improvement with breathing exercises may be largely due to factors such as relaxation, voluntary reduction in use of rescue medication, or engagement of the patient in their care. Avoidance of indoor air pollution In addition to passive and active smoking, other major indoor air pollutants that are known to impact on respiratory health include nitric oxide, nitrogen oxides, carbon monoxide, carbon dioxide, sulfur dioxide, formaldehyde, and 328 biologicals (endotoxin). Sources include cooking and heating devices, particularly if they are not externally flued (vented). Installation of non-polluting, more effective heating (heat pump, wood pellet burner, flued gas) in the homes of children with asthma does not significantly improve lung function but significantly reduces symptoms of asthma, days off 329 school, healthcare utilization, and pharmacist visits. Strategies for dealing with emotional stress 330 Emotional stress may lead to asthma exacerbations in children and adults. Hyperventilation associated with laughing, 331,332 333,334 crying, anger, or fear can cause airway narrowing. However, it is important to note that asthma is not primarily a psychosomatic disorder. Avoidance of outdoor allergens For patients sensitized to outdoor allergens such as pollens and molds, these are impossible to avoid completely. Avoidance of outdoor air pollution Meta-analysis of epidemiological studies showed a significant association between air pollutants such as ozone, nitrogen oxides, acidic aerosols, and particulate matter and symptoms or exacerbations of asthma, including emergency 93 335 room visits and hospitalizations. Certain weather and atmospheric conditions like thunderstorms may trigger asthma exacerbations by a variety of mechanisms, including dust and pollution, by increasing the level of respirable allergens, and causing changes in temperature and/or humidity. Reduction of outdoor air pollutants usually requires national or local policy changes. For example, short-term traffic restrictions imposed in Beijing during the Olympics reduced 336 pollution and was associated with a significant fall in asthma outpatient visits. Food chemicals, either naturally occurring or added during processing, may also trigger asthma symptoms especially when asthma is poorly controlled. Sulfites (common food and drug preservatives found in such foods as processed 337 potatoes, shrimp, dried fruits, beer, and wine) have often been implicated in causing severe asthma exacerbations. However, the likelihood of a reaction is dependent on the nature of the food, the level and form of residual sulfite, the 337 sensitivity of the patient, and the mechanism of the sulfite-induced reaction. There is little evidence to support any general role for other dietary substances including benzoate, the yellow dye, tartrazine, and monosodium glutamate in worsening asthma. This list is based on consensus, and indications for referral may vary, as there is substantial variation between health systems in the delivery of the majority of asthma care: by primary health care providers in some countries, and by specialists in others. Before referral, depending on the clinical context, identify and treat modifiable risk factors (Box 2-2, p. This is most effectively achieved through a partnership between the patient and their health care providers. In developing, customizing and evaluating self-management interventions for different cultures, sociocultural factors 338 should be taken into account. However, using an inhaler is a skill that must be learnt and maintained in order for the medication to be delivered effectively. Unfortunately, many health care providers are 339 unable to correctly demonstrate how to use the inhalers they prescribe. After training, inhaler technique falls off with time, so checking and re-training must be repeated regularly. This is particularly important for patients with poor symptom control or a history of exacerbations. Pharmacists and nurses can provide highly effective 340,345,346 inhaler skills training. There is increasing awareness of the importance of poor adherence in chronic diseases, and of the potential to 348 develop interventions to improve adherence. Approximately 50% of adults and children on long-term therapy for 138 asthma fail to take medications as directed at least part of the time. In clinical practice, poor adherence may be identified by an empathic question that acknowledges the likelihood of incomplete adherence and encourages an open discussion. Checking the date of the last prescription or the date on the inhaler may assist in identifying poor adherence. In some health systems, pharmacists can assist in identifying poorly adherent patients by monitoring dispensing records. In clinical studies, poor adherence may be identified by short adherence behavior questionnaires, or from dispensing 349 350 records; dose or pill counting; electronic inhaler monitoring; and drug assay such as for prednisolone. Specific drug and non-drug factors involved in poor adherence are 351 listed in Box 3-13, p. Issues such as ethnicity, health 352,353 148 literacy, and numeracy are often overlooked. Treating to control symptoms and minimize future risk Interventions that improve adherence in asthma Few adherence interventions have been studied comprehensively in asthma. Further studies are needed of adherence strategies that are feasible for implementation in primary care. All individuals will require certain core information and skills but most education must be personalized and provided in a number of steps. For young children, the focus of asthma education will be on the parent/carer, but young children can be taught simple asthma management skills. Adolescents may have unique difficulties regarding adherence, and peer support group 366 education may help in addition to education provided by the health care provider. The key features and components of an asthma education program are provided in Box 3-14. Social and psychological support may also be required to maintain positive behavioral change, and skills are required for effective medication delivery. At the initial consultation, 369,370 verbal information should be supplemented with written or pictorial information about asthma and its treatment. Patients and their families should be encouraged to make a note of any questions that arise from reading this information or as a result of the consultation, and should be given time to address these during the next consultation. Asthma education and training can be delivered effectively by a range of health care providers including pharmacists 345,346,371 and nurses (Evidence A). Trained lay health educators (also known as community health workers) can deliver discrete areas of respiratory care such as asthma self-management education, with, in one study, increased symptom372 free days and reduced healthcare utilization compared with usual care and in another, comparable outcomes to those 373 achieved by practice nurses based in primary care (Evidence B). These findings suggest the need for additional studies to assess applicability in other settings and populations. With patient-directed self-management patients make changes in accordance with a prior written action plan without needing to first contact their health care provider. With doctordirected self-management, patients still have a written action plan, but refer most major treatment decisions to their physician at the time of a planned or unplanned consultation. Benefits include a one-third to two-thirds reduction in asthma-related hospitalizations, emergency department visits and unscheduled doctor or clinic visits, missed work/school days, and 140 nocturnal wakening. It has been estimated that the implementation of a self-management program in 20 patients prevents one hospitalization, and successful completion of such a program by 8 patients prevents one emergency 140,375 department visit. Less intensive interventions that involve self-management education but not a written action plan 376 368 are less effective, and information alone is ineffective. Self-monitoring of symptoms and/or peak flow Patients should be trained to keep track of their symptoms (with or without a diary), and notice and take action if necessary when symptoms start to worsen. Based on existing studies, the main benefit is likely to be for more severe asthma (Evidence B). Treating to control symptoms and minimize future risk 73 the efficacy of self-management education is similar regardless of whether patients self-adjust their medications 376 according to an individual written plan or whether the medication adjustments are made by a doctor (Evidence A). Thus patients who are unable to undertake guided self-management can still achieve benefit from a structured program of regular medical review. Examples of written asthma action plan templates, including for patients with low literacy, can be found on several websites. Health care providers should become familiar with action plans that are relevant to their local health care system, treatment options, and cultural and literacy context. Details of the specific treatment adjustments that can be recommended for written asthma action plans are described in the next chapter (Box 4-2, p. Regular review by a health care provider the third component of effective asthma self-management education is regular review by a health care provider. Follow-up by tele-healthcare is unlikely to benefit in mild asthma but may be of benefit in those 377 with severe disease at risk of hospital admission. Comorbidities may contribute to respiratory symptoms and impaired quality of life, and some contribute to poor asthma control. Active management of comorbidities is recommended because they may contribute to symptom burden, 384 impair quality of life, and lead to medication interactions. Obesity Clinical features 315-318 Asthma is more difficult to control in obese patients. In addition, lack of fitness and reduction in lung volume due to abdominal fat may contribute to dyspnea. Because of other potential contributors to dyspnea and wheeze in obese patients, it is important to confirm the diagnosis of asthma with objective measurement of variable 48 airflow limitation (Box 1-2, p. Asthma is more common in obese than non-obese patients, but both overand under29,49 diagnosis of asthma occur in obesity. Weight reduction should be included in the treatment plan for obese patients with asthma 323 (Evidence B). Increased exercise alone appears to be insufficient (Evidence B); however a weight loss program plus twice-weekly aerobic and strength exercises improved symptom control, lung function and inflammatory markers 324 compared with weight loss alone (Evidence B). Weight loss improves asthma control, lung function, health status and 319,320 reduces medication needs in obese patients, but the quality of some studies is poor. Asymptomatic gastroesophageal reflux is 384 not a likely cause of poorly controlled asthma. For patients with asthma and symptoms suggestive of reflux, an empirical trial of anti-reflux medication, such as a proton pump inhibitor or motility agent, may be considered, as in the general population. If the symptoms do not resolve, specific investigations such as 24-hour pH monitoring or endoscopy may be considered. In general, benefits of proton pump inhibitors in asthma 387 appear to be limited to patients with both symptomatic reflux and night-time respiratory symptoms. Other treatment options include motility agents, lifestyle changes and fundoplication. In summary, symptomatic reflux should be treated, but patients with poorly controlled asthma should not be treated with anti-reflux therapy unless they also have symptomatic reflux (Evidence A). Anxiety and depression Clinical features 390 Psychiatric disorders, particularly depressive and anxiety disorders, are more prevalent among people with asthma.
More recently blood pressure ranges by age and gender order triamterene 75mg fast delivery, he was also located in front of the rectum and underdiagnosed with prostate cancer heart attack right arm triamterene 75 mg with mastercard. Its function is to Conclusion He was currently following up with produce seminal fluid pulse pressure youtube buy cheap triamterene 75 mg online, which helps protect hematology/oncology for his newly diagand nourish sperm cells blood pressure 50 over 0 purchase triamterene 75 mg without a prescription. I do believe that we can help individuals to understand the nature of their condition heart attack vol 1 pt 14 75mg triamterene with visa, as well as show compassion and help them live the rest of their lives as comfortably as possible blood pressure medication increased heart rate purchase triamterene online from canada. The Lower Urinary Tract and Male Genital System, Pathologic Basis of Disease, Volume 7. Objectives: To evaluate the clinical efficacy of a novel product for the treatment of inflammatory acne vulgaris. Methods: A study was performed with Bioscreen on 10 patients over the course of three months. Patients were evaluated weekly for the first month then biweekly for the remaining two months. Subjects were treated by both topical and oral routes, with adjustments in the dosing regimen based on clinical results. Results: There were 10 patients in the study, all of which completed the study and demonstrated at least a mild-moderate reduction in inflammatory acne lesions. There were no side effects reported, and all patients continue to use Bioscreen to date. Conclusions: Bioscreen is safe, well-tolerated, and effective for treatment of inflammatory acne. Further studies with more patients will be necessary to substantiate the current findings. Introduction proliferation and alteration of keratinocyte neutrophils subsequently penetrate and desquamation is considered the first step weaken the wall of the follicle. This results in barrier eventually ruptures and allows more tory, affecting nearly all ages and races. It has the potential to leave this hyperproliferation has not been clearly in an inflammatory foreign body reaction permanent scars on the skin of those established, but interleukins, changes in which clinically presents itself as acne. The most statistical accuracy is compromised by a adrenarche at an average of eight years of common of which include antibiotics, lack of criteria uniformity in describing the age. Almost 90% circulation are taken up locally into the cells decrease the inflammation and microorof this number is composed of individuals of the pilosebaceous unit where they are ganisms that cause acne. This metabolism stimulates the Leeds Acne Grading scale estimate that sebum production locally and also results acne treatment, long term antibiotic use greater than 90% of males and 80% of in increases in the number of sebaceous has been documented to cause resistance females will be affected by acne by 21 years lobules and the size of the follicle. Higher sebum secretion over the age of 25 report premenstrual rates are associated with higher levels of P. Acne is a multifactorial disease of sebaceous regions and is the most prevalent including teratogenicity. They work by surrounding Spironolactone, which has anti-androgen which include pustules, papules and cysts. Spironolactone binds the fied as essential to the development of acne are destructive to the natural follicle barrier. It have stigmas that could prevent some activity of Propionibacterium acnes and creates this immune response by recruiting patients from employing them in acne inflammation. Similar to many acne patients, she has had periods of clearing, only followed up with bouts of flaring. She was placed on Bioscreen, with one pill by mouth daily and application of the topical product three times a day. The patient was given informed consent regarding this product, including education on the mechanism of action and expectations. Physical examination at baseline revealed many erythemaFigure 1: At baseline, scattered across Figure 4: At baseline, there are tous papules and pustules, with some cyst the face are erythematous papules and numerous erythematous papules and formation on her forehead and periorally. Scattered open and closed comedones were and closed comedones are also noted also present on exam. Even as early as one week ure 2) there was a dramatic decrease in both the number and size of inflammatory lesions. She continued to have improvement and clearing over time, mostly in regard to acne that was inflammatory in nature. At the end of the study (see Figure 3), she had minimal inflammatory lesions and only areas of post-inflammatory hyperpigmentation. Throughout the study, comedonal Figure 2: As early as one week there Figure 5: One week into treatment activity was decreased, although slight. She was a marked reduction in cystic there is a remarkable reduction in was very satisfied with the results and did activity and improvement in the papuoverall erythematous lesion count. This patient continues to use Bioscreen both topically and orally as maintenance therapy to date. The study parameters were discussed in detail with the patient, informed consent was provided, and he was started on Bioscreen. He was instructed to apply the Figure 3: At 3 months, there is Figure 6: Continued improvement at the topical solution three times daily and take continued improvement with near 3-month period. A baseline photoclearing of erythematous papules, graph was taken (see Figure 4). Each patient was open and closed comedones involving the arose from the problems with current treated by both topical and oral routes, cheeks, forehead, nose, chin and jawline. We introduce the agent two case reports, emphasizing the safety, taken at each visit (see Figures 5, 6). There Bioscreen to the world of acne treatment efficacy, and tolerability of this new and was marked improvement in the inflamregimens. He continued to have marked She had been an established patient of ours reduction in inflammatory lesion count Methods for over 2 years. Numerous acne regimens throughout the remainder of the study, Clinical trials were performed with had been implemented, including topical particularly evident at the 2 month period Bioscreen on 10 patients over the course benzoyl peroxide/clindamycin products, (see Figure 6). All patients showed at oral antibiotics, anti-bacterial cleansers, effects reported. She had noticed flares the product and is pleased with the success no observed side effects or concerns around her menstrual period, and was he is making. An understanding of commonly used when referring to antibithe pathogenesis of acne, and the road otics and microorganisms. Typical antimiblocks to effective treatment makes the crobial theory uses a language of proteins, use of Bioscreen a welcome innovation. These parameters include protons, electrons, magnetic fields, coefficient carumcarvi, with the exact percentages of electrical resistance and the movebeing proprietary information. The success of destruction has exhibited the ability to of Bioscreen is a result of its ability to spare innate bacteria that normally live in interfere with these specific parameters, the human body, such as Lactobacilli. The thus disrupting the electronic charge of product is 100% biodegradable and comes the water environment of microorganin a powder or liquid, and can be applied in isms. In part the Bioscreen strategy is various vehicles depending on the desired based on the assumption that there is an therapy. This versatility is ideal for dermaintrinsic neutral property to water at the tological applications. Our current clinical molecular level in the absence of microortrials have shown positive outcomes, with ganisms. Microorganisms alter this envia significant reduction in inflammatory ronment in a species and patient-specific acne. We believe that using this product in manner, which increases the positive or conjunction with a comedolytic agent will negative charge of the water medium. Acne Prevalence, Knowledge About Acne and Psychological Morbidity in science employed in studying antimicroMid-Adolescence: A Community-Based Study. Recent Findings in the Epidemiologic Evidence, inactivating microorganisms which coloClassification, and Subtypes of Acne Vulgaris. Temporal that when microorganisms are placed Changes in Sebum Excretion and Propionibacterial Colonization in Preadolescent Children With and Without under substantial stresses, the energy Acne. Inactivation of Listeria innocua in Liquid Whole Ege consists of passing a short, high-voltage by Pulsed Electric Fields in Nisin. The outcome of the damage to the vital components of the cell is cell lysis and death. The clinical and histological encounter prompts a thorough review of infectious associations, systemic causes, and drug reactions which have been reported to cause eosinophilic cellulitis. Background count is usually normal, but up to 50% of patients can have peripheral eosinophilia. In 1971, Wells described four patients Wells syndrome should only be diagnosed who presented with clinically similar in the absence of systemic symptoms. Flame syndrome and eosinophilic cellulites are plaque of 3 weeks duration on the left figures are then surrounded by histiocytes. Additional Finally, longstanding lesions exhibit phagoplaques and nodules are noted near Over the last 25 years, several case cytic histiocytes and giant cells around the 1,2,4 the largest plaque on the left thigh and reports have surfaced, which have validated flame figures. Numerous 5-10 mm syndrome can be divided into primary non painful nodules were noted in both and secondary categories. An early inflammatory phase can the eosinophils and histiocytes focally present as localized erythema and edema surround degenerated collagen, forming of the skin. Eosinophilic cellulites associated with squemous cell carcinoma of the of no benefit. Suspecting a drug reaction, consulTreatment options are as varied as cipitating event. Poorsattar S, Sidbury matoid arthritis and switch the patient to dosages and Class I topical steroids R. Eosinophilic celminocycline, doxycycline and low dose lulitis like reaction to subcutaneous Etanercept injection. Boura P, Sarantopoulos A, Lefaki I, Skendros P, Papament options are based primarily on case dopoulos P. Severe episode of actic for eosinophils, can increase the high fever with rash, lymphadenopathy, neutropenia and eosinophilia after minocycline therapy for acne. Arch adhesion and survival of mature eosinoIntern Med 1994;154:1983-4 phils, can stimulate eosinophil function, 8. Eosinophilic cellulites associated with urticaria: A report of two and can increase eosinophil production, cases. A colecao institucional do Ministerio da Saude pode ser acessada, na integra, na Biblioteca Virtual em Saude do Ministerio da Saude: < Manual de vigilancia da leishmaniose tegumentar [recurso eletronico] / Ministerio da Saude, Secretaria de Vigilancia em Saude, Departamento de Vigilancia das Doencas Transmissiveis. Edicao eletronica da 2fi edicao do livro: Manual de Vigilancia da Leishmaniose Tegumentar Americana, atualizado.
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