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Should you try a “natural alternative” before medication?

Herbal remedies are often promoted as a substitute for drug therapies.

Natural and herbal remedies are often promoted as a substitute for drug therapies. But do they actually work?

The idea of taking medication can be frightening. And as consumers and patients that want to make our own informed health decisions, it’s understandable and even appropriate to question our physicians when they recommend drug treatments. We need to understand the rationale for any medication that’s recommended or prescribed, the benefits of therapy, the side effects, and if there are any other approaches that might be more appropriate. Dietary supplements and natural health products are widely marketed as being safe and effective, and are occupying more and more shelf space in pharmacies, usually right beside the pharmacy counter. Many of my patient encounters in the pharmacy have included a discussion on the merits of drug therapy, versus the supplements that may have flashy packaging and impressive claims of effectiveness.

One encounter from my time working at a local pharmacy still sticks with me. I met a new patient who was anxious and eager to get my advice. He’d been cautioned by his family doctor that he was on the borderline of being diagnosed with diabetes. He had come to the pharmacy seeking a supplement that could help him avoid diabetes and medication. Rather than recommend any supplement, I suggested that the best approach he could probably take would be to lose some weight and get some exercise – it could be more effective than any supplement or drug, and would definitely help his health. He agreed, and then asked me what supplement he could take that could help him with some weight loss.

This type of discussion occurs all the time, and seems more common when there’s a lack of trust in the physician, or when the goals of treatment aren’t understood. The patient, reluctant to accept the physician’s recommendation, heads to the pharmacy for what they believe is a second opinion. In some cases, the patient may question the physician’s advice: “All my physician wants to do is prescribe drugs,” is a statement I’ve heard more than once. In those that are reluctant to accept medical treatment, there’s often a willingness to consider anything that’s available without a prescription – particularly if it’s perceived as “natural.” Natural products and dietary supplements are thought to be gentle, safe, and effective, while medicine may be felt to be unnatural, harsh, and potentially dangerous. Yet when I explain to patients that there’s actually little evidence to suggest most supplements offer any meaningful health benefits, I am sometimes met with puzzled or dismissive looks. The supplement industry’s marketing has been remarkably effective, glossing over the fact that the research done on dietary supplements is overall unconvincing and largely negative when it comes to having anything useful to offer for health. (more…)

Posted in: Naturopathy

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A systematic review about nothing

Water
There is dubious content in PubMed that you won’t find unless you look for it, or stumble across it inadvertently. It’s the entire field of alternative medicine which is abstracted and complied along with the actual medical literature. In this world, the impossible is accepted as fact, and journal articles focus on the medical equivalent of counting angels on pinheads. I’ve been trying to avoid blogging about alternative medicine practices like homeopathy lately because the practice itself is a scientific dead end. There is no emerging evidence or interesting research to describe, because there is no science to build on. But research on homeopathy is interesting if one wants to understand how placebo effects can appear to be real. Importantly, research and clinical trials of homeopathy allow us to see the underlying (baseline) challenges, flaws, and biases in evaluating real medicine more clearly. Today I want to review a newly-published systematic review of, adverse effects attributed to homeopathy. The casual reader might not see the multiple problems with this type of research. But once you understand the basis of homeopathy, the conclusion that one can draw is quite different from that of the author’s. And if inert sugar pills can appear to have medicinal effects, and even adverse effects, then we can better adjust for these biases when we’re studying actual medicine. (more…)

Posted in: Clinical Trials, Homeopathy

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The rise and inevitable fall of Vitamin D

Is Vitamin D a panacea? The evidence says otherwise.

Is vitamin D a panacea? The evidence says otherwise.

It’s been difficult to avoid the buzz about vitamin D over the past few years. While it has a  long history of use in the medical treatment of osteoporosis, a large number of observational studies have linked low vitamin D levels to a range of illnesses. The hypothesis that there is widespread deficiency in the population has led to interest in measuring vitamin D blood levels. Demand for testing has jumped as many physicians have incorporated testing into routine care. This is not just due to alternative medicine purveyors that promote vitamin D as a panacea. Much of this demand and interest has been driven by health professionals like physicians and pharmacists who have looked at what is often weak, preliminary and sometimes inconclusive data, and concluded that the benefits of vitamin D outweigh the risks. After all, it’s a vitamin, right? How much harm can vitamin D cause? (more…)

Posted in: Herbs & Supplements, Nutrition

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Fooling Myself

They may have different packages, but these products are all the same inside.

Nothing says opportunistic like selling water for pain control.

The first principle is that you must not fool yourself — and you are the easiest person to fool.

Richard Feynman

I like to think of myself as a rational person, but I’ve been fooled by my own experience again and again. I’ve made bad decisions and wasted time and money believing what I was seeing, instead of being objective and looking at the evidence. One of my most memorable lessons has come over the past 14 years with my Labrador Retriever, Casey.

First the personal

We acquired Casey as a puppy, and she was less than a year old when she started limping. Investigations confirmed dysplasia, a genetic condition that leads to degenerative joints, arthritis, and pain. We were devastated. After considering the few treatment options that existed, we decided to skip surgery and treat it conservatively. I had no desire to start her on a lifetime of anti-inflammatory drugs, being very familiar with their side effect profile. I was familiar with a supplement used widely in humans that had some weak but somewhat promising evidence: We started giving her glucosamine and chondroitin supplements regularly. And we watched and waited.

It took some time, but Casey did appear to improve. We were thrilled. Life went on, and other than the occasional rough play session, Casey’s limping was mild, and she thrived. We continued the supplements, confident that we were doing good. But eventually I started paying attention to the emerging evidence on glucosamine and chondroitin. Once touted as a panacea for arthritis and joint pain, there had finally been some high-quality trials conducted – and the results were disappointing. Even this blog covered the issue, and contributors like Harriet were skeptical of glucosamine. Its supposed mechanism of action really wasn’t even that plausible. I started to wonder if the supplements were really doing anything for my dog’s pain. Eventually I decided on a trial – so I stopped the supplements about seven years after I started them. Neither my wife nor I could notice any difference at all in her mobility. Nor did the veterinarian. We’d been fooling ourselves, spending hundreds of dollars in the process. (more…)

Posted in: Critical Thinking, Herbs & Supplements, Science and Medicine

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Where science meets supplements

Various herbal remedies and supplements.

Various herbal remedies and supplements.

For those of you that missed the Science-Based Medicine day at NECSS last week, I’ve put the highlights in the following post:

The supplement industry is big business, and the popularity of these products seems to keep growing. I once worked at a small independent pharmacy that specialized in supplements, homeopathy and “alternative medicine” as way to differentiate itself from the big chain pharmacies. A lot has changed in a decade. Today, even national chain pharmacies have aisles and aisles of herbal remedies, dietary supplements, and even homeopathy. Yet despite the preponderance of products on store shelves, there is little evidence to suggest that supplements are necessary or even improve health (and may even cause harm). The right for consumers to buy products for themselves, and make their own self-care decisions, is an important one that respects individual autonomy. Regrettably, the regulations of these products are so weak and ineffective that the sale of these products quite possibly harms, rather than helps, the average consumer. The system is rigged against consumers, and it prevents the use of supplements in an evidence-based way. (more…)

Posted in: Herbs & Supplements

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Is there a naturopathic standard of care?

Stephans
Public outcry over the death of Ezekiel Stephan, the 19-month-old Alberta toddler who died of bacterial meningitis in 2012, continues to grow following last’s weeks court decision, which found both of his parents guilty of failing to provide the necessaries of life. David and Collet Stephan failed to seek appropriate medical care for their obviously-ill child, instead relying on a variety of vitamins, supplements, and remedies from the family’s own home business, Truehope Nutritional Support. While sentencing will not take place until later this year, David Stephan hasn’t hesitated to lash out with an open letter to the jury that suggests he remains unrepentant for the series of decisions that led to the death of his son:

I only wish that you could’ve seen how you were being played by the Crown’s deception, drama and trickery that not only led to our key witnesses being muzzled, but has also now led to a dangerous precedent being set in Canada.

The precedent referred by Stephan seems to his perceived “right” to prioritize his beliefs in what is demonstrable pseudoscience and quackery over the “right” for his child to receive appropriate medical care. Ezekiel had never seen a physician. He had received no vaccinations, including vaccination against Haemophilus influenza type b (Hib), a vaccine which protects against bacterial meningitis. And as he lay dying, the parents chose to use an Echinacea tincture recommended by a naturopath, Tracey Tannis, who never even examined Ezekiel. Given the involvement of Tannis in this tragedy, there are renewed questions about naturopathy in Canada, whether naturopaths are capable of self-regulation, and the standard of care they provide. (more…)

Posted in: Naturopathy, Science and Medicine

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The Brown M&M’s of Science-Based Medicine

David Lee Roth. Quality Guru.

David Lee Roth. Quality Guru.

Medicine is constantly changing, and like most health professionals, I am required to maintain my competency to practice. I doubt pharmacists are unique in being inundated with offers of continuing medical/pharmacy education. Some courses are free, some cost hundreds of dollars, and it can be difficult to distinguish the high-quality programs from the biased or low-quality education that furthers a agenda, rather than seeking to truly educate. You can consider the reputation of the provider, or the author, and sometimes the sponsorship gives a clue. When it comes to determining if a program’s content is science-based or not, I find the learning objectives may be all I need to read. One program I saw recently referred to “integrative” approaches to the treatment of an illness. Another claimed it would teach you a  “holistic” approach to managing complex medical condition. Both programs set off skeptical alarm bells. I realized then I’d found the science-based medicine equivalent of a brown M&M. And I have the band Van Halen to thank for that association. (more…)

Posted in: Commentary, Humor, Science and Medicine

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Statins for everyone? Not so fast.

In rosuvastatin we trust?

In rosuvastatin should we trust?

People love the idea of preventive medicine. Preventing a disease, before it occurs, seems intuitively obvious. But when it comes to taking medicine to prevent a disease before it occurs, people tend to be much less comfortable. Not only are there the concerns about the “medicalization” of healthy people, there are good questions about benefits, risks, and costs. Cardiovascular disease will kill many of us, so there’s been decades of research studying how to prevent that first heart attack or stroke. But even if you’re born with good genes and do everything possible to prevent heart disease (e.g., don’t smoke, exercise regularly, eat a healthy diet, moderate your alcohol, and keep your weight down) you’re still at risk of heart disease. And if you have one or more risk factors for disease, your lifetime risk goes up dramatically. Once you’ve had your first heart attack or stroke, the effectiveness of medical therapy is clear. Drug therapy with medication like the “statins” class of cholesterol-lowering drugs reduces deaths from cardiovascular disease. Given their unambiguous effectiveness, and the high likelihood that many of us will eventually have cardiovascular disease of some sort, the idea of “pre-treating” otherwise-healthy people with drug therapy to possibly prevent that first event has been held out as a potential public health strategy. There’s new evidence that tests this hypothesis, and the results are surprising. (more…)

Posted in: Clinical Trials, Public Health

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More drugs, more supplements, and potentially more problems

drugs and supplements

Early in my career I was fortunate to be offered a role as a hospital pharmacist, working on an inpatient ward along with physicians, nurses, and a number of other health professionals. My responsibilities included conducting a detailed medication review with each newly admitted patient. We would sit together, often with family members, going through what was sometimes a literal garbage bag full of medications, and documenting the drug, the dose, and the reason for use. I can’t remember the most medications I ever counted, but a dozen or more was normal. Some were taking medications four or five times per day, every day. Were all these drugs necessary? In many cases, no. They’d been started at different times, often by different physicians. Some drugs treated the side effects of other medications. Few had ever had a health professional document them all in a single list. There had rarely been an overall review for safety and appropriateness. Few patients knew the treatment goals of their medications. Often, they’d never been asked about their treatment preferences.

In addition to auditing every prescribed medication, I asked about vitamins, supplements and over-the-counter drugs. I usually encountered the same scenario – multiple products, often without any clear medical need. There were vitamins for “eyes”, tonics for “the blood”, and supplements believed to treat or prevent illness. There was regular (and sometimes dangerous) over-the-counter painkiller consumption. Sometimes all of these combinations were clearly antagonistic: concurrent laxatives and treatments for diarrhea, or sleeping pills taken along with stimulants. Worryingly, few had disclosed the use of many of these products to their physician beforehand.

Medication reviews were a tremendous amount of work – but enormously rewarding. It was not difficult to find one or more cases of drugs potentially causing harm, or situations with clear drug-drug or drug-supplement interaction. In some cases, it was the medications that had put them in the hospital in the first place. Working with the residents and medical staff we could usually find ways to simplify their regimen, often discontinuing one or more drugs, reducing the doses of others, and suggesting ways to cut their supplement and over-the-counter drug use – or at a minimum, reduce the risk that these products could cause problems. Not only did patients end up with simpler medication schedules, we were helping them feel better, too. Before every patient was discharged, they’d get a follow-up visit from me. I’d provide a detailed list of current medications with a simplified schedule designed to make medication use easier. We’d provide copies for them to take to the pharmacy and to any specialist. In many cases, patients were still on a long list of drugs. But we’d cleaved away the most harmful and unnecessary, trying to leave only the medications that were appropriate. (more…)

Posted in: Herbs & Supplements, Pharmaceuticals, Science and Medicine

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Not natural, not safe: Grapefruit Seed Extract

The image is "natural", but is grapefruit seed extract a case of misleading advertising?

The image is “natural”, but is grapefruit seed extract a case of misleading advertising?

Where do you draw the line between “supplement” and “drug”? And how much processing of a “natural” substance can occur before it’s no longer “natural”? These seemingly-philosophical questions are very real when it comes to the supplement industry. In many countries, regulators have implemented weaker safety, effectiveness and quality standards for anything branded a supplement or natural health product. The result has been a boon and boom for manufacturers, with thousands of products flooding the market. This same boom has challenged consumers and health professionals who are seeking products that are safe, effective, and manufactured to high quality standards (and in the bottle you are buying). Nowhere is this challenge better illustrated than a supplement that I’ve seen for sale for some time. Grapefruit seed extract (GSE), according to promoters, is a panacea that destroy bacteria, viruses and fungi anywhere in the body, without any risk of harm. But the actual science is quite telling. Grapefruit seed is a supplement that’s of such poor quality that even herbal medicine boosters recommend against its use. (more…)

Posted in: Herbs & Supplements

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