Doubts surrounding Complementary and Alternative Medicine - Arnaldo E. Pérez Mercado, M.D.
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Doubts surrounding Complementary
and Alternative Medicine
Arnaldo E. Pérez Mercado, M.D.
Disclosures • Consultant: Baxter Pharmaceuticals
Objectives • Be able to recognize differences between popular forms of complementary and alternative medicine • Review evidence in favor of or against complementary alternative medicine • Understand potential risks and benefits of complementary alternative medicine
Introduction
• What is complementary and alternative
medicine (CAM)?
– Medical and health care systems, practices, and
products that are not generally considered part
of conventional medicine
• Complementary medicine
– Used together with conventional medicine
• Alternative medicine
– Used in place of conventional medicine
NIH National Center for Complementary and Alternative Medicine.
http://nccam.nih.gov/health/whatiscam
Types of CAM
• Natural products • Manipulative body-based
– Herbal products practices
– Minerals – Spinal manipulation
– Other “natural” sources – Massage therapy
• Mind and body practices • Miscellaneous
– Meditation – Movement therapies
– Yoga – Traditional healing
– Acupuncture – Energy field manipulation
– Tai chi • Alternate systems
– Hypnotherapy, etc. – Naturopathy
– Homeopathy
NIH National Center for Complementary and Alternative Medicine.
http://nccam.nih.gov/health/whatiscam
2007 National Health Interview Survey
2007 National Health Interview Survey
Naturopathy: 0.3% 2007 National Health Interview Survey
2007 National Health Interview Survey
Naturopathy • “Naturopathy is a traditional approach to health that is holistic, meaning that it encompasses the whole being. It is based on natural and preventative care. Naturopathic medicine combines many methodologies, such as acupuncture, massage, chiropractic adjustment, homeopathy and herbal cures, along with sensible concepts such as good nutrition, exercise and relaxation techniques.” Association of Accredited Naturopathic Medical Colleges. http://www.aanmc.org/naturopathic-medicine/naturopathic-medicine-faq.php
Iridology
– “Iridology is the study of the iris, or colored part,
of the eye.”
– “It identifies inherited dispositions (how our body
reacts to our environment and what symptoms to
expect), and future challenges (where we are
likely to have more problems as we age).”
International Iridology Practitioners Association
http://www.iridologyassn.orgIridology Dr. Ignatz von Peczely
Iridology • Assumes all bodily organs are represented on the iris via intricate neural connections • Dysfunction of most organs is allegedly marked on the iris • Right half of the body is represented in the right iris, the left half in the left iris.
Iridology and kidney disease
88
100
57
80
57 37
60 Control
44
Kidney Disease
40
20 12
0
A
B
C
Adapted from
Simon A, Worthen DM, Mitas JA. An evaluation of iridology. JAMA. 1979;2421385- 1389Iridology and kidney disease • “Iridology had no clinical or statistically significant ability to detect the presence of kidney disease.” • “Iridology was neither selective nor specific, and the likelihood of correct detection was statistically no better than chance.” Simon A, Worthen DM, Mitas JA. An evaluation of iridology. JAMA. 1979;2421385- 1389
Iridology and gallbladder disease
54
60 49 54 41
44
54
40 54 41 49
49 Gallbladder disease
20
Control
0
A
B
C
D
E
Adapted from
Knipschild P. Looking for gallbladder disease in the patient's iris. BMJ. 1988;2971578- 1581Iridology and gallbladder disease • “The median validity was 51% with 54% sensitivity and 52% specificity.” • “These results were close to chance validity” • “This study showed that iridology is not a useful diagnostic aid” Knipschild P. Looking for gallbladder disease in the patient's iris. BMJ. 1988;2971578- 1581
Natural Products • What is “natural”? • FDA has no formal definition • “The agency will maintain its current policy not to restrict the use of the term "natural" except for added color, synthetic substances, and flavors”1 • “Nothing artificial or synthetic (including all color additives regardless of source) has been included in, or has been added to, a food that would not normally be expected to be in the food.”1 1. Federal Register Documents. 58 FR 2431, January 6, 1993
2007 National Health Interview Survey
Glucosamine & Chondroitin
• Glucosamine (C6H13NO5)
– An amino sugar and precursor in the synthesis of
glycosylated proteins and lipids
– Often made from shells of shrimp, crabs, and
lobsters
– Frequently used in conjunction with chondroitin
as treatment for osteoarthritis
• Chondroitin
– A glycosaminoglycanGlucosamine & Chondroitin Clegg DO, Reda DJ, Harris CL, Klein MA et al. N Engl J Med. 2006 Feb 23;354(8):795-808.
Glucosamine & Chondroitin • “The analysis of the primary outcome measure did not show that either supplement, alone or in combination, was efficacious.” • “Analysis of the prespecified subgroup of patients with moderate-to severe pain demonstrated that combination therapy significantly decreased knee pain related to osteoarthritis” Clegg DO, Reda DJ, Harris CL, Klein MA et al. N Engl J Med. 2006 Feb 23;354(8):795-808.
Glucosamine & Chondroitin • “Because our study was conducted under pharmaceutical rather than dietary-supplement regulations, agents identical to the ones we used may not be commercially available.” • “Physicians and patients alike should be aware of our data suggesting that celecoxib has a much faster time to response than glucosamine, chondroitin sulfate, or the two in combination. Clegg DO, Reda DJ, Harris CL, Klein MA et al. N Engl J Med. 2006 Feb 23;354(8):795-808.
Echinacea • Herb extract from plants of genus Echinacea • Often marketed as a treatment for flu or common cold • Often marketed as immune system stimulant
Barrett B, Brown R, Rakel D, et al. Echinacea for Treating the Common Cold: A Randomized Trial. Annals of Internal Medicine. 2010 Dec;153(12):769-777.
Echinacea • “Illness duration and severity were not statistically significant with echinacea compared with placebo. ” • “However, the trends were in the direction of benefit.” • “Our previous research suggests that few people—no more than 1 in 4—would judge this level of benefit worthwhile, given the cost, inconvenience, and possible adverse effects.” Barrett B, Brown R, Rakel D, et al. Echinacea for Treating the Common Cold: A Randomized Trial. Annals of Internal Medicine. 2010 Dec;153(12):769-777.
Ginkgo biloba • Herb derived from Ginkgo tree • Generally marketed as a treatment for dementia or cognitive decline
DeKosky ST, Williamson JD, Fitzpatrick AL et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008 November 19; 300(19): 2253– 2262.
Ginkgo biloba • “The results from the GEM Study did not show that G biloba is effective in preventing or delaying the onset of all-cause dementia in participants older than 75 years.” • “G biloba also had no effect on the risk for developing AD in this age group.” DeKosky ST, Williamson JD, Fitzpatrick AL et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008 November 19; 300(19): 2253– 2262.
Fish oil/omega-3 supplements • Omega-3 fatty acids are essential – alpha-linolenic acid (ALA), – eicosapenta-enoic acid (EPA) – docosahexaenoic acid (DHA) • Certain ethnic populations with diets high in polyunsaturated fatty acids had lower incidence of heart disease
Fish oil/omega-3 supplements • In 2001 the Nutrition Committee of the AHA recommended at least 2 meals of fatty fish per week to reduce CAD risk.1 • In 2004, the FDA approved omega-3-acid ethyl ester formulation for prescription use as treatment for hypertriglyceridemia 1. Krauss R, Eckel R, Howard D, et al. AHA Scientific Statement: AHA Dietary Guidelines Revision 2000: A Statement for Healthcare Professionals From the Nutrition Committee of the American Heart Association. J. Nutr. January 1, 2001 vol. 131 no. 1 132-146
Koski R. Omega-3-acid Ethyl Esters (Lovaza) For Severe Hypertriglyceridemia. Pharmacy and Therapeutics 2008 May; 33(5): 271–303.
Homeopathy • Originated by Samuel Hahneman in the late 18th century • Based on the “law of similars” (e.g. like cures like) • Homeopathic remedies consist of serial dilutions of a chosen substance • More dilute solutions are believed to be more potent
Retrieved on-line on August 15, 2012 from http://www.drzimmermann.org/userfiles/image/potentisation%20image.jpg
Homeopathy • 110 homoeopathy trials and 110 matched conventional-medicine trials were analyzed. • Smaller trials and those of lower quality showed more beneficial treatment effects • With higher quality trials, the odds ratio was 0·88 (95% CI 0·65—1·19) for homoeopathy (eight trials) and 0·58 (0·39—0·85) for conventional medicine (six trials). • Findings suggest that the “clinical effects of homoeopathy are placebo effects.” Shang A, Huwiler-Muntener, Nartey L. et al. Lancet 2005; 366: 726-32
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