Pharmacology For Nurses: A Pathophysiologic Approach: Fifth Edition

Pharmacology for Nurses: A Pathophysiologic
Approach
Fifth Edition
Chapter 10
The Role of Contemporary
and Alternative Therapies
in Pharmacology
Copyright © 2017, 2014, 2011 Pearson Education, Inc. All Rights Reserved
Complementary and Alternative
Medicine (CAM)
• Considered outside mainstream health care

• Very diverse set of therapies and healing systems
Major Characteristics of CAM
• Treat each person as individual

• Consider health care of whole person
• Emphasize integration of mind and body
• Promote disease prevention, self-care, self-healing
• Recognize role of spirituality
Research
• Rigorous research lacking, though underway for many

therapies
• Seeks effectiveness or lack of effectiveness
Nurses and CAM
• Have long known of healing benefits

• Can reduce reliance on some medications, which
reduces adverse effects
• Can bring greater compliance
• Advantages and limitations should be presented to
patients
CAM Healing Methods (1 of 2)
• Ingested therapies
– Herbal therapies, nutritional supplements, special
diets
CAM Healing Therapies (1 of 2)
• Alternate health care systems

– Naturotherapy, homeopathy, chiropractic
– Native American medicine (sweat lodges, medicine
wheels)
– Chinese traditional medicine (acupuncture, Chinese
herbals)
CAM Healing Therapies (2 of 2)
• Biologic-based therapies
– Herbal therapies, nutritional supplements, special
diets
• Manual healing
– Massage, physical therapy, pressure-point therapies,
hand-mediated biofield therapies
• Mind-body interventions
– Yoga, meditation, hypnotherapy
– Guided imagery, biofeedback
– Movement-oriented therapies (music and dance)
CAM Healing Methods (2 of 2)
• Spiritual
– Shamans, faith, prayer
• Other therapies
– Bioelectromagnetics, detoxifying therapies, animal-
assisted therapy
Herbs
• Technically a botanical without any woody tissue such as

stems or bark
• Meaning has changed to refer to any plant product with
some useful application either as a food enhancer or a
medicine
• Documented use for thousands of years
Table 10.2 Popular Herbal Supplements (1 of 4)
Herb Feature
Herb Medicinal Part Primary Use(s)
(Chapter)
Acai Berries Vitamin and mineral supplement, antioxidant,
—
possible weight loss
Aloe vera Leaves Topical application for minor skin irritations
49
and burns
Bilberry Berries and Terminate diarrhea, improve and protect
50
leaves vision, antioxidant
Black cohosh Roots Relief of menopausal symptoms 46
Chlorophyll/chlor Leaves Improve digestion, vitamin and mineral
—
ella supplement
Cranberry Berries/juice Prevent urinary tract infection 24
Echinacea Entire plant Enhance immune system, treat the common
34
cold
Herb Feature
(Chapter)
Elderberry Berries and Congestion in respiratory system due to colds
—
flowers and flu
Evening primrose Oil extracted Source of essential fatty acids, relief of
from seeds premenstrual or menopausal symptoms, relief
—
of rheumatoid arthritis and other inflammatory
symptoms
Flaxseed Seeds and oil Reduce blood cholesterol, laxative
(ground) and/or —
oil
Garlic Bulbs Reduce blood cholesterol, reduce blood
31
pressure, anticoagulation
Ginger Root Antiemetic, antithrombotic, diuretic, promote
gastric secretions, antiinflammatory, increase
41
blood glucose, stimulation of peripheral
circulation
Herb Feature
(Chapter)
Ginkgo Leaves and seeds Improve memory, reduce dizziness 20
Ginseng Root Relieve stress, enhance immune system,
28
decrease fatigue
Grape seed Seeds/oil Source of essential fatty acids,
antioxidant, restore microcirculation to 26
tissues
Green tea Leaves Antioxidant; lower LDL cholesterol;
prevent cancer; relieve stomach —
problems, nausea, vomiting
Horny goat weed Leaves and roots Enhance sexual function —
Milk thistle Seeds Antitoxin, protection against liver disease 22
Red rice yeast Dried in capsules Reduce blood cholesterol
—
extract
Herb Feature
(Chapter)
Saw palmetto Berries Treatment of benign prostatic hyperplasia
47
Soy Beans Source of protein, vitamins, and minerals;

relief of menopausal symptoms, prevent
cardiovascular disease, anticancer —
Stevia Leaves Natural sweetener —

St. John’s wort Flowers, leaves, Reduce depression, reduce anxiety, anti-
16
stems inflammatory
Valerian Roots Relieve stress, promote sleep —
Wheat or barley Leaves Improve digestion, vitamin and mineral —
grass supplement
Dietary and Herbal Supplements
• Use waned with rise of pharmacology in late 1800s

• Marketing, increased awareness, and availability brought
resurgence in 1970s
• Majority of adult Americans take or have taken botanicals
on a regular basis
Aging Population
• Pain
• Arthritis
• Changes in hormones
• Prostate enlargement
High Cost of Prescription Medications
• Leads patients to seek CAM therapies
Examples of Herbal Supplements
• Garlic
• Soy
• St. John’s wort
• Cranberry
• Ginseng
• Bilberry
Active Ingredient(s) in Herbs
• Usually found only in specific part of the plant

• May have multiple active ingredients, unlike most modern
drugs
• Potency can depend on where herb was grown or how it
was grown or harvested
Active Chemicals in Herbs
• Work synergistically
• May not have same activity if isolated
Herbal Formulations
• Two basic formulations: solid and liquid
Solid Formulations of Herbs
• Pills
• Tablets
• Capsules
• Salves
• Ointments
Liquid Formulations of Herbs
• Extracts
• Infusions
• Teas
• Tinctures
Figure 10.2 Three Different Ginkgo Formulations:
Tablets, Tea Bags, and Liquid Extract
Al Dodge/Pearson Education, Inc.
Table 10.4 Diseases for Which Medical Consensus
Exists That Herbal Therapies May Be Useful
Disease Herbal Therapy
Chronic venous insufficiency Horse chestnut seed extract
Claudication Ginkgo biloba
Depression St. John’s wort
Hypercholesterolemia Garlic
Hyperlipidemia Plant sterols and stanols
Hypertension Hawthorn
Insomnia Valerian
Low back pain Devil’s claw, white willow bark
Memory impairment Ginkgo biloba
Menopausal symptoms Black cohosh, St. John’s wort
Migraine prophylaxis Butterbur
Nausea and vomiting Ginger
Rheumatoid arthritis Evening primrose oil, black currant seed oil
Common Drug–Herb Interactions
• Obtain patient’s health history to prevent drug–herb

interactions
Dietary Supplement Health and Education
Act of 1994 (DSHEA)
• Regulatory act for dietary supplements

• Less rigid than the Food, Drug, and Cosmetic Act (FD&C
Act)
• Dietary supplements are exempted from FD&C Act
standards
• Gives Food and Drug Administration power to remove
products considered harmful
Food, Drug, and Cosmetic Act Definition of
Dietary Supplements
• Products intended to enhance or supplement the diet

– Botanicals
– Vitamins
– Minerals
– Metabolites
Table 10.5 Documented Herb-Drug
Interactions (1 of 2)
Herb Interacts With Effect(s)
Echinacea Amiodarone, anabolic steroids, Possible increased hepatotoxicity
ketoconazole, methotrexate
Feverfew Aspirin and other nonsteroidal anti- Increased bleeding risk
inflammatory drugs (NSAIDs), heparin,
warfarin (Coumadin)
Garlic Aspirin and other NSAIDs, warfarin Increased bleeding risk
(Coumadin), insulin, oral antidiabetic Additive hypoglycemic effects
drugs
Ginger Aspirin and other NSAIDs, heparin, Increased bleeding risk
warfarin
Ginkgo Anticonvulsants Aspirin, NSAIDs, heparin Possible decreased anticonvulsant
and warfarin (Coumadin) Tricyclic effectiveness Increased bleeding potential
antidepressants Possible decreased seizure threshold
Table 10.5 Documented Herb-Drug
Interactions (2 of 2)
Herb Interacts With Effect(s)
Ginseng CNS depressants Digoxin (Lanoxin) Increased sedation Increased toxicity

Diuretics Insulin and oral hypoglycemic Possible decreased diuretic effects
agents Warfarin (Coumadin) Increased hypoglycemic effects Decreased
anticoagulant effects
Goldenseal Diuretics May decrease diuretic effects

St. John’s wort CNS depressants and opioid analgesics Increased sedation May decrease
Cyclosporine (Sanimmune) cyclosporine levels Decreased antiretroviral
Efavirenz, indinavir, protease inhibitors activity Decreased drug effectiveness
Oral contraceptives Selective serotonin Possible serotonin syndrome*
reuptake inhibitors (SSRIs), tricyclic Decreased anticoagulant effects
antidepressants Warfarin
Valerian Barbiturates, benzodiazepines, and other Increased sedation

central nervous system (CNS)
depressants
*Serotonin syndrome: headache, dizziness, sweating, agitation.
DSHEA Weaknesses
• Not necessary to demonstrate effectiveness prior to

marketing
• Manufacturer not required to prove safety
• Labels not monitored for accuracy in product amounts or
claims of benefits of product
Figure 10.3 L-Carnitine Is a Popular
Dietary Supplement
Notice the claims of improving athletic performance and weight loss, neither of which has
been supported by the scientific literature.
Dietary Supplement and Nonprescription
Drug Consumer Protection Act (2007)
• Companies must
– Include contact information on product labels for
reporting adverse events
– Notify the FDA of any serious adverse event reports
within 15 days of receiving such reports
– Keep extensive records on reports
Further FDA Rules
• Manufacturers of dietary supplements required to

evaluate the identity, purity, potency, and composition of
their products and report on label
“Natural” Does Not Always Mean Safer
• Some active chemicals are the same as in prescription

and OTC medications
• Substituting alternative therapy for established medical
treatment may prolong condition
Allergic Reactions
• Natural products may contain several chemicals or

ingredients
• Safer to begin with smaller doses
Seek Latest Medical Information on CAM
• Nurses need to keep current with updated information
Educate Patients
• Strengths and weaknesses of CAM

• Encourage patients to seek information from reputable
sources
• Tell pregnant/lactating women never to take supplements
without approval from health care provider
Avoid False Hope of Cure
• Ensure patients’ understanding of uses and limitations of

CAM
• Encourage skepticism of claims on manufacturer labels
• Never condemn patient’s desire to use alternative
therapies
Patient Health History
• Aids in avoiding adverse reactions

• Aids in identifying drug interactions
Echinacea Traits
• Interacts with amiodarone, anabolic steroids,

ketoconazole, methotrexate
• Results in possible increased hepatotoxicity
Interactions with Feverfew, Ginger, and
Ginkgo (partial)
• Aspirin
• Heparin
• NSAIDs
• Warfarin
• Results in possible increased bleeding risk
Interactions with Garlic and Ginseng
(Partial)
• Insulin
• Oral hypoglycemic agents
• Results in increased hypoglycemic effects
Interaction with Ginkgo (Partial)
• Anticonvulsants—decreased effectiveness
• Tricyclic antidepressants—decreased seizure threshold
Interactions with CNS Depressants
• Herbs that interact:

– Ginseng
– St. John’s wort
– Valerian
• Results in increased sedative effect
Specialty Supplements
• Nonherbal dietary products are used to enhance a wide

variety of body functions
• Occur naturally in the body
• Excessive amounts may have harmful effects
• Example—chondroitin and glucosamine
• Link with benefits is unclear
Table 10.6 Selected Specialty
Supplements (1 of 2)
Supplement
Name Primary Uses Feature
(Chapter)
Amino acids Build protein, muscle strength, and endurance —
Carnitine Enhances energy and sports performance, heart
health, memory, immune function, and male 27
fertility
Coenzyme Prevents heart disease, provides antioxidant
23
Q10 therapy
DHEA Boosts immune functions and memory —
Fish oil Reduces cholesterol levels, enhances brain
function, increases visual acuity (due to 33
presence of omega-3 fatty acids)
Table 10.6 Selected Specialty
Supplements (2 of 2)
Supplement
Name Primary Uses Feature
(Chapter)
Glucosamine Reduces symptoms of arthritis and other
and joint problems 48
chondroitin
Lactobacillus Maintains intestinal health
—
acidophilus
Selenium Reduces the risk of certain types of cancer —
Vitamin C Prevents colds —
Standardizing Herbal Products
• Attempts have been made to standardize measurement

of active ingredient, but with no comprehensive success
yet
• Uses marker substance such as percent flavones in
ginkgo
• Until science is better, it is best to conceptualize the
active ingredient of an herb as being the entire herb itself
Table 10.3 Standardization of Selected
Herb Extracts
Herb Standardization Percent
Black cohosh rhizome Triterpene glycosides 2.5
Cascara sagrada bark Anthocyanides 25
Echinacea purpurea, whole Echinacosides
4
herb
Ginger rhizome Pungent compounds Greater than 10
Ginkgo leaf Flavone glycosides 24–25
Lactones 6
Ginseng root Ginsenosides 5–15
Kava kava rhizome Kavalactones 40–45
Milk thistle root Silymarin 80
Saw palmetto fruit Fatty acids and sterols 80–90
St. John’s wort Hypericins 0.3–0.5
Hyperforin 3–5
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Pharmacology for Nurses: A Pathophysiologic

• Considered outside mainstream health care

• Treat each person as individual

• Rigorous research lacking, though underway for many

• Have long known of healing benefits

• Alternate health care systems

• Technically a botanical without any woody tissue such as

Soy Beans Source of protein, vitamins, and minerals;

Stevia Leaves Natural sweetener —

• Use waned with rise of pharmacology in late 1800s

• Leads patients to seek CAM therapies

• Usually found only in specific part of the plant

• Two basic formulations: solid and liquid

Al Dodge/Pearson Education, Inc.

• Obtain patient’s health history to prevent drug–herb

• Regulatory act for dietary supplements

• Products intended to enhance or supplement the diet

Ginseng CNS depressants Digoxin (Lanoxin) Increased sedation Increased toxicity

Goldenseal Diuretics May decrease diuretic effects

Valerian Barbiturates, benzodiazepines, and other Increased sedation

*Serotonin syndrome: headache, dizziness, sweating, agitation.

• Not necessary to demonstrate effectiveness prior to

• Manufacturers of dietary supplements required to

• Some active chemicals are the same as in prescription

• Natural products may contain several chemicals or

• Nurses need to keep current with updated information

• Strengths and weaknesses of CAM

• Ensure patients’ understanding of uses and limitations of

• Aids in avoiding adverse reactions

• Interacts with amiodarone, anabolic steroids,

• Herbs that interact:

• Nonherbal dietary products are used to enhance a wide

• Attempts have been made to standardize measurement

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