Natural Medicines Highlights

In this episode, TRC Healthcare editors, Sara Klockars, PharmD, BCPS, and Stephen Small, PharmD, BCPS, BCPPS, BCCCP, CNSC, tackle the topic of Natural Medicines. 

Listen in as they define what natural medicines are... and discuss the safety and efficacy of several natural medicines, including ashwagandha, berberine, and turmeric.  They’ll also discuss how to navigate discussions with patients about supplements, including tips for choosing a quality supplement.  

None of the speakers have anything to disclose. 

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

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You can find more about these topics with resources that are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Be Prepared With Guidance About Ashwagandha
• Article: Don’t Recommend Berberine as a GLP-1 Agonist Alternative
• Article: Give Guidance About Coenzyme Q10
• Article: Clarify the Effectiveness and Safety of Melatonin
• Article: Be Prepared With Advice About Turmeric 

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📣 New Podcast!📣

🌱Natural Medicines: Evidence in Practice 

Evidence, not hype. Concise, clinician‑ready guidance on natural medicines and integrative care. Episode 1: GLP‑1s & Nutrition is live now!

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Transcript

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00:00:05 NARRATOR

Welcome to medication talk, the official podcast of TRC Healthcare, homopharmacist letter Prescriber Insights RX advanced and the most trusted clinical resources on today's episode.

00:00:16 NARRATOR

Listen in as our editors to find what natural medicines are and discuss the safety and efficacy of several natural medicines.

00:00:23 NARRATOR

Including Ashwagandha, berberine and turmeric.

00:00:27 NARRATOR

They'll also discuss how to navigate discussions with patients about supplements, including tips for choosing a quality supplement. You'll hear from two of our pharmacist editors on our team at TRC Healthcare, associate editor Sarah Clockers and assistant editor Steven Small.

00:00:42 NARRATOR

This podcast is an excerpt from one of TR Cs monthly live CE webinars each.

00:00:47 NARRATOR

Experts of the frontline providers discuss and debate challenges in practice, evidence based practice recommendations and other topics relevant to our subscribers.

00:00:56 NARRATOR

Webinar originally aired on November 18th, 2024.

00:01:02 NARRATOR 2

And now the CE information.

00:01:07 NARRATOR

This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians and nurses.

00:01:15 NARRATOR

Please log into your pharmacist letter pharmacy technician's letter or prescriber insights account and look for the title of this podcast in the list of available CE courses.

00:01:24 NARRATOR

None of the speakers have anything to disclose.

00:01:30 NARRATOR

Now let's start our discussion.

00:01:34 Sara Klockars

So to kick us off, Steve, we're talking about natural medicine's highlights.

00:01:39 Sara Klockars

So could you briefly just answer the question? What are natural medicines?

00:01:45 Stephen Small

Sure. And it's a great question.

00:01:47 Stephen Small

So natural medicines are a form of alternative or complementary medicine, and for today's discussion we'll be talking about herbal supplements, which you may have heard, also called botanicals.

00:01:59 Stephen Small

They come as tablets, capsules, powders, even teas.

00:02:03 Stephen Small

And they're among the most common type of dietary supplements used over the past few decades.

00:02:08 Stephen Small

Now the term dietary supplements represents quite a broad category that that falls underneath. They include products taken by mouth, of course, to supplement the diet, and could be things like vitamins, minerals, herbals and botanicals and even enzymes.

00:02:25 Sara Klockars

That's.

00:02:26 Sara Klockars

Thanks for that high level overview and I think another question we have is why are we even talking about this today?

00:02:33 Sara Klockars

We have some really good stats to share about four out of five adults in the US take a dietary supplement.

00:02:41 Sara Klockars

And consumers spent over $12 billion on supplements in the year 2022, so supplement use is increasing, and we continue to get a lot of questions about this.

00:02:55 Sara Klockars

So now let's dive into the details on five of the top search natural medicines, as these tend to raise a lot of questions in practice.

00:03:06 Sara Klockars

Today we'll be talking more about ashwagandha berberine.

00:03:10 Sara Klockars

Coenzyme Q10, melatonin and turmeric.

00:03:14 Sara Klockars

So let's start with ash. Go, go.

00:03:17 Sara Klockars

So where does ashwagandha come?

00:03:19 Sara Klockars

It's an Evergreen shrub that grows in areas of Asian Africa.

00:03:24 Sara Klockars

Ashwagandha is traditionally used as an adaptogen.

00:03:28 Sara Klockars

These are natural substances.

00:03:30 Sara Klockars

Herbs roots mushrooms.

00:03:34 Sara Klockars

And they're thought to work on the body, stress response and support the ability to kind of adjust to stress.

00:03:40 Sara Klockars

Let's talk about what conditions it's affected for.

00:03:43 Sara Klockars

And there are actually two big categories shagonda's possibly effective for improving symptoms of anxiety or psychological stress, based on some small studies that suggest modest benefit.

00:03:58 Sara Klockars

There are also some small studies in patients with insomnia that suggest ashwagandha may modestly reduce the time to fall asleep, increase total sleep time and improve sleep quality when compared to placebo.

00:04:11 Sara Klockars

But just.

00:04:12 Sara Klockars

Out that the doses for these uses varies.

00:04:15 Sara Klockars

Lian studies and studies can't really be compared apples to apples, so.

00:04:20 Sara Klockars

For anxiety or stress, we see doses up to 1000 milligrams daily for up to 12 weeks and then for insomnia. The doses that were looked at were between 120 milligrams to 600 milligrams daily.

00:04:35 Sara Klockars

For six to 12 weeks.

00:04:38 Sara Klockars

There is a.

00:04:39 Sara Klockars

List of indications that as Shwagnda has insufficient evidence for and there's just really not enough evidence to say if it's helpful or harmful.

00:04:49 Sara Klockars

For many uses, such as ADHD, aging, athletic performance, asthma and COPD, diabetes.

00:04:59 Sara Klockars

Fibromyalgia, fertility and many, many others.

00:05:05 Sara Klockars

So when it comes to safety and side effects orally, ashwagandha seems well tolerated at typical doses, may cause some drowsiness and in larger doses it can cause GI upset, nausea and vomiting.

00:05:22 Sara Klockars

There are limited safety data and that was looking at doses up to 1250 milligrams for up to six months of use.

00:05:31 Sara Klockars

But we really want to reinforce safety concerns with this supplement.

00:05:36 Sara Klockars

Severe liver injury has been reported even with low doses or short term use.

00:05:43 Sara Klockars

Symptom onset with those cases occurred within 5 to 8 days of starting ashwagandha, and in some cases liver injury occurred after more than a year.

00:05:55 Sara Klockars

So just tell patients to be aware of symptoms of liver damage such as.

00:06:01 Sara Klockars

Jaundice, weight loss, nausea, stomach pain and then also.

00:06:06 Sara Klockars

Advise patients with existing liver disease, such as hepatitis, to avoid this supplemental together.

00:06:12 Sara Klockars

In the.

00:06:13 Sara Klockars

News in all of this is that in most cases, liver enzymes normalize within one to five months after stopping ashwagandha.

00:06:21 Sara Klockars

Let's review some information here for ashwagandha. When it comes to pregnancy and lactation, pregnant patients might feel stressed or need like.

00:06:32 Sara Klockars

Need sleep.

00:06:33 Sara Klockars

But pregnant patients should avoid ashwagandha, since it may have abortifacient effects.

00:06:38 Sara Klockars

And recommend avoiding.

00:06:39 Sara Klockars

In lactation, we just don't have.

00:06:41 Sara Klockars

Lot of evidence.

00:06:43 Sara Klockars

Also, when it comes to Pediatrics.

00:06:48 Sara Klockars

Listen for, you know, parents asking about using this for their kids and we don't want to use it at this time.

00:06:54 Sara Klockars

Just don't have enough studies and kids to show it safe.

00:06:58 Sara Klockars

Also.

00:07:01 Sara Klockars

Interactions. So it only makes sense that if we have this supplement that can cause rare liver injury, we probably don't want to couple it with another hepatotoxic Med.

00:07:13 Sara Klockars

I would avoid using ashwagandha.

00:07:17 Sara Klockars

For patients who are taking isoniazid methotrexate, then itoin just anything that can potentially harm the liver and increase that risk of liver injury.

00:07:28 Sara Klockars

There are also concerns with Ashwagandha having immuno stimulant effects, meaning it could decrease the effects of immunosuppressants, or it could exacerbate auto immune diseases.

00:07:42 Sara Klockars

So just be really cautious with folks with autoimmune disorders such as multiple sclerosis.

00:07:48 Sara Klockars

Rheumatoid arthritis or patients on those immunosuppressants such as biologics or tacrolimus?

00:07:55 Sara Klockars

And then.

00:07:57 Sara Klockars

Also caution with.

00:07:58 Sara Klockars

It might have additive effects with thyroid hormones, and it might exacerbate hyperthyroidism.

00:08:05 Sara Klockars

And then there's a chance it may increase risk of low blood sugars or low blood pressure.

00:08:10 Sara Klockars

If patients are also on other medications.

00:08:14 Sara Klockars

To lower their blood glucose or blood pressure, just be cautious with that as well.

00:08:18 NARRATOR

So maybe just a.

00:08:19 Sara Klockars

Little bit more increased monitoring for patients with diabetes.

00:08:24 Sara Klockars

Or hypertension.

00:08:28 Sara Klockars

I meant to just summarize with some pearls here with ashwagandha.

00:08:34 Sara Klockars

Just be sure to counsel patients to report any symptoms of liver damage.

00:08:40 Sara Klockars

And they might present with the yellowing of the skin.

00:08:43 Sara Klockars

Or jaundice weight.

00:08:44 Sara Klockars

Maybe some nausea and stomach pain complaints and also.

00:08:50 Sara Klockars

We're going to want to have patients stop ashwagandha.

00:08:55 Sara Klockars

Two weeks before surgery. And that's because it can cause drowsiness.

00:09:00 Sara Klockars

It may have some sedative effects, so just to to mitigate any concerns with surgery and anesthesia, we're just going to have patients stop this before.

00:09:10 Sara Klockars

Also point to labels.

00:09:11 Sara Klockars

Ashwagandha plant is also called winter.

00:09:16 Sara Klockars

And the ripened fruit winter cherry is used to treat some different things like arthritis or gout, or it's used in kidney and bladder conditions. But for ashwagandha that we're talking about today.

00:09:30 Sara Klockars

We are actually looking at the root, so be sure to check the label for the root extract when using it for stress, anxiety or insomnia.

00:09:40 Sara Klockars

And then also.

00:09:41 Sara Klockars

Ashwagandha comes in a lot of combo.

00:09:44 Sara Klockars

So just a plug to always, you know, check those labels. Some products combine it with black pepper extract or peppermint, which in theory enhances the absorption of ashwagandha and may increase its effects.

00:09:59 Sara Klockars

That that wraps up a little bit on ashwagandha.

00:10:04 Sara Klockars

Thanks for watching questions during this.

00:10:08 Sara Klockars

What questions do you have for me from the audience?

00:10:13 Stephen Small

Yeah, of your asks.

00:10:14 Stephen Small

Does Ashwagandha help menopausal symptoms even though it doesn't help with a lot of other things?

00:10:21 Sara Klockars

Oh, that's a good question, Steve, because folks with menopausal symptoms often have stress anxiety and insomnia.

00:10:29 Sara Klockars

There is a potential it could help with those.

00:10:31 Sara Klockars

There is one study I see here where taking Ashwagandha route 300 milligrams twice a day for eight weeks.

00:10:38 Sara Klockars

May improve symptom severity by 24%.

00:10:41 Sara Klockars

And.

00:10:42 Sara Klockars

Also reported improved quality of life in hot flashes.

00:10:46 Sara Klockars

That's only based on one small study.

00:10:48 Sara Klockars

And you know, it might just be something that if somebody wants to try it for, you know, a month or two and see if it's helpful, that might not be a bad idea.

00:10:57 Sara Klockars

But we don't have a lot of data to say. Yes, this is going to be effective.

00:11:02 Sara Klockars

Thank you.

00:11:05 Sara Klockars

OK, I'm gonna move us along.

00:11:09 Sara Klockars

To berberine, Steve, and I'm gonna hand the reins over to you to talk a little bit about berberine.

00:11:15 Stephen Small

Excellent. So as we move over to berberine, it actually comes from the Barbary shrub known as Berberus vulgaris.

00:11:24 Stephen Small

And then in terms of the background, let's take a moment to ask what is berberine.

00:11:28 Stephen Small

It's a yellow bitter alkaloid compound that you'll find naturally in certain plants like the barbary shrub or golden seal.

00:11:36 Stephen Small

But the majority of berberine actually comes from the roots or rhizomes, and berberine is a hot topic right now because some people have called it nature's ozempic. And Sarah, you and I know GOP ones like ozempic are becoming very, very popular.

00:11:51 Stephen Small

And are prone to shortages because of that.

00:11:53 Stephen Small

And this is what's interesting research in animals has shown that berberine increases GLP.

00:11:59 Stephen Small

Secretion in our bodies and we know that GLP, one agonist treat diabetes.

00:12:05 Stephen Small

Increasing insulin secretion to decrease glucose, but they also decrease stomach emptying to help us feel full.

00:12:12 Stephen Small

So with that news, I can see why patients may be asking about this supplement and turning to it, especially with all these shortages going on.

00:12:19 Stephen Small

But let's see what the evidence says.

00:12:22 Stephen Small

When it comes to diabetes, there is evidence showing berberine is possibly.

00:12:26 Stephen Small

Believe it or not, clinical studies have shown that adding berberine to lifestyle changes can moderately reduce blood glucose.

00:12:34 Stephen Small

A1C in people with Type 2 diabetes.

00:12:38 Stephen Small

These A1C changes, though they change from about .4 to .7%.

00:12:43 Stephen Small

And this is also seen when berberine is combined with other diabetes meds.

00:12:48 Stephen Small

Thinking things like metformin, right?

00:12:50 Stephen Small

And.

00:12:51 Stephen Small

1C Labs were seen to decrease by 6 to 9 percent there as well.

00:12:57 Stephen Small

Now I'm open to your thoughts arah, but based on that I would avoid recommending berberine on its own for diabetes.

00:13:03 Stephen Small

Berberine's evidence is positive, but we do know we have robust data for actual prescription GOP and agonist right and our other diabetes meds on the market.

00:13:13 Stephen Small

So I could see this is being an option to add on to other diabetes meds instead if that makes sense.

00:13:20 Sara Klockars

It does, and I would agree with that assessment as.

00:13:23 Sara Klockars

I don't think I would ever recommend using it on its own just because we don't have those long term outcomes.

00:13:30 Stephen Small

Yeah, not a solo candidate for sure.

00:13:32 Stephen Small

So Berbrin has another interesting use Sarah and it's hypertension.

00:13:36 Stephen Small

Where it is also possibly effective. There's evidence that berberine if you take it daily for two months added with amlodipine actually decreases blood pressure.

00:13:46 Stephen Small

Now the extent we're talking about here is a systolic decrease of about 5 millimetres of mercury.

00:13:52 Stephen Small

And just two millimetres.

00:13:54 Stephen Small

For diastolic blood pressure, now at first I thought that doesn't seem like a.

00:13:58 Stephen Small

Lot but.

00:13:59 Stephen Small

Evidence suggests decreasing systolic blood pressure by 5mm of mercury may decrease the risk of CV events like a heart attack by a potentially 10%.

00:14:09 Stephen Small

That was actually surprising to me.

00:14:11 Stephen Small

To keep in mind though, we have no direct evidence that berberine prevents those kinds of CV outcomes, only that it lowers blood pressure.

00:14:19 Stephen Small

So until those studies occur, we can't make that direct claim.

00:14:25 Stephen Small

So on a related note, we also have hyperlipidemia.

00:14:28 Stephen Small

A lot of CV themes here where Berbran is also found to be possibly effective.

00:14:33 Stephen Small

Now the berberine dosage I found most often used here in these studies was 500 milligrams twice daily.

00:14:40 Stephen Small

Or some people used it three times a day at a dose ranging from 200 to 500 milligrams, and some took it up to two years.

00:14:48 Stephen Small

Now the clinical studies I found suggest that berberine alone might be as effective as statins with lowering lipid levels, which is interesting compared to these lipid lowering meds on their own, combining them with berberine decreases total cholesterol by 10 to 15 milligrams per deciliter.

00:15:06 Stephen Small

Triglycerides up to 30 and LDL by up to 9, but again this is in combination. So it's kind of like what we're talking about. Diabetes. I wouldn't want to use this so low.

00:15:17 Stephen Small

In one interesting nugget I found though, is that these lab improvements may not be seen when taking burbrine longer than three months.

00:15:24 Stephen Small

There's some conflicting evidence.

00:15:26 Stephen Small

We need to think about and probably we need to use that when we talk about patients, when we're framing their expectations, right.

00:15:35 Sara Klockars

That's really interesting, I think, and a huge thing to point out that if the improvements don't last, it may not be worth recommending it interesting.

00:15:44 Stephen Small

Absolutely. Especially when we're thinking about the cost too.

00:15:47 Stephen Small

And then we also have interest in weight loss.

00:15:50 Stephen Small

Here's where things.

00:15:51 Stephen Small

It's actually where we have insufficient evidence to recommend Burr brain for this indication.

00:15:56 Stephen Small

This is important, Sarah, because we all know that a lot of our GOP and agonists are getting new indications for weight loss and some patients.

00:16:03 Stephen Small

May be extrapolating from that, but they can use this quote natures of zenpec for for weight loss.

00:16:10 Stephen Small

Now, several small studies were analyzed and showed that berberine up to 1500 milligrams daily for up to two years can reduce weight, but only by about 4 1/2 lbs. And a BMI decrease of about .5.

00:16:23 Stephen Small

This is when it's compared with placebo.

00:16:26 Stephen Small

Life changes or no intervention, it could sound decent, but these results didn't require patients to be overweight or even obese to be.

00:16:34 Stephen Small

So it's kind of hard to say that this is meant for the intended population here. So for treating obesity, I would pretty much advise against Burberry.

00:16:42 Stephen Small

That's more evidence.

00:16:44 Stephen Small

And then there are some other uses. I found that people were interested in for berberine, but these also had insufficient evidence.

00:16:51 Stephen Small

Included things like Afib, heart failure, stroke and even irritable bowel disease or viral hepatitis.

00:16:57 Stephen Small

List really goes on and on.

00:16:59 Stephen Small

But the evidence for all these, like I said, is insufficient to really support them.

00:17:03 Stephen Small

Just don't have the studies.

00:17:06 Stephen Small

And with that in mind, let's talk about the safety that we should always think about with these supplements.

00:17:10 Stephen Small

The good news is that it's generally well tolerated, even if given topically, which I found to be an interesting route that some people used. The most common side effects I saw were mostly GI related. Talking about things like diarrhea, nausea, or abdominal pain.

00:17:25 Stephen Small

What's interesting and concerning about Burberry is that it does stimulate uterine contractions.

00:17:30 Stephen Small

Least the evidence suggests that.

00:17:32 Stephen Small

And when we're talking about a pregnant patient, those uterine contractions could cause preterm birth.

00:17:37 Stephen Small

Definitely don't want that.

00:17:39 Stephen Small

So this makes berberine likely unsafe in pregnant patients, and if the pregnant patient is taking it, it may also lead to something called chronic terus in the baby after it's born.

00:17:50 Stephen Small

This is where bilirubin and the baby's blood can get so high, to the point it becomes toxic and can actually cause nerve damage or brain damage, which can be fatal.

00:17:58 Stephen Small

This is something we always looked out for in the NICU.

00:18:01 Stephen Small

During my past role.

00:18:04 Stephen Small

Now Berbrin also transfers through breast milk, so there is still that same connectorous concern even after the baby's born and breastfeeding.

00:18:11 Stephen Small

So overall I would just avoid berberine and pregnant and lactating patients based on that.

00:18:19 Stephen Small

And this flows well into our concerns of Pediatrics based on that lack of breastfeeding safety evidence, we know that giving birth directly to newborns is not a good idea.

00:18:28 Stephen Small

Whether it's through breastfeeding or taking it directly, and we also don't have evidence to support its safety even in older kids, so it's best to avoid giving this to children until we have more data.

00:18:42 Stephen Small

And with interactions, I was surprised to find out that there is actually quite a few evidence shows that it may increase levels metabolized by CYP, 2C92D6 and even 3A4.

00:18:54 Stephen Small

So this makes me think of drugs that could.

00:18:57 Stephen Small

Raise levels like cyclosporine, warfarin or even oral contraceptives.

00:19:02 Stephen Small

We also have to think about the additive effects it can do to some of those indications we talked about earlier.

00:19:07 Stephen Small

Can actually increase the effects of antiplatelet meds, anti hypertenses diabetes meds of course.

00:19:13 Stephen Small

Sedatives.

00:19:15 Stephen Small

So if I had a patient interested in berberine Sarah, there are some other points I want to consider as well.

00:19:21 Stephen Small

We have to keep in mind dosage forms.

00:19:23 Stephen Small

Soft gel capsules for berberine have gel to make from pork or even bovine or cow sources.

00:19:29 Stephen Small

So this may not align with some cultural or religious dietary beliefs that we should always think about, but it's also available on topical.

00:19:36 Stephen Small

Ointments and aromatherapy essential oils. As an alternative, if people wish to do that, although the evidence may not be there for those specific routes.

00:19:45 Stephen Small

I also found some products where berberine is combined with other ingredients like cinnamon, so looking at labels closely can help patients know what they're actually taking.

00:19:56 Stephen Small

Sarah, what questions do we have coming in for me?

00:20:00 Sara Klockars

OK, it looks like there's one here about interactions as well. So let's talk a little bit about interactions.

00:20:09 Sara Klockars

Are there any drug interactions with SSRIs?

00:20:13 Sara Klockars

What do we know about that?

00:20:14 Sara Klockars

Answer This audience question.

00:20:16 Stephen Small

That's a great question because SSRI as we know are so common and we do need to think about this combination. Now we know that berberine inhibits 3A42C9 and 2D6.

00:20:27

But.

00:20:27 Stephen Small

We don't have that direct evidence saying there's interaction between like actual SSRIs and berberine.

00:20:33 Stephen Small

We can think about and extrapolate from that evidence. I would think about.

00:20:38 Stephen Small

Metabolize through those enzymes specifically.

00:20:41 Stephen Small

Otherwise, they could increase those SSRI levels to toxic amounts and lead to things like serotonin.

00:20:48 Stephen Small

So based on those classes of CYP enzymes, I would probably avoid SSRI options like fluoxetine, sertraline, or paroxetine since they go through those.

00:20:57 Stephen Small

But when I think about this too, then the vaccine cetalapram and mirtazapine.

00:21:03 Stephen Small

Don't go through those or go through.

00:21:05 Stephen Small

Less so. Those may be better options to choose from if you need to.

00:21:10 Sara Klockars

So what is coenzyme Q?

00:21:12 Sara Klockars

Well, it's naturally found in the body with the highest concentrations in the mitochondria of certain organ cells, like the heart, liver, kidney and pancreas.

00:21:23 Sara Klockars

It acts like an antioxidant, neutralizing free radicals that can cause.

00:21:29 Sara Klockars

Cell damage and it also is touted to improve energy levels and help augment the immune system, and you also may hear coenzyme Q10 go by some other names.

00:21:42 Sara Klockars

Such as ubiquinone or ubiquinol and so just to be aware of that, if patients ask for one of those, it's considered one of those physiologic forms of coenzyme Q10.

00:21:56 Sara Klockars

So let's start with where Coenzyme Q10 is likely affective.

00:22:00 Sara Klockars

So there are two rare conditions.

00:22:04 Sara Klockars

Where patients may have symptomatic Co enzyme Q 10 deficiency and this can be genetic or acquired due to different medications or conditions. And then also it can be used to reduce symptoms of mitochondrial muscle disease.

00:22:21 Sara Klockars

And that can also be genetic or.

00:22:24 Sara Klockars

But these are just very rare indications where it is effective.

00:22:30 Sara Klockars

And then.

00:22:32 Sara Klockars

There are some areas where Coenzyme Q10 is possibly effective, and a few that I want to mention today where you may have had questions about in practice are congestive heart failure. But that is when it is added to standard heart failure medications.

00:22:50 Sara Klockars

And may improve fatigue, sleep and tender points and pain in patients with fibromyalgia.

00:22:58 Sara Klockars

And then lastly, I want to mention that Coenzyme Q, 1000 milligrams to 150 milligrams a day.

00:23:06 Sara Klockars

May actually help prevent migraine headaches.

00:23:09 Sara Klockars

It won't.

00:23:10 Sara Klockars

Them, but it may help prevent them.

00:23:12 Sara Klockars

Just note, it may take up to three months to see any benefit, so if somebody's wanting to try Coenzyme Q10 for migraines, just encourage them to try it for at least three months and.

00:23:24 Sara Klockars

Actually, the American Academy of Neurology considers this as possibly effective for migraine prevention in adults.

00:23:32 Sara Klockars

And then, like the other supplements we're talking about today, there's a long, long list of things that's been studied for the coenzyme.

00:23:38 Sara Klockars

10 is possibly ineffective for conditions like Parkinson's disease or Alzheimer's, so we generally wouldn't want to advise patients to take it for those indications.

00:23:49 Sara Klockars

And it's also likely ineffective for athletic performance, meaning there's no evidence it's beneficial to use this supplement.

00:23:57 Sara Klockars

And then there's also interest in a lot of other uses, angina, chronic fatigue syndrome, hypertension.

00:24:06 Sara Klockars

But there's just really not enough evidence to say it's helpful for these or other conditions.

00:24:13 Sara Klockars

Statins like atorvastatin or simvastatin can lower coenzyme Q10 levels in the blood and muscle tissue.

00:24:19 Sara Klockars

And it's thought that this can lead to issues like muscle pain or weakness.

00:24:24 Sara Klockars

But evidence on whether Coenzyme Q10 helps is actually conflicting. Some individual studies suggest a modest benefit.

00:24:34 Sara Klockars

But when looking at a meta analysis where we put those results of these several small studies together, it suggests there are no improvement on muscle pain or statin tolerability. And those doses that have been studied range from 100 milligrams to 600 milligrams a day for one.

00:24:52 Sara Klockars

Three months.

00:24:53 Sara Klockars

So I think it's important that we talk about the safety now that we know that it may or may not be effective.

00:25:01 Sara Klockars

Let's review some safety information.

00:25:05 Sara Klockars

We can clarify that orally coenzyme Q10 is generally well tolerated. So like many other supplements, the most common side effects are GI related.

00:25:17 Sara Klockars

Diarrhea is probably the most common.

00:25:20 Sara Klockars

One way to minimize it with this supplement is by dividing doses. But I had mentioned previously. You can see doses up to 600 milligrams a day.

00:25:29 Sara Klockars

We're definitely going to want to divide those doses to to limit the GI side effects if needed.

00:25:35 Sara Klockars

And then if asked about using Coenzyme Q10 during pregnancy, this is 1 supplement that's possibly safe when taken orally.

00:25:43 Sara Klockars

This is based on very limited evidence taking 100 milligrams twice daily.

00:25:50 Sara Klockars

Starting at 20 weeks gestation and taking until term, but the same doesn't hold true for breastfeeding patients.

00:25:56 Sara Klockars

Just not enough evidence to say whether Coenzyme Q10 is safe during lactation.

00:26:03 Sara Klockars

And then also in children, if you're asked about Coenzyme Q10 and kids, you can explain it's possibly safe when taken orally based on limited studies down to two months of age.

00:26:15 Sara Klockars

And this is using one to 10 milligrams per kilogram per day for up to nine months.

00:26:22 Sara Klockars

And keep in mind though that this is likely for those patients found to have deficiencies, since those rare disorders I mentioned where this is likely effective or often diagnosed in childhood.

00:26:34 Sara Klockars

We want to let patients know that coenzyme Q10 doesn T have any major drug interactions, but it's still prudent to add the supplement to patient profiles just in case. I do want to point out a few things.

00:26:48 Sara Klockars

Some research shows that coenzyme Q10 can lower blood pressure, but other studies.

00:26:54 Sara Klockars

Have shown conflicting results, so it's just one of those things where you're just going to want to have patients report any lower blood pressure signs of dizziness.

00:27:03 Sara Klockars

And then Steve, I also want to point out that Coenzyme Q10 is structurally similar to vitamin K or MINIQUINONE.

00:27:12 Sara Klockars

And this actually helps promote blood clotting, so.

00:27:17 Sara Klockars

Advise caution and patients taking warfarin since coenzyme Q10 might decrease its effects, so patients may need some more frequent monitoring.

00:27:27 Sara Klockars

It's just important to note that coenzyme Q10, even though it's well tolerated, doesn't have a lot of interaction.

00:27:35 Sara Klockars

It's structurally similar to that vitamin K, so something to keep in the back of your mind.

00:27:41 Stephen Small

That's a really good point.

00:27:43 Sara Klockars

And as I shared earlier, coenzyme Q10 comes in two forms, ubiquinol and ubiquinone.

00:27:50 Sara Klockars

However, there is no advantage of one form or the other, and because coenzyme Q10 comes in a gel or a soft gel capsule form.

00:28:00 Sara Klockars

It may contain gelatin, so some patients may wish to avoid it due to allergies or lifestyle, so just keep that in mind with this capsule, and if this is the case, you may find some alternative coenzyme Q10 products made with cellulose instead.

00:28:15 Sara Klockars

And since Conzyme Q10 is a fat soluble vitamin, it may be helpful if patients take it with fat containing foods to help boost that absorption.

00:28:26 Sara Klockars

All.

00:28:26 Sara Klockars

So that wraps up the presentation.

00:28:29 Sara Klockars

Steve, did you get any good audience questions about Coenzyme Q10?

00:28:35 Stephen Small

Yeah, we.

00:28:35 Stephen Small

We actually have one here about infertility and audience members asking what role does Coq 10 play in infertility?

00:28:45 Sara Klockars

Great question.

00:28:48 Sara Klockars

Infertility falls into the long list of indications where we don't have enough reliable evidence to recommend it.

00:28:55 Sara Klockars

It looks like.

00:28:56 Sara Klockars

There are a few small studies in infertile women where coenzyme Q10 may increase the odds of pregnancy, but it doesn't seem to impact the rate of live birth. So.

00:29:09 Sara Klockars

There's also some information in mails.

00:29:13 Sara Klockars

Where coenzyme Q10 may improve sperm function. But once again when you're looking at long term efficacy, there's no good evidence that it increases pregnancy rates.

00:29:26 Stephen Small

Yeah. Loving these audience questions, Sarah.

00:29:29 Stephen Small

Now flipping gears, what about melatonin?

00:29:32 Stephen Small

Pretty popular among our patients, right?

00:29:34 Stephen Small

I've even taken melatonin in the past when I've had sleeping issues, and that's what most of us think of melatonin is.

00:29:40 Stephen Small

Used for.

00:29:41 Stephen Small

Sleep. But I found there's also interest in using it for other things like ADHD, migraines and others that we'll talk about.

00:29:49 Stephen Small

I've gotten so many questions about dosing or interactions in my career, even as a role as a pediatric pharmacist in a hospital.

00:29:57 Stephen Small

I think we all encounter these from time to time.

00:29:59 Stephen Small

So let's see what we need to consider.

00:30:03 Stephen Small

I could see why many think of melatonin as safe and being a natural medicine, since it's a hormone made in our bodies. It's produced in the brain by the pineal gland to regulate our circadian rhythm.

00:30:15 Stephen Small

Helps regulate our sleep patterns.

00:30:18 Stephen Small

And people with trouble sleeping may have low melatonin levels.

00:30:22 Stephen Small

In fact, it is likely effective for specific sleep disorders.

00:30:27 Stephen Small

Includes delayed sleep phase syndrome.

00:30:31 Stephen Small

This is where a person's bedtime is delayed by two or more hours beyond the usual bedtime.

00:30:37 Stephen Small

As an example that I can think of, the patient might not be able to fall asleep until 4:00 AM and then find it hard to wake up until the afternoon.

00:30:45 Stephen Small

Obviously that can disrupt things like work, social activities and things like that.

00:30:49 Stephen Small

Studies have used 5 milligrams nightly in adults and up to 6 milligrams in kids for this.

00:30:56 Stephen Small

For adults, it was used up to about nine months, whereas for kids was used for just one month, which to me is pretty short.

00:31:03 Stephen Small

And evidence also suggest it's likely effective in some patients with a condition called non 24 hour sleep wake disorder.

00:31:11 Stephen Small

Now, I wasn't completely familiar with this when I looked it up.

00:31:14 Stephen Small

This is something that can particularly affect blind patients.

00:31:18 Stephen Small

They find their bedtime gradually getting pushed back farther and farther every day from minutes to even hours.

00:31:24 Stephen Small

And then this gets them out of sync with that usual 24 hour circadian rhythm, and the doses used here were up to 4 milligrams nightly in kids and 10 milligrams in adults with durations up to about six years, which is pretty long time.

00:31:39 Stephen Small

Then that brings the question of what about for insomnia?

00:31:41 Stephen Small

Because what we just looked at were for specific sleep disorders and insomnia, we know is pretty common.

00:31:47 Stephen Small

Now I was surprised to find out that it does shorten time to fall asleep, but the time frame that was studied it only showed about 7:00 to 12:00 minutes difference.

00:31:56 Stephen Small

Some folks could argue that's not a whole lot of time, especially if you're someone lying awake at night for hours, right?

00:32:02 Stephen Small

But each case.

00:32:04 Stephen Small

May be different, so it kind of depends on the benefit there.

00:32:07 Stephen Small

Similarly, total sleep time when using melatonin for insomnia might only be increased by 8 minutes, which again doesn't sound like a whole lot.

00:32:15 Stephen Small

The data here is unclear.

00:32:19 Stephen Small

And then that question, I always get what about dosing?

00:32:22 Stephen Small

So if adult patients want to take melatonin for insomnia, suggest starting with a dose of up to 3 milligrams or up to 1 milligram in kids.

00:32:32 Stephen Small

And you should be taken 30 to 60 minutes before bed to give it enough time to absorb and to act.

00:32:38 Stephen Small

Then recommend adjusting that dose up or down based on the patient's response and side effects. And keep in mind that most adults won't need over 6 milligrams per day.

00:32:48 Stephen Small

Over 3 milligrams per day in kids.

00:32:52 Stephen Small

So hopefully that kind of explains it and sets up kind of a nice frame of mind when we're starting and adjusting these doses.

00:33:02 Stephen Small

Now onto some of our possibly effective indications here.

00:33:06 Stephen Small

It's actually possibly effective for many other conditions, one that sticks out to me is jetlag during maybe a vacation or a trip. It could help with alertness and reduce daytime sleepiness and tiredness, but it is conflicting. Whether it helps decrease the time to fall asleep like we saw.

00:33:21 Stephen Small

Insomnia.

00:33:22 Stephen Small

Now, it may also be possibly effective for migraine prophylaxis.

00:33:27 Stephen Small

Taking before bed for up to six months can prevent migraine headaches and maybe even decrease the need for taking pain meds for it.

00:33:35 Stephen Small

Now what's interesting is that it's not clear if melatonin helps from migraine.

00:33:39 Stephen Small

The studies didn't compare melatonin to a placebo or another treatment to really have a fair comparison.

00:33:45 Stephen Small

It's hard to say at this time.

00:33:47 Stephen Small

For treatment, whether it's effective.

00:33:51 Stephen Small

And then there are several indications where we have lack of effectiveness, where it doesn't seem to improve sleeping problems in patients, for example, those who do shift work.

00:34:00 Stephen Small

There's interest in melatonin for many other uses such as ADHD or to prevent delirium even in hospitalized patients.

00:34:07 Stephen Small

But again, we don't have enough evidence to whether to say it's actually helpful for these instances, and I would be very hard pressed to have to recommend these in those scenarios.

00:34:18 Stephen Small

Now I've got many questions about melatonin safety from patients and prescribers.

00:34:22 Stephen Small

So thankfully, oral melatonin is generally well tolerated side effects to focus on would be things like drowsiness or dizziness and even headache or nausea and short term use is likely safe in adults based on evidence using up to 8 milligrams per day for up to six months.

00:34:39 Stephen Small

And possibly say for up to two years in some patients and thankfully dependence has not been found.

00:34:48 Stephen Small

But we should advise against taking melatonin in pregnancy or lactation.

00:34:52 Stephen Small

What's interesting here is there's evidence that high doses, and we're talking a whopping like 75 to 300 milligrams daily, might inhibit ovulation and impair pregnancy.

00:35:03 Stephen Small

And there's not enough evidence to say whether it's safe. Drug pregnancy at lower doses or breastfeeding.

00:35:08 Stephen Small

So we can't really make a safe recommendation there.

00:35:12 Stephen Small

But what about for Pediatrics?

00:35:14 Stephen Small

In fact, short term use is possibly safe. Studies we found in children have been limited in duration, such as up to only four weeks.

00:35:22 Stephen Small

A pretty short amount of time.

00:35:23 Stephen Small

What's important here is there's some concern that taking melatonin might adversely affect gonadal development in kids.

00:35:29 Stephen Small

Reproductive development, but the data's limited.

00:35:33 Stephen Small

Clear 0.

00:35:34 Stephen Small

Recommend parents only intentionally give melatonin to their kids if there's a real medical reason to do so, I would say that healthy kids shouldn't be taking melatonin on a regular basis to fall asleep.

00:35:46 Stephen Small

And we need to think about other risks here, too. Although rare, pediatric overdoses of melatonin have occurred and they've resulted in hospitalization needing mechanical ventilation and even death.

00:35:58 Stephen Small

So in fact, we found that 11,000 emergency department visits occurred between 2019 and 2022 alone.

00:36:06 Stephen Small

So some of the formulations are colorful gummies and I can see how they look like enticing candy to kids.

00:36:14 Stephen Small

To me, I would recommend parents choose a product with a child resistant cat.

00:36:19 Stephen Small

And counsel.

00:36:20 Stephen Small

Secure meds outside of children's reach, just like we do with all meds, and even with supplements.

00:36:26 Stephen Small

Now, if patients want to take melatonin, we should also ask about current meds and think about interactions, right?

00:36:33 Stephen Small

Are some situations where I would be more cautious?

00:36:36 Stephen Small

One example is patients on anti seizure meds or meds that lower the seizure threshold.

00:36:41 Stephen Small

I'm thinking things like bupropion, for example.

00:36:44 Stephen Small

Some research suggests melatonin might increase seizure risk in certain patients, especially children. And melatonin might also stimulate immune function.

00:36:55 Stephen Small

And then, since melatonin has sedating effects, that's what we're using it for, right?

00:36:59 Stephen Small

It can have additive effects with other CNS depressants. Things like opioids or benzodiazepines and can increase drowsiness, dizziness and sleepiness.

00:37:09 Stephen Small

Melatonin also inhibits CYP 1A2 and.

00:37:14 Stephen Small

Two C 19, so it may increase the level of drugs that go through those pathways.

00:37:20 Stephen Small

All that said, I do have some practice Earls that we can.

00:37:22 Stephen Small

Sarah, first we can all help patients look for possible causes of insomnia before thinking about moving to melatonin to treat it.

00:37:31 Stephen Small

So, for example, meds such as stimulants for ADHD or some Ssri's can impact sleep.

00:37:37 Stephen Small

And underlying conditions may also be contributing to insomnia that we should account for. Thinking about things like pain or depression or even restless leg syndrome and even heartburn when you think about it, can worsen insomnia.

00:37:49 Stephen Small

We should be thinking about the source of that.

00:37:53 Stephen Small

And we can help emphasize sleep hygiene. Things like doing relaxation exercises or avoiding bright lights from ATV or a phone right before bed.

00:38:04 Stephen Small

And then if you are moving to melatonin products, help your patients sort through them.

00:38:08 Stephen Small

Try to recommend one that's immediate release.

00:38:11 Stephen Small

There's not much evidence for delayed or timed release formulations for some of our sleep issues that we talked about earlier.

00:38:17 Stephen Small

Also, it would be good to be aware that melatonin comes in different dosage forms, like tabs or gummies, and some are labeled in micrograms instead of milligrams and making sure we don't confuse those.

00:38:29 Stephen Small

So double check those strengths and units to make sure patients get the right item.

00:38:33 Stephen Small

And you might get questions where the melatonin is made. Most are synthetic, so made in a lab, but some products are sourced from actual animal pineal glands. Believe it or not, it was kind of surprised to hear that. So you may have some patients that don't want it.

00:38:47 Stephen Small

That way.

00:38:48 Stephen Small

And to consider that.

00:38:50 Stephen Small

And then regardless of why a patient is using melatonin, remind them not to drive or operate, you know, heavy machinery for up to four or five hours after taking melatonin because of that potential for causing daytime sleepiness.

00:39:06 Stephen Small

So that was a lot about melatonin.

00:39:08 Stephen Small

So, Sarah, what kind of audience member questions do we have on that?

00:39:11 Stephen Small

Sure. We had many.

00:39:13 Sara Klockars

Yes, we have an audience member asking.

00:39:17 Sara Klockars

Does taking melatonin inhibit the body's own melatonin production?

00:39:22 Stephen Small

Meds, thinking of things like opioids and benzodiazepines like thorazepam, we do worry that patients will not be able to produce or transmit those neurotransmitters like they did before the Med, right?

00:39:33 Stephen Small

And we know this can set the stage for things like withdrawal when the Med is stopped.

00:39:38 Stephen Small

And that's a common issue with many sleep meds.

00:39:40 Stephen Small

What's interesting here is that giving melatonin doesn't seem to decrease endogenous melatonin production. So withdrawal symptoms like rebound insomnia haven't been reported when it's stopped.

00:39:53 Stephen Small

And this also makes me think about romeldeon the prescription melatonin analog on the market. It also doesn't report having withdrawal effects either, and it's not a controlled substance.

00:40:03 Stephen Small

Pretty interesting.

00:40:05 Sara Klockars

Very interesting.

00:40:06 Sara Klockars

Points.

00:40:08 Sara Klockars

Switch gears now and take a closer look at turmeric, which continues to be one of the top selling herbal supplements.

00:40:18 Sara Klockars

So many people often think of turmeric as safe, since it's a spice and it's in many of our spice cabinets. It's derived from the root of the turmeric plant, which is a member of the ginger family. Curcumin is the yellow colored primary.

00:40:34 Sara Klockars

Active constituent derived from turmeric, and it's also commonly used to colored foods and cosmetics.

00:40:41 Sara Klockars

Also, curcumin seems to have anti-inflammatory and antioxidant effects, which leads us to the interest for using it.

00:40:50 Sara Klockars

A variety of conditions.

00:40:53 Sara Klockars

So let's talk about some areas where turmeric is possibly effective.

00:40:57 Sara Klockars

There are some small clinical studies showing benefit in patients with functional dyspepsia.

00:41:05 Sara Klockars

There are also some data that suggest turmeric may improve symptoms of knee arthritis, such as knee pain and stiffness, and we'll talk about these two indications in a little bit more depth in a minute.

00:41:16 Sara Klockars

And then there's also some evidence that suggests oral curcumin seems to attenuate fat deposition and improve some metabolic parameters such as liver enzymes, hemoglobin A1C, and total cholesterol in adults with non alcoholic fatty liver disease or what is now being called metabolic dysfunction associated stiototic Li.

00:41:40 Sara Klockars

So let's hone in on its use and functional dyspepsia or indigestion, since we see this commonly in practice, and this is sometimes called non ulcer dyspepsia, since these patients don't have an ulcer.

00:41:55 Sara Klockars

And these patients may have stomach pain or bloating after eating or heartburn symptoms, and we have some evidence that shows that oral curcumin is similarly effective when compared with the proton pump inhibitor omeprazole.

00:42:09 Sara Klockars

But turmeric might not provide further symptom reduction in patients also taking Famotidine or omeprazole.

00:42:18 Sara Klockars

So if patients want to take turmeric for dyspepsia, suggest trying 500 milligrams four times a day of the curcumin constituent. And most studies were short term, using it for this indication, lasting from 7 to 30 days.

00:42:36 Sara Klockars

And I think I've had more questions about using turmeric for arthritis, even from some friends and family members.

00:42:44 Sara Klockars

Let's look at the evidence here.

00:42:47 Sara Klockars

Several meta analysis show that turmeric may reduce knee pain and stiffness and may improve physical function and even reduce the need for rescue medicines when compared to place.

00:43:00 Sara Klockars

However, those benefits were reduced in patients as age increased and also as body mass index increased, and these studies used a variety of products and doses.

00:43:13 Sara Klockars

They weren't the best quality evidence, so it just really makes it hard to draw.

00:43:17 Sara Klockars

Conclusions.

00:43:19 Sara Klockars

It's also unclear how turmeric compares to Nsaid's or other meds that we may use for osteoarthritis.

00:43:26 Sara Klockars

Aren't any good comparative studies out there?

00:43:31 Sara Klockars

And not all turmeric product studies seem to be effective for improving symptoms of osteoarthritis.

00:43:36 Sara Klockars

We really have some mixed evidence there.

00:43:40 Sara Klockars

Some doses included a turmeric extract of 500MG3 to four times daily for four to six weeks, or turmeric extract, 500 milligrams twice daily for three months.

00:43:54 Sara Klockars

In general, turmeric extract has most often been used in doses of 1 1/2 grams daily for up to three months.

00:44:03 Sara Klockars

Just know there's no best dose for osteoarthritis.

00:44:09 Sara Klockars

On the other hand, turmeric does not seem to improve the healing of peptic or gastric ulcers when compared to placebo.

00:44:18 Sara Klockars

And turmeric doesn't seem to improve cognitive function or slow cognitive decline in patients with Alzheimer's disease.

00:44:25 Sara Klockars

There's interest in term work for many, many other uses such as diabetes, irritable bowel, bowel syndrome, ulcerative colitis, but there's really just not enough evidence to say whether it's helpful for these conditions.

00:44:38 Sara Klockars

That's just a quick overview of efficacy.

00:44:41 Sara Klockars

Let's move on to safety.

00:44:44 Sara Klockars

We can clarify that oral turmeric is generally well tolerated when used short term.

00:44:51 Sara Klockars

Products providing up to 8 grams of curcumin have been safely used for up to two months, so that's good and caution patients about the GI side effects. Like all of these supplements, diarrhea or nausea are the most common side effects.

00:45:07 Sara Klockars

But also caution that at least 70 reports of liver damage are linked with turmeric, especially at high doses or with highly bioavailable formulations, such as those containing black pepper extract or peppermint.

00:45:20 Sara Klockars

Some of these cases occurred after two weeks.

00:45:23 Sara Klockars

Others up to 14 months of use and sometimes term work was used with other supplements and medications. In most cases of limer damage resolved upon discontinuation of the supplement.

00:45:37 Sara Klockars

And be aware for patients who are pregnant or lactating, turmeric and usual amounts in food is likely safe in pregnancy and.

00:45:46 Sara Klockars

So if you're just using it as a regular spice, it is fine, but advise against medicinal doses of turmeric and pregnancy, it might stimulate the uterus.

00:45:56 Sara Klockars

And there's also not enough evidence to say if medicinal amounts are safe and lactation, and then when looking at Pediatrics research with turmeric is limited.

00:46:07 Sara Klockars

We should really not be using the same kids either.

00:46:12 Sara Klockars

There are no.

00:46:14 Sara Klockars

Known major interactions with turmeric, but there are some situations in which we need to be more cautious.

00:46:21 Sara Klockars

So if a patient wants to take turmeric, we should ask about current meds and make sure we're updating those Med lists.

00:46:28 Sara Klockars

So for example, advice caution and patience on antidepressants.

00:46:32 Sara Klockars

Research suggests turmeric may have anti platelet effects.

00:46:36 Sara Klockars

And so there might be an increased risk of bleeding.

00:46:41 Sara Klockars

And since we have rare case reports of liver damage, we'd want to avoid turmeric in patients who already.

00:46:48 Sara Klockars

Liver disease, such as hepatitis and then caution against using turmeric with those known hepatotoxic meds like isoniazid or methotrexate, since this could increase the risk of liver injury.

00:47:01 Sara Klockars

And also be aware that turmeric might increase levels of drugs metabolized by different cytochrome P-450 enzymes, for example.

00:47:10 Sara Klockars

Want to watch for meds such as duloxetine apixaban and substrates of P glycoprotein such as ribaroxiban?

00:47:19 Sara Klockars

Just really want to be cautious.

00:47:21 Sara Klockars

This is mostly in vitro and animal research, so there is one case report of a transplant patient with acute kidney toxicity.

00:47:31 Sara Klockars

An elevated tachralamus levels after 10 days of turmeric powder.

00:47:35 Sara Klockars

Consumption.

00:47:37 Sara Klockars

But this was at a dose of 15 or more spoonfuls a day, so it's a very large amount that led to the possible drug interaction.

00:47:45 Sara Klockars

Just be aware that it's mostly in vitro and animal, but the risks is still there.

00:47:51 Stephen Small

Yeah, that's a huge amount. Very interesting.

00:47:55 Sara Klockars

OK.

00:47:56 Sara Klockars

So if you practice pearls and thinking of safety first, we wanna ensure patients report any symptoms of liver damage.

00:48:02 Sara Klockars

So if they have any stomach pain, nausea, weight loss, yellowing of the skin, be sure to report that right away.

00:48:10 Sara Klockars

And since there are so many products out there and not necessarily a standard formulation of turmeric.

00:48:17 Sara Klockars

Point patients to the supplement facts to check on the amount in each product and it may be labeled as curcumin complex.

00:48:24 Sara Klockars

Cumin curcuminoids can be labeled as a lot of different things and also be aware that some turmeric supplements claim to boost absorption.

00:48:35 Sara Klockars

And so they might be labeled as having liposomal or nanoparticle formulations.

00:48:41 Sara Klockars

Or adding that peppermint or black pepper extract I mentioned earlier to boost that absorption.

00:48:48 Sara Klockars

Just point patients to labels to see what they're really getting with turmeric products.

00:48:53 Sara Klockars

And then also advise that there's no good evidence that any one product works best.

00:48:59 Sara Klockars

Special forms are often more costly as well.

00:49:03 Sara Klockars

So Steve?

00:49:04 Sara Klockars

We get into audience questions. It's time for a fun fact.

00:49:08 Sara Klockars

Did you know? A typical dose of 1 to 2G a day of turmeric extract works out to be about 5 to 10 teaspoonfuls of turmeric spice.

00:49:18 Stephen Small

It's that sounds like a lot.

00:49:20 Stephen Small

It would.

00:49:20 Sara Klockars

Be really tough to get these doses from the spice itself.

00:49:25 Sara Klockars

So are there any?

00:49:26 Sara Klockars

Questions about term work. We should chat about today.

00:49:31 Stephen Small

That's a really vibrant color.

00:49:33 Stephen Small

Listener.

00:49:34 Stephen Small

Can turmeric die?

00:49:36 Stephen Small

Skin or eyes or even teeth.

00:49:40 Sara Klockars

And that was a great question. We had to look into that a little bit. But yellow discoloration of the skin has been reported rarely.

00:49:48 Sara Klockars

Are some reports of temporary yellow skin dust coloration?

00:49:54 Sara Klockars

There's also a report of someone who drank 3 or 4 glasses of soaked fresh turmeric root and powder, and they had yellow skin pigmentation that slightly improved after about four weeks.

00:50:07 Sara Klockars

Yeah, there are some cases out there.

00:50:09 Sara Klockars

There's a possibility it might even.

00:50:12 Sara Klockars

Impact some dental restoration. So depending on what the dentist is using, it could even stain some teeth.

00:50:18 Sara Klockars

That's interesting too.

00:50:20 Sara Klockars

So, Steve, I was wondering if you could help me discuss how we can help navigate discussions with patients on choosing a product.

00:50:30 Stephen Small

Absolutely happy to help with that. Now. Many patients we know use natural medicines or supplements, but they don't want to share this info with us for a variety of reasons. However, as we discussed today, there are potential interactions.

00:50:45 Stephen Small

Safety concerns side effects with supplements. We need to think about, so it's best to directly ask the patient at every encounter and I would document these in the patient's profile, in the pharmacy and the EHR.

00:50:57 Stephen Small

I would be sure to ask open-ended questions that begin with why? How what to allow the patient to respond and that'll be based on their experience and their understanding. And I think it's important about having an open mind here that can help open the door to honest.

00:51:12 Stephen Small

With our patients.

00:51:14 Stephen Small

And I think that can lead to shared decision making and a discussion about those risks and benefits of using those supplements.

00:51:22 Sara Klockars

Excellent. Super helpful. As we do tend to get a lot of these questions in practice, so that's great information.

00:51:29 Stephen Small

Absolutely.

00:51:31 Sara Klockars

So it's really important to explain to patients that most alternative therapies are not regulated.

00:51:38 Sara Klockars

By the US Food and Drug Administration, or FDA, or in Canada by Health Canada as strictly as conventional medicine is.

00:51:47 Sara Klockars

And unfortunately, there have been a number of high profile events over the past two decades that have really raised concerns about the quality of supplements on the market and the main concerns relate to whether the labels accurately list the ingredients in the product.

00:52:04 Sara Klockars

And ingredient quantities.

00:52:08 Sara Klockars

And then we also get really worried about unwanted drugs or contaminants in the product.

00:52:14 Sara Klockars

So we want to continue to educate patients that natural does not necessarily mean risk free.

00:52:20 Sara Klockars

For example, there are reports of some turmeric sources being contaminated with lead.

00:52:26 Sara Klockars

That's an example of one of the supplements.

00:52:27 Sara Klockars

Talked about today.

00:52:28 Sara Klockars

And then we want to guide patients towards products that are certified by a reputable third party if possible to help ensure they get a quality product and it has labeled ingredients and doesn't have harmful levels of contaminants.

00:52:46 Sara Klockars

And there have been a lot of reports lately of different things being recalled because they are finding different ingredients in these products and one that came to mind.

00:52:56 Sara Klockars

Mine was undeclared ingredients for berberine products and other supplements touted for weight.

00:53:03 Sara Klockars

There's other different contaminants in there, and sometimes it's even other, you know, prescription medications.

00:53:10 Sara Klockars

But Steve, do you?

00:53:11 Sara Klockars

Do you have anything to comment here on?

00:53:14 Stephen Small

Yeah, it's unfortunate and scary that some of those products are on the market, but I think we're the best suited professional to help guide our patients through that, so.

00:53:22 Stephen Small

Talking about selected quality certifications like you mentioned, there have been efforts to demonstrate that commitment to quality, so some manufacturers have chosen to pursue those third party certifications you talked about.

00:53:35

There.

00:53:35 Stephen Small

Are currently a number of different ones that offer.

00:53:39 Stephen Small

That program for supplement manufacturers.

00:53:41 Stephen Small

And you may see some of these logos on supplement bottles. The details of each of these programs though, as well as their ability to truly confirm product quality, can vary.

00:53:51 Stephen Small

So knowing that insurance and outs of.

00:53:52 Stephen Small

Are import.

00:53:54 Stephen Small

One example is the USP verified product.

00:53:58 Stephen Small

These are tested and have verified ingredients, potency and manufacturing processes.

00:54:03 Stephen Small

They've even tested for those.

00:54:06 Stephen Small

So looking for these certifications can help us guide our patients to a safe product.

00:54:14 Sara Klockars

Thank you for reviewing that.

00:54:16 Sara Klockars

And we also have a great resource in our Natmed Pro. If you go to the tools in the search, the charts, there's a quality certifications chart and it reviews all of the different third party quality certifications.

00:54:32 Sara Klockars

And what they actually analyze for the specific products.

00:54:38 NARRATOR

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