Editors: McPhee, Stephen J.; Papadakis, Maxine A.; Tierney, Lawrence M.
Title: Current Medical Diagnosis & Treatment, 46th Edition
Copyright 2007 McGraw-Hill
> Table of Contents > 42 - Complementary & Alternative Medicine
Complementary & Alternative Medicine
Ellen F. Hughes MD, PhD
Bradly P. Jacobs MD, MPH
Brian M. Berman MD
The use of complementary and alternative medicine (CAM) has become common in the United States. To maintain effective clinician-patient communication and ensure responsible clinical practice, it is important that clinicians learn the theory, practice, and scientific evidence associated with these therapies. This chapter provides an overview of four alternative medicine therapies: herbal medicine, nonherbal dietary supplements, acupuncture, and homeopathy.
CAM is defined by the National Institutes of Health (NIH) as a
CAM modalities have been
Biologically based practices use substances found in nature, such as herbs, special diets, or vitamins (in doses outside those used in conventional medicine).
involves the use of energy fields, such as magnetic fields or biofields (energy fields that some believe surround and
Manipulative and body-based practices
use manipulation or movement of one or more body
Mind-body medicine uses a variety of techniques designed to enhance the mind's ability to affect bodily function and symptoms, such as meditation, prayer, art and music healing, and imagery.
Whole medical systems
are built on complete systems of theory and practice that have evolved apart from ”and often earlier than ”the conventional medical approach used in the United States. Systems such as traditional Oriental medicine, acupuncture, homeopathy, naturopathy, Ayurveda, and Tibetan medicine often use one or more of the
The Centers for Disease Control and Prevention
The most commonly reported CAM
The most common conditions for which adults used CAM were similar to those seen in most primary care offices:
Most people who use CAM combine it with conventional medicine because they perceive the combination to be
In January 2005, the Institute of Medicine of the National Academies released a report on the use of CAM in the United States. They recommended health profession
Funding for biomedical research in this field has increased dramatically. The NIH established the Office of Alternative Medicine in 1992 with an annual budget of $2 million; in 1998, its role was expanded as the National Center for Complementary and Alternative Medicine (NCCAM). NCCAM's budget for fiscal year 2005 is $123 million. Although some CAM modalities are not easily evaluated using randomized control trial methodology, the 2005 Institute of Medicine report recommends that conventional and CAM treatments both be held to similar standards of safety and efficacy.
Astin JA: Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548.
Barnes PM et al: Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;(343):1.
Eisenberg DM et al: Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med 2001;135:344.
Eisenberg DM et al: Trends in alternative medicine use in the United States, 1990 “1997: results of a follow-up national survey. JAMA 1998;280:1569.
Institute of Medicine. Complementary and Alternative Medicine in the United States 2005. http://www.nap.edu/books/0309092701/html/
The use of herbs for medicinal purposes has increased dramatically over the past
In the 1850s, 80% of medicines in the
United States Pharmacopeia
were derived from plants. Today, approximately 20 “30% of the drugs listed in
are plant-derived ”important examples include atropine, colchicine, digoxin, and many antineoplastic
Herbal medicines have been dispensed for centuries by traditional herbalists who have been involved with their cultivation and preparation as well as assessment of their potency. At present, most herbal products are commercially cultivated,
In 1994, the United States Congress passed the Dietary Supplement and Health Education Act (DSHEA). DSHEA classifies vitamins, minerals, herbs, and amino acids as nutritional or dietary supplements. Under DSHEA, supplements can be marketed without proof of safety or efficacy as long as no claim is made for their use in the diagnosis, treatment or cure, or prevention of disease. Manufacturers can, however, make structure and function claims that a product enhances a normal body function or state such as thinking, mood, or immune function. For example, saw palmetto can be marketed to support urinary
In March 2003, the FDA proposed new labeling and manufacturing standards for all dietary supplements. Prior to this, consumers had no guarantee of the quality of the products they purchased. They could not be certain that the plant was accurately identified; that the product was free of microbial, pesticide, and heavy metal contamination; or that all batches contained the same
Such lack of consistency prompted the Institute of Medicine to call on the government to amend DSHEA to implement improved quality-control manufacturing standards for supplements, more accurate labeling requirements, and greater consumer
Patients should be advised to follow certain guidelines when considering whether to use herbal medicines ( Table 42-1 ).
Table 42-1. Advice to patients using herbal medicines.
Product Formulations & Standardization
Herbal formulations include liquids (
To ensure a consistent percentage of the primary active ingredients across batches and brand names, standardized extracts have been developed. Since multiple constituents may have pharmacologic activity, determining the active ingredients for standardization purposes can be a difficult task. The European scientific community has
Safety of Herbal Medicines
Although many medicinal herbs are relatively safe, some have significant toxicity. Herbs
Basch EM et al: Natural Standard Herb and Supplement Handbook: The Clinical Bottom Line. Elsevier Mosby, 2005.
Bent S et al: Commonly used herbal medicines in the United States: a review. Am J Med 2004;116:478.
Blendon RJ et al: Americans' views on the use and regulation of dietary supplements. Arch Intern Med 2001;161:805.
Bruno JJ et al: Herbal use among US elderly: 2002 National Health Interview Study. Ann Pharmacother 2005;39:643.
Estes JD et al: High prevalence of potentially hepatotoxic herbal supplement use in patients with fulminant hepatic failure. Arch Surg 2003;138:852.
Hu Z et al: Herb-drug interactions: a literature review. Drugs 2005;65:1239.
Kelly JP et al: Recent trends in use of herbal and other natural products. Arch Intern Med 2005;165:281.
Wolsko PM et al: Lack of herbal supplement characterization in published randomized controlled trials. Am J Med 2005;118:1087.
Review of the evidence for Selected Herbal Medicines
Table 42-2 provides an overview of selected herbal medicines.
Table 42-2. Overview of selected herbal medicines.
St. John's Wort ( Hypericum perforatum )
St. John's wort is used in the treatment of mild to moderate depression. Most preparations are standardized to hypericin or hyperforin. The precise mechanisms of action are not known. Irreversible monoamine oxidase inhibitory activity noted in vitro has not been
Over the past two decades, St. John's wort has been studied in thousands of patients with mild to moderate depression. Most of the 60-plus randomized controlled clinical trials, systematic reviews, and meta-analyses have shown that it is more effective than placebo and as effective as tricyclic agents for the treatment of mild to moderate depression. Several recent placebo-controlled studies
St. John's wort is generally well tolerated. Side effects are not common and include mild
Bjerkenstedt L et al: Hypericum extract LI-160 and fluoxetine in mild to moderate depression: a randomized, placebo-controlled, multicenter study in outpatients. Eur Arch Psychiatry Clin Neurosci 2005;255:40.
Fava M et al: A double-blind, randomized trial of St. John's wort, fluoxetine and placebo in major depressive
Hypericum Depression Trial Study Group: Effect of Hypericum perforatum (St John's wort) in major depressive disorder: a randomized controlled trial. JAMA 2002;287:1807.
Knuppel L et al: Adverse effects of St. John's wort: a systematic review. J Clin Psychiatry 2004;65:1470.
Linde K et al: St. John's wort for depression: meta-analysis of randomized controlled trials. Br J Psychiatry 2005;186:99.
Madabushi R et al: Hyperforin in St. John's wort drug interactions. Eur J Clin Pharmacol 2006;14:1.
Szegedi A et al: Acute treatment of moderate to severe depression with hypericum extract WS5570 (St. John's wort): randomized controlled double blind non-inferiority trial versus paroxetine. BMJ 2005;330:503.
Garlic was the top-selling herb in 2004 with greater than $27 million in sales. The German Federal Health Agency Commission E and the European Scientific Cooperative on Phytotherapy have approved garlic for the treatment of hyperlipidemia and atherosclerosis. Allicin, the ingredient believed responsible for garlic's therapeutic benefit and odor, is highly unstable. Both heat and acid destroy the
Doses of 600 “900 mg of freeze-dried herb (equivalent to one-half to one clove of raw garlic) appear to have small effects on cholesterol (4 “12% reduction when taken for 4 “6 weeks), minimal effect on blood pressure (< 10 mm Hg), and none on
Garlic is well tolerated and apparently safe for long-term use. In addition to the well-known breath and body odor, common side effects include gastrointestinal upset, nausea, and flatulence.
A more than 50% reduction in blood levels of saquinavir after garlic supplementation has been reported. Although the induction of the cytochrome P450 system was hypothesized as the mechanism of action of this significant herb-drug interaction, a recent
Markowitz JS et al: Effects of garlic ( Allium sativum L .) supplementation on cytochrome P450 2D6 and 3A4 activity in healthy volunteers. Clin Pharmacol Ther 2003;74:170.
Mulrow C et al: Garlic: Effects on cardiovascular risks and disease, protective effects against cancer, and clinical adverse effects. Rockville, MD: Agency for Healthcare Research and Quality; 2003. AHRQ publication 01-E023.
Piscitelli SC et al: The effect of garlic supplements on the pharmacokinetics of saquinavir. Clin
Stevinson C et al: Garlic for
Tattelman E: Health effects of garlic. Am Fam
Williams MJ et al: Aged garlic extract
The dried leaf of the ginkgo tree has been used medicinally for thousands of years. More than 400 studies over the past 30 years have investigated ginkgo's ability to improve blood flow in a variety of conditions, including memory impairment, dementia, peripheral
Early studies that assessed ginkgo's efficacy on cognitive function in the elderly showed a modest improvement when compared to placebo. The longest of these studies (1 year) showed stabilization of cognitive and functional
In general, ginkgo is well tolerated in healthy adults at recommended doses for up to 6 months. Allergic skin reactions, gastrointestinal disturbances, and headache occur in less than 2% of patients. There are theoretical concerns about a risk of increased bleeding because antiplatelet activating factor activity has been demonstrated in vitro. Nearly 20 cases of increased bleeding in patients taking ginkgo have been reported, but establishing a causal relationship is challenging because many of these patients had other risk factors including age and use of medications, such as warfarin, aspirin, or NSAIDs. Of note, no excess bleeding complications have been reported in clinical trials and no differences in
Gingko has also been evaluated for its effect on intermittent claudication. A meta-analysis of nine randomized, placebo-controlled, double-blinded trials of patients treated with EGb 761 showed a modest treatment effect in the increase of pain-free walking distance in favor of ginkgo over placebo. There is insufficient evidence to support ginkgo's efficacy in treating tinnitus, acute mountain sickness, vertigo, or SSRI-associated sexual dysfunction.
Bent S et al: Spontaneous bleeding associated with Ginkgo biloba. A case report and systematic review of the literature. J Gen Intern Med 2005;20:657.
Birks J: Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev 2002;(4):CD003120.
Elsabagh S et al: Differential cognitive effects of Ginkgo biloba after acute and chronic treatment in healthy young volunteers. Psychopharmacology (Berl) 2005;179:437.
Jiang X et al: Effect of ginkgo and ginger on the pharmacokinetics and pharmacodynamics of warfarin in healthy subjects. Br J Clin Pharmacol 2005;59:425.
Kohler S et al: Influence of a 7-day treatment with Ginkgo biloba special extract EGb 761 on bleeding time and coagulation: a randomized, placebo-controlled, double-blind study in healthy volunteers. Blood Coagul Fibrinolysis 2004;15:303.
Pittler MH et al: Complementary therapies for peripheral arterial disease: systematic review. Atherosclerosis 2005;181:1.
Soloman PR et al: Ginkgo for memory enhancement: a randomized controlled trial. JAMA 2002;288:835.
van Dongen M et al: Ginkgo for elderly people with dementia and age-associated memory impairment: a randomized clinical trial. J Clin Epidemiol 2003;56:367.
Echinacea ranks second among the top-selling herbs in the United States, accounting for more than $300 million in sales annually. Three of nine
species are currently used for the treatment and prevention of upper respiratory infections. Preparations are made from roots (
), above-ground parts (
The quality of most clinical trials has been limited by use of multiple products and doses (including formulations containing multiple herbs) and the lack of
The majority of early trials reported that echinacea is effective in reducing the duration and severity of colds if started within several days of the onset of symptoms but no more effective when taken to prevent infection. A well-designed, 2005 trial studied three different
root preparations for the prevention and treatment of laboratory-induced rhinovirus infections. Four hundred
In general, echinacea is well tolerated, with few reported adverse events. Rare allergic reactions including rash have been reported (especially in patients with ragweed allergies), and there was a single case of recurrent erythema nodosum. The German Commission E recommends that patients who are pregnant, have autoimmune disease, or who are immunocompromised not take echinacea because of its immune-stimulating effects. The Commission also recommends that its use be limited in others to less than 4 weeks. The data supporting these recommendations are not clear.
Barrett B et al: Treatment of the common cold with unrefined echinacea. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2002;137:939.
Goel V et al: A proprietary extract from the echinacea plant ( Echinacea purpurea ) enhances systemic immune response during a common cold. Phytother Res 2005;19:689.
Linde K et al: Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev 2006;(1):CD000530.
Sperber SJ: Echinacea purpurea for prevention of experimental rhinovirus colds. Clin Infect Dis 2004;38:1367.
Turner RB et al: An evaluation of Echinacea angustifolia in experimental rhinovirus infections. N Engl J Med 2005;353:341.
Yale SH et al: Echinacea purpurea therapy for the treatment of the common cold: a randomized, double-blind, placebo-controlled clinical trial. Arch Intern Med 2004;164:1237.
Kava beverages prepared from the dried rhizome of the
plant have been consumed for centuries as ceremonial drinks in the South Pacific islands. Its present-day uses include the treatment of anxiety, stress, and insomnia. The active ingredients (kavapyrones) have central muscle-
A systematic review and meta-analysis of eleven randomized, double-blind, placebo-controlled trials concluded that kava was more effective than placebo in
Kava has been well tolerated in clinical trials. Less than 2.3% of patients report gastrointestinal complaints, drowsiness, tremor, headache, or allergic skin reactions. There are several case reports of patients feeling sedated, disoriented, or ataxic after consuming high doses of kava (or kava in combination with alcohol or prescription drugs that act on the central nervous system). These include two driving under the influence arrests of patients who had consumed 8 “16 cups of a kava beverage. Kava may have dopamine
In 2001, the German government reported 29 cases of hepatitis, cirrhosis, and liver failure possibly associated with the use of kava. Although 18 of these reports were in patients who were also taking medications with known or potential liver toxicity, one case involved a previously healthy 50-year-old man who was not taking prescription medications or alcohol who required a liver transplant. As a result of almost 80 case reports, kava products have been taken off the market in the European Union, Australia and Canada. Warnings about possible hepatic toxicity have been issued to patients with acute or chronic liver disease. How kava causes hepatic toxicity is not clear, but possible mechanisms of action include idiosyncratic reactions, differences in preparation (commercial kava is prepared in acetone, methanol, or ethanol while traditional kava is aqueous), inhibition of the cytochrome P450, or reduction in liver glutathione levels.
Clouatre DL: Kava Kava: examining new reports of toxicity. Toxicol Lett 2004;150:85.
Cote CS et al: Composition and biological activity of traditional and commercial kava extracts. Biochem Biophys Res Commun 2004;322:147.
Ernst E: Herbal remedies for anxiety ”a systematic review of controlled clinical trials. Phytomedicine 2006;13:205.
From the Centers for Disease Control and Prevention. Hepatic toxicity possibly associated with kava-containing products ”United States, Germany, and Switzerland, 1999 “2002. JAMA 2003;289:36.
Perez J et al: Altered mental status and ataxia secondary to acute Kava
Witte S et al: Meta-analysis of the efficacy of the acetonic kava-kava extract WS1490 in patients with non-psychotic anxiety disorders. Phytother Res 2005;19:183.
Ginseng root has been used for medicinal purposes in Asia for over 2000 years. There are three major forms of ginseng in use today: Asian ginseng ( Panax ginseng ); American ginseng ( Panax quinquefolius ); and Siberian ginseng ( Eleutherococcus senticosus ), which is not a member of the Panax genus. The German Commission E monograph on ginseng root approves its use as a tonic to counteract weakness and fatigue, as a restorative for declining stamina and impaired concentration, and as an aid to convalescence. Extracts are made from dried roots and contain ginsenosides. Over 25 ginsenosides have been isolated, each with unique and sometimes oppositional effects on the cardiovascular, central nervous, and immune systems. The mechanisms of action have not been clearly delineated.
There is an
Ginseng is well tolerated at recommended doses, with few adverse effects. A recent systematic review of adverse reactions reports that the incidence is similar in ginseng monopreparations and placebo. Possible drug interactions have been reported between P ginseng and warfarin, phenelzine, calcium channel blockers, digoxin, and alcohol. Earlier reports of ginseng abuse syndrome and other toxicities are now attributed to adulterants found in earlier unregulated over-the-counter ginseng products. Indeed, 13 of 21 ginseng products recently evaluated for quality and purity failed because they contained unacceptable levels of pesticides or heavy metals or inadequate concentrations of ginsenosides.
Coon JT et al: Panax ginseng: a systematic review of adverse effects and drug interactions. Drug Safety 2002;25:323.
McElhaney JE et al: A placebo-controlled trial of a proprietary extract of North American ginseng (CVT-E002) to prevent acute respiratory illness in institutionalized older adults. J Am Geriatr Soc 2004;52:13.
Predy GN et al: Efficacy of an extract of North American ginseng containing poly-furanosyl-pyranosyl-saccharides for preventing upper respiratory tract infections: a randomized trial. CMAJ 2005;173:1043.
Sievenpiper JL et al: Decreasing, null and increasing effects of eight popular types of ginseng on acute postprandial glycemic indices in healthy
Sievenpiper JL et al: Null and opposing effects of Asian ginseng ( Panax ginseng C.A. Meyer) on acute glycemia: results of two acute dose escalation studies. J Am Coll Nutr 2003;22:524.
Vogler BK et al: The efficacy of ginseng. A systematic review of randomised clinical trials. Eur J Clin Pharmacol 1999;55:567.
Yuan CS et al: Brief communication: American ginseng
Saw palmetto is used by over 2 million men in the United States to treat benign prostatic hyperplasia, and in Europe, it is often the first-line therapy for lower urinary tract symptoms. Lipophilic extracts are prepared from the berries of the dwarf palm tree ( Serenoa repens ) and are standardized to sterols and free fatty acids. Several mechanisms of action have been proposed, including inhibition of 5±-reductase activity, as well as antiandrogenic, anti-inflammatory, and antiproliferative activity. The most studied brand of saw palmetto (Permixon) is not available in the United States.
A 2004 meta-analysis of 17 trials (14 randomized) using Permixon in 4280 patients showed significant improvement in peak flow rate, reduction in nocturia relative to placebo, and a 5-point reduction in the International Prostate Symptom Score. These clinical data are comparable to effects of some ±-blockers. In contrast, a well-designed 2006 trial showed no difference in symptom scores, flow rates, prostate size, postvoid
Saw palmetto is very well tolerated by most patients for up to 3 “5 years, with only mild and rare gastrointestinal symptoms being reported. Saw palmetto has not been shown to reduce prostate size or lower the serum level of prostate-specific antigen. No herb-drug interactions have been reported. In a 2003 study, the herb did not alter cytochrome P450 activity in healthy volunteers. Saw palmetto was one of eight ingredients in PC-SPES, a popular herbal product used by many men with prostate cancer. PC-SPES was withdrawn from the market when it was found to be contaminated with the prescription drugs diethylstilbestrol and warfarin.
Bent S et al: Saw palmetto for benign prostate hyperplasia. N Engl J Med 2006;354:557.
Boyle P et al: Updated meta-analysis of clinical trials of Serenoa repens extract in the treatment of symptomatic benign prostatic hyperplasia. BJU Int 2004;93:751.
Buck AC: Is there a scientific basis for the therapeutic effects of Serenoa repens in benign prostatic hyperplasia? Mechanisms of action. J Urol 2004;172:1792.
Fong YK et al: Role of phytotherapy in men with lower urinary tract symptoms. Curr Opin Urol 2005;15:45.
Markowitz JS et al: Multiple doses of saw palmetto ( Serenoa repens ) did not alter cytochrome P450 2D6 and 3A4 activity in normal volunteers. Clin Pharmacol Ther 2003;74:536.
The dried young stems of
have been used for thousands of years in traditional Oriental medicine to treat respiratory disorders, especially bronchospasm and congestion. Ephedra has also been widely marketed for its stimulant and appetite suppressant effects (alone or in combination with caffeine-like herbs). Ephedra's alkaloids are structurally similar to amphetamines. A meta-analysis concluded that patients taking ephedra or ephedra plus
Bent S et al: The relative safety of ephedra compared with other herbal products. Ann Intern Med 2003;138:468.
Bent S et al: Safety and efficacy of citrus aurantium for weight loss. Am J Cardiol 2004;94:1359.
Haller CA et al:
McBride BF et al: Electrocardiographic and hemodynamic effects of a multicomponent dietary supplement containing ephedra and caffeine: a randomized controlled trial. JAMA 2004;291:216.
Shekelle PG et al: Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance: a meta-analysis. JAMA 2003;289:1537.
Sales of dietary supplements have increased dramatically over the past decade. The Dietary Supplement Health Education Act of 1994 has made it possible for manufacturers to sell dietary supplements directly to the public without FDA approval or oversight. Reports of adulteration and contamination are available, but the magnitude of this problem remains unknown. Furthermore, there have been several reports of the
-Adenosylmethionine (SAMe) is an endogenous compound that serves as a methyl group donor for hundreds of compounds, including neurotransmitters, fatty acids, nucleic acids,
A 2002 Evidence Report and Technology Assessment by the Agency for Healthcare Research and Quality concluded that SAMe is more effective than placebo for relief of symptoms of depression, pain of osteoarthritis, and pruritus in cholestasis of pregnancy, and in intrahepatic cholestasis. Furthermore, the authors concluded that SAMe was equivalent to standard therapy for depression and osteoarthritis but not for cholestasis of pregnancy. Early studies suggesting that SAMe may be helpful in treating depression were limited by short duration and poor methodology. SAMe may affect multiple neurotransmitters; increased levels of serotonin, 5-hydroxyindoleacetic acid, and dopamine as well as inhibition of norepinephrine reuptake have been noted after SAMe administration. An
Studies of alcohol-fed baboons suggest that SAMe increases glutathione levels and attenuates liver
Arnold O et al: Double-blind, placebo-controlled pharmacodynamic studies with a nutraceutical and a
Chiaie R et al: Efficacy and tolerability of oral and intramuscular S -adenosyl-L-methionine 1,4-butanedisulfonate (SAMe) in the treatment of major depression: comparison with imipramine in 2 multicenter studies. Am J Clin Nutr 2002;76:1172S.
Hardy M et al: S -adenosyl-L-methoionine for treatment of depression, osteoarthritis, and liver disease. Agency for Healthcare Research and Quality (AHRQ) 2002; (Evidence Report/Technology Assessment 64):1.
Mato JM et al: S -Adenosylmethionine in alcoholic liver cirrhosis: a randomized, placebo-controlled, double-blind, multicenter clinical trial. J Hepatol 1999;30:1081.
Soeken KL et al: Safety and efficacy of S -adenosylmethionine (SAMe) for osteoarthritis. J Fam Pract 2002;51:425.
Dehydroepiandroesterone (DHEA) and its sulfate ester, DHEAS, are secreted by the
Table 42-3. Overview of selected dietary supplements.
The mechanism of action of DHEA remains unknown. Preliminary evidence suggests that DHEA supplementation might be useful in depression, dysthymia, systemic lupus erythematosus (SLE), insulin sensitivity, and adrenal insufficiency.
Animal studies suggest that DHEA and DHEAS have excitatory effects on the central nervous system, which may account for their influence on mood and sense of well-being. A 6-week clinical trial randomized 52 subjects with major or minor depression to monotherapy with DHEA or placebo and found DHEA to be superior as measured by multiple well-
Low DHEA levels in men and women with SLE and reduction in interleukin-10 levels after supplementation compared with placebo suggest that DHEA may play a causative role. One hundred women with active, mild to moderate SLE were randomized to receive 200 mg/d of oral DHEA or placebo for 24 weeks. DHEA was well tolerated, significantly reduced the number of SLE flares, and improved patients' global assessment of disease activity. DHEA supplementation has been shown to reduce abdominal visceral fat and insulin resistance. Villareal and colleagues randomized 56 adults to DHEA (50 mg/d) or placebo for 6 months and found reductions in visceral fat,
Side effects of DHEA include acne, deepening of the voice, and facial hair growth. No serious adverse events have been reported. The long-term effects of DHEA supplementation
Arlt W et al: Dehydroepiandrosterone replacement in women with adrenal insufficiency. N Engl J Med 1999;341:1013.
Chang D-M et al: Dehydroepiandrosterone treatment of women with mild-to-moderate systemic lupus erythematosus: a multicenter randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2002;46:2924.
Dhatariya K et al: Effect of dehydroepiandrosterone replacement on insulin sensitivity and lipids in hypoadrenal women. Diabetes 2005;54:765.
Schmidt PJ et al: Dehydroepiandrosterone monotherapy in midlife-onset major and minor depression. Arch Gen Psychiatry 2005;62:154.
Villareal DT et al: Effect of DHEA on abdominal fat and insulin action in elderly women and men: a randomized controlled trial. JAMA 2004;292:2243.
Glucosamine & Chondroitin
Glucosamine and chondroitin have been used in Europe alone and in combination to treat osteoarthritis since the 1980s. These compounds are substrates for the production of articular cartilage. Glucosamine stimulates the production of glycosaminoglycans, leading to increased synthesis of cartilage. Chondroitin may help maintain articular fluid
Two meta-analyses and a Cochrane Review of twenty randomized, double-blind, placebo-controlled trials involving more than 2570 patients with osteoarthritis support the use of glucosamine (or glucosamine and chondroitin) in the treatment of osteoarthritis of the knee. The Cochrane Review identified efficacy only for trials using preparations manufactured by Rotta Pharmaceuticals. GAIT is a multicenter randomized double-blind placebo- and celecoxib-controlled clinical trial involving 1583 persons randomized to glucosamine, chondroitin, glucosamine and chondroitin, celecoxib, or placebo. Investigators found no difference overall between the supplements alone and in combination and placebo. In a predefined subgroup of patients with moderate to severe pain, combined therapy with glucosamine and chondroitin sulfate provided greater pain relief than placebo, which in that
Glucosamine not only reduces the symptoms of osteoarthritis but may also slow the progression of the disease. Reginster and coworkers randomized 212 patients with osteoarthritis of the knee to receive either 1500 mg/d of glucosamine or placebo. After 3 years, patients taking glucosamine reported a 24% reduction in symptoms versus a 10% increase in the placebo group. X-rays revealed that the treatment patients experienced a loss of only 0.06 mm joint space versus 0.31 mm in the placebo group after 3 years. Glucosamine was very well-tolerated and did not elevate serum glucose levels. Similar results were found in 200 patients with mild to moderate knee osteoarthritis who were randomized to glucosamine sulfate or placebo for 3 years. Patients in the glucosamine group had greater pain relief and less joint space narrowing on radiographs. Several negative trials have been reported in patients with more severe arthritis and in those taking forms of glucosamine other than those made by the European manufacturer Rotta Pharmaceuticals. No drug-herb interactions have been reported. In contrast to NSAIDs, glucosamine is not an analgesic and may take weeks to months before improvement is noticed. In summary, clinical trial literature suggests that glucosamine with or without chondroitin is well tolerated,
Clegg DO et al: Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med 2006;354:795.
Hughes R et al: A randomized, double-blind, placebo-controlled trial of glucosamine sulphate as an analgesic in osteoarthritis of the knee. Rheumatology (Oxford) 2002;41:279.
Pavelka K et al: Glucosamine sulfate use and delay of progression of knee osteoarthritis: a 3-year, randomized, placebo-controlled, double-blind study. Arch Intern Med 2002;162:2113.
Reginster JY et al: Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomized, placebo-controlled clinical trial. Lancet 2001;357:251.
Richy F et al: Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis. Arch Intern Med 2003;163:1514.
Towheed TE et al: Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev 2005;(2):CD002946.
Coenzyme Q 10
Coenzyme Q 10 (Ubidecarenon; also known as ubiquinone-10) is an endogenous provitamin that resides in the lipid layer of the mitochondria. It plays a crucial role in oxidative phosphorylation for adenosine triphosphate (ATP) production and is necessary for the basic functioning of all cells. It has also been observed to have effects on membrane stabilization, free radical scavenging, and calcium-dependent slow channels. Coenzyme Q 10 levels decrease with age. Deficiencies have been observed among patients with certain chronic medical conditions, including cardiovascular disease (hypertension, acute coronary syndromes, congestive heart failure), renal failure, male infertility, periodontal disease, cancer, HIV/AIDS, muscular dystrophies, Parkinson's disease, and Alzheimer's disease. Certain prescription medications may also lower coenzyme Q 10 levels, including HMG-CoA reductase inhibitors, diabetes medications, ²-blockers, diuretics, and antidepressants. Serum levels of coenzyme Q 10 are increased by taking supplements, but whether this results in clinical benefit remains unproven.
Studies of coenzyme Q
for the prevention and treatment of cardiovascular disease have had mixed results. A 2005 study of 121 patients undergoing elective cardiac surgery showed enhanced myocardial tolerance to in vitro hypoxia-reoxygenation stress among persons receiving coenzyme Q
(300 mg daily) for 2 weeks preoperatively, compared with placebo. A preliminary study showed that combining coenzyme Q
with mild hypothermia after cardiac arrest improved 3-month survival (17/25 vs 7/24;
= .04) and may improve neurologic outcomes. In parts of Russia, Europe, and Japan, coenzyme Q
is part of standard therapy for congestive heart failure. Earlier trials in patients with congestive heart failure demonstrated fewer disease exacerbations, reduced hospitalizations, improved ejection fraction, and more favorable quality-of-life measurements. However, a 1999 study showed that coenzyme Q
had no effect on ejection fraction, hemodynamic parameters, or quality of life. A study of 55 patients with class III and class IV congestive heart failure receiving standard medical therapy also showed no benefit of coenzyme Q
on ejection fraction, peak
Because coenzyme Q
is lipophilic, it is often formulated with vegetable oil or vitamin E to enhance its absorption. Its bioavailability is also enhanced when it is taken with meals, especially fat-rich
Berman M et al: Coenzyme Q 10 in patients with end-stage heart failure awaiting cardiac transplantation: a randomized, placebo-controlled study. Clin Cardiol 2004;27:295.
Damian MS et al: Coenzyme Q 10 combined with mild hypothermia after cardiac arrest: a preliminary study. Circulation 2004;110:3011.
Hodgson JM et al: Coenzyme Q 10 improves blood pressure and glycaemic control: a controlled trial in subjects with type 2 diabetes. Eur J Clin Nutr 2002;56:1137.
Rosenfeldt F et al: Coenzyme Q
therapy before cardiac surgery improves mitochondrial function and in vitro contractility of myocardial
Singh RB et al: Effect of coenzyme Q
on risk of atherosclerosis in patients with recent myocardial infarction. Mol
In acupuncture, certain locations on the surface of the body are stimulated, often with
The earliest reference to acupuncture can be traced to a text on Chinese medicine called
The Yellow Emperor's Classic of Internal Medicine
Huang Ti Nei Ching
), which dates from the second century BC. This text is often referenced to support the authenticity of a particular practice or theory and is used as part of the curriculum in training colleges. Acupuncture spread through much of Asia and by the sixteenth century Jesuit missionaries had brought the practice to Europe. As early as 1912, William Osler described its use in the first edition of
The Principles and Practice of Medicine.
For lumbago, he wrote, acupuncture is, in acute cases, the most efficient treatment. Research and
Mechanism of Action
Acupuncture for analgesia stimulates the
Yet, in 2003, Han found that acupuncture or electrical stimulation in specific frequencies can facilitate the release of certain neuropeptides in the central nervous system. Peripheral stimulation of the skin or deeper structures showed activation of specific brain structures and the spinal cord via neural pathways, producing profound physiologic effects and stimulating self-healing mechanisms.
Han JS: Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci 2003;26:17.
Stux G, Berman B, Pomeranz B (editors): Basics of Acupuncture. 5th ed. Springer, 2003.
Wu MT et al: Central nervous pathways for acupuncture stimulation: localization of processing with functional MR imaging of the brain ”preliminary experience. Radiology 1999;212:133.
Training, Licensure, & Regulation
Acupuncture educational programs are accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). Typical acupuncture training for nonphysicians in the United States requires completion of an accredited 4-year (2500 hours) master's degree training program. In order to become a licensed acupuncturist (LAc), a national and, frequently, state board examination must be passed. Although many states do not require physicians to obtain additional training, most states require a minimum of 200 hours of training in an
In the United States and Europe, Oriental medicine-trained practitioners conduct a comprehensive
Treatment involves inserting four to fifteen needles at selected acupuncture points for 10 “30 minutes ”though certain schools leave the needles in place for only a few seconds to minutes. Needles are approximately 37-gauge, stainless
Patients can expect to see the practitioner weekly or biweekly for 4 “10 weeks, followed by less frequent
In current practice in the United States and Europe, acupuncture is generally considered safe, associated with a very low incidence of adverse events. Precautions useful for avoiding serious adverse events are listed in
. The most frequent problems are vasovagal or sedating reactions such as presyncope, syncope, and drowsiness. These are easily prevented by having the patient lie flat on the table, monitoring patients during the initial visit, and permitting the patient to remain in the office until a normal state of awareness is achieved. Serious complications in the literature over the past 30 years have been due to the reuse of needles between patients, leading to transmission of infection such as hepatitis B and C or HIV, and needling the thorax in patients with emphysema, leading to pneumothorax. There have also been case reports of unusual serious adverse events, including endocarditis in patients with prosthetic heart
Table 42-4. How to avoid preventable adverse events associated with acupuncture.
Most surveys estimate that the frequency of adverse events is 1:100,000 to 1:10,000. A 14-year review of the world literature identified 193 complications and concluded that acupuncture is generally safe except for patients with emphysema, in whom the risk of pneumothorax is significant. Another review identified 300 complications reported in the literature over a 30-year period.
Clinical uses of Acupuncture
In the United States, acupuncture is frequently used to treat acute non-life-
Table 42-5. Overview of acupuncture literature for selected medical conditions.
A 2001 systematic review of randomized controlled trials of acupuncture for stroke rehabilitation identified nine trials, including 538 persons meeting study entry criteria. Six of nine trials found acupuncture superior to control interventions, but study quality was poor. These findings suggest that acupuncture appears promising for the treatment of stroke, but studies of high quality are needed to confirm these preliminary findings.
Sze et al performed a meta-analysis assessing the efficacy of acupuncture with and without stroke rehabilitation. Fourteen trials with 1213 patients met the study inclusion criteria. The pooled random-effects estimates of change in motor impairment and disability were 0.06 (95% CI, “0.12 to 0.24) and 0.49 (95% CI, 0.03 to 0.96) for acupuncture and no acupuncture in addition to stroke rehabilitation, respectively. For the comparison of real acupuncture with sham acupuncture, the pooled random-effects estimate of the change in disability was 0.07 (95% CI, “0.34 to 0.48). This study suggests that in conjunction with stroke rehabilitation, acupuncture has no additional effect on motor recovery but has a small positive effect on disability. This may be due to a true placebo effect or to the wide variation in study quality. More high-quality studies are needed to assess the efficacy of acupuncture as an adjunct for stroke rehabilitation.
Park J et al: Effectiveness of acupuncture for stroke: a systematic review. J Neurol 2001;248:558.
Sze FK et al: Does acupuncture improve motor recovery after stroke? A meta-analysis of randomized controlled trials. Stroke 2002;33:2604.
A criterion-based review of 51 controlled trials of acupuncture for the treatment of chronic pain found 24 trials reporting results favoring acupuncture. Using a 100-point quality scale, only 11 trials scored at least 50 points. The investigators concluded that poor study quality made it
Overall, there is some evidence suggesting benefit of acupuncture for persons with chronic pain when compared with placebo and insufficient evidence to suggest acupuncture is superior to standard medical care or sham acupuncture. The ability to make definitive recommendations regarding efficacy for chronic pain is hampered by poor methodologic study quality.
Alimi D et al: Analgesic effect of auricular acupuncture for cancer pain: A randomized, blinded, controlled trial. J Clin Oncol 2003;15:4120.
Ezzo J et al: Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain 2000;86:217.
Green S et al: Acupuncture for lateral
Lewith et al: Acupuncture versus placebo for the treatment of chronic mechanical neck pain. A randomized, controlled trial. Ann Intern Med 2004;141:911.
Low Back Pain
Manheimer and colleagues published a meta-analysis in 2005 on acupuncture in the treatment of low back pain that included 33 randomized, controlled trials that met inclusion criteria, involving a total of 2138 patients. For the primary outcome of short-term relief of chronic pain, the meta-analysis showed that acupuncture is significantly more effective than sham treatment and no additional treatment. Similar conclusions were reached in a Cochrane systematic review of 35 randomized controlled trials (involving 2861 patients) published by Furlan and coworkers. Furlan et al also concluded that acupuncture improved function in patients with chronic low back pain. Neither review found that acupuncture was more effective than other active therapies for chronic low back pain. However, when acupuncture was added to other conventional therapies, it relieved pain and improved function more than the conventional therapies alone. Effect sizes tended to be small. The data was sparse and inconclusive for acute low back pain.
Furlan AD et al: Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration. Spine 2005;30:944.
Manheimer E et al: Meta analysis: acupuncture for low back pain. Ann Intern Med 2005;142:651.
In 2001, Ezzo and colleagues performed a systematic review of acupuncture for osteoarthritis of the knee. Seven trials assessed 393 patients on the outcomes of pain, function, global improvement, and imaging. For pain and function, limited support was found for the efficacy of acupuncture over a wait list control or treatment as usual. For pain, real acupuncture was more effective than sham acupuncture. For level of function, however, real acupuncture was not found to be more effective than sham acupuncture.
Vas and colleagues performed a randomized, controlled trial of 97 patients suffering from osteoarthritis of the knee. The patients were separated into two groups: one received acupuncture in conjunction with diclofenac and the other received placebo acupuncture with diclofenac. The study concluded that acupuncture, as an adjunctive therapy to pharmacologic treatment for osteoarthritis of the knee, was more effective than pharmacologic treatment alone.
In a larger and more extensive trial, the NIH funded a multicenter randomized controlled trial based at the University of Maryland; 570 patients were tested to see whether acupuncture provides greater pain relief and improved function compared with sham acupuncture or education in patients with osteoarthritis of the knee. The 570 patients were separated into three groups: 190 patients received true acupuncture, 191 received sham acupuncture, and 189 received educational treatment. Over a period of 26 weeks the two acupuncture groups received a total of 23 sessions. After 8 weeks, optimal acupuncture effects were observed in the experimental, true acupuncture group compared with the sham acupuncture. Overall, Berman and colleagues concluded that acupuncture may have an important role in adjunctive therapy as a part of a
An additional randomized controlled trial of 300 patients with osteoarthritis of the knee was published in 2005 by Witt et al, comparing acupuncture with sham and no acupuncture. The acupuncture and sham acupuncture groups received twelve treatments over 8 weeks. Sham acupuncture involved superficial needling at nonacupuncture points not at the knee, whereas in the Vas and Berman studies there was no needle penetration. There was greater improvement in the acupuncture group than both the sham and waiting list groups in both pain and function at end of treatment. However, the benefit appeared to decrease over time and was no longer significant at 26 weeks.
Berman BM et al: Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee. Ann Intern Med 2004;141:901.
Ezzo J et al: Acupuncture for osteoarthritis of the knee: A systematic review. Arthritis Rheum 2001;44:819.
Vas J et al: Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ 2004;329:1216.
Witt C et al: Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet 2005;366:136.
Acute Dental Pain
The NIH consensus development statement on acupuncture states, There is evidence of efficacy for postoperative dental pain. A review in 1998 identified 16 controlled trials of acupuncture for the treatment of acute dental pain. Among the eight randomized and at
Ernst E et al: The effectiveness of acupuncture in treating acute dental pain: a systematic review. Br Dent J 1998; 184:443.
Lao L et al: Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Arch Otolaryngol Head Neck Surg 1999;125:567.
Melchart et al performed a systematic review in 2002 to evaluate the treatment of acupuncture for recurrent headaches. That group identified 26 randomized and quasi-randomized trials involving 1151 subjects in which 16 trials studied migraine headaches, 6 studied tension headaches, and 4 studied mixed headaches. Of the 16 trials that used sham acupuncture, 8 found real acupuncture superior to sham acupuncture and 4 found a trend in favor of real acupuncture. Two trials found no difference between groups, and 2 trials were uninterpretable. In the remaining 10 trials, conflicting results were reported. Overall, investigators believed there was evidence that acupuncture is effective in the treatment of recurrent headaches.
In a 2004 trial performed by Vickers and colleagues, 401 patients with chronic headache, predominantly migraine, received up to 12 acupuncture treatments and the results showed that the experimental group experienced 22 fewer days of headache per year, used 15% less medication, made 25% fewer visits to general practitioners, and took 15% fewer sick days, in comparison to the group that received no acupuncture in addition to
Melchart D et al: Acupuncture for idiopathic headache. Cochrane Database Syst Rev 2002;(1):CD001218.
Vickers AJ et al: Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial. BMJ 2004;328:744.
Linde performed a systematic review of randomized and possibly randomized clinical trials that evaluated the effects of acupuncture for the treatment of asthma. Seven trials met study entry criteria, including 174
Martin performed a systematic review and meta-analysis from 11 randomized controlled trials. Trials compared acupuncture at real and placebo points with outcome measures consisting of at least one of the following: peak expiratory flow rate, forced expiratory volume in 1 second (FEV 1 ), and vital capacity. Studies in which bronchoconstriction was experimentally induced showed a significant effect favoring real acupuncture. Overall, no evidence for an effect of acupuncture in reducing asthma was found; however, methodologic shortcomings such as small sample size may have precluded identifying statistically significant differences between groups.
Linde K et al: Acupuncture for chronic asthma. Cochrane Database Syst Rev 2000;(2):CD000008.
Martin J et al: Efficacy of acupuncture in asthma: systematic review and meta-analysis of published data from 11 randomised controlled trials. Eur Respir J 2002;20:846.
Nausea & Vomiting
Based on multiple randomized controlled trials, there is strong evidence demonstrating effectiveness of acupuncture in the treatment of pregnancy-induced, chemotherapy-induced, and postoperative nausea and vomiting. One review identified 33 trials using a particular acupuncture point (P6) for treatment of nausea and vomiting. None of the four trials in which acupuncture was given while the patient was under general anesthesia demonstrated a positive effect. Among the remaining 29 trials, 27 identified real acupuncture as being more effective than sham acupuncture or placebo control. In subgroup analyses, all five studies evaluating acupuncture for cancer chemotherapy-induced nausea and vomiting were positive. Six of the seven studies for pregnancy-induced symptoms were positive. Among trials in which acupuncture was performed while the subjects were not under general anesthesia, 16 of 17 studies of treatment for postoperative nausea and vomiting were positive. In sensitivity analyses, 11 of the 12 high-quality trials involving over 2000 patients identified acupuncture as superior to control. A subsequent review on studies of treatment
Lee A et al: The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:1362.
Shen J et al: Electroacupuncture for control of myeloablative chemotherapy-induced emesis. JAMA 2000;284:2755.
Vickers AJ: Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J R Soc Med 1996;89:303.
Nicotine, Heroin, Cocaine, & Alcohol Addiction
There is good evidence suggesting that acupuncture is not effective in maintaining abstinence from nicotine addiction. Systematic reviews have identified multiple trials of sufficient quality to determine that there is no evidence to support its use. In a randomized trial comparing electroacupuncture and sham control for nicotine withdrawal symptoms, there was no difference in nicotine withdrawal symptoms or abstinence rates at day 14. The NIH consensus development statement acupuncture states, There is evidence that acupuncture does not demonstrate efficacy for cessation of smoking.
Despite insufficient evidence to support its use, auricular acupuncture is in widespread use throughout American drug treatment facilities. Although heroin, alcohol, and cocaine addiction studies have frequently reported positive outcomes, serious methodologic flaws are present. For example, an 8-week clinical trial showed patients assigned to acupuncture were significantly more likely to remain abstinent from cocaine use. However, analyses did not adjust for the 50% versus 20% dropout rate in the acupuncture and relaxation groups, respectively. A randomized controlled, single-blind trial conducted in six community-based clinics in the United States found that acupuncture was not more effective than needle insertion control or relaxation alone in reducing cocaine use. Until scientifically rigorous studies can demonstrate efficacy, acupuncture should not be used as monotherapy in the treatment of these addictions.
Avants SK et al: A randomized controlled trial of auricular acupuncture for cocaine dependence. Arch Intern Med 2000;160:2305.
Margolin A et al: Acupuncture for the treatment of cocaine addition: a randomized controlled trial. JAMA 2002;287:55.
White A et al: Acupuncture for smoking cessation. Cochrane Database Syst Rev 2002;(2):CD000009.
Christian F.S. Hahnemann is credited with devising the system of homeopathy in 1790. Three main principles of homeopathy include the law of similars, the use of dilute concentrations of medicines, and potentization. The second and third principles remain the most
The law of similars is also known as the principle of like cures like ; it is derived from the observation that a homeopathic medicine when given to a healthy volunteer will produce a constellation of symptoms similar to those it will cure in an ill patient. Since the 1800s, the process of testing medicines on healthy volunteers to record the symptoms provoked (known as provings ) has been recorded and compiled to create several materia medicas. A randomized double-blind crossover trial was performed to evaluate whether homeopathic substances can bring about symptoms different from observation and placebo. Investigators report an insignificant tendency to report more symptoms when taking belladonna 30CH compared with control arms. However, there was no indication that symptoms were different between groups or compared with baseline presentations.
The second principle ”the use of dilute concentrations of medicine ”entails
Potentization is based on the claim that once a medicine is at low concentration, the more dilute the solute the more potent the effect.
The World Health Organization states that homeopathy is the second most used medical system internationally, with over $1 billion in expenditures for such therapy. Twenty to 30 percent of French and German physicians use homeopathy in clinical practice. In Great Britain, five homeopathic
Mechanisms of Action
Although there are several mechanisms under investigation, none are well validated. One of the more interesting findings in the
Adverse Events & Interactions
Given the low concentration of homeopathic medicines, the probability of adverse events is remote. However, adverse events have been reported from ingestion of large quantities of remedies containing heavy metals. Some patients report an exacerbation of symptoms initially. Homeopaths explain this reaction as the initial phase of the healing response. Homeopathic remedies are not known to have interaction with conventional medicines.
Training, Licensure, & Regulation
In Europe, practitioners usually enroll in a 3 “6 year professional degree program or physicians enroll in postgraduate training. In the United States, homeopathic educational programs are accredited by the Council for Homeopathic Education, which was founded in 1982 as an independent agency to assess homeopathic training in the United States and Canada. There are two levels of training for homeopaths. The Primary Care Certificate in Homeotherapeutics requires 60 “100 hours of course work and passage of a written examination. The more advanced level, the Diplomate in Homeotherapeutics (DHt), requires an additional 3 years of clinical practice. There is comprehensive homeopathic training that involves 3 or more years of
The Homeopathic Pharmacopoeia of the United States was included in the original Food and Drug Act of 1938, which declared that homeopathic remedies may be purchased without a physician prescription, in the same manner as over-the-counter, nonprescription compounds. Unlike over-the-counter drugs in the United States, there is no requirement for testing for safety and effectiveness. However, the FDA does require the products to meet good manufacturing practices for quality, purity, packaging, and strength. In addition, the FDA requires companies to include on the label indications for use, dilutions, and ingredients.
The initial consultation takes about 1 “1.5 hours, with significant time spent on obtaining a detailed history. Attention is given to the physical, mental, and emotional symptoms, overall personality type, and any internal or external factors that influence the presenting symptoms, such as emotions, wind, season of the year, and reactions to different foods. The symptom inventory is then matched to an appropriate remedy taken from the materia medica. Follow-up visits may last for a few minutes to 40 minutes. During the follow-up visit, the practitioner determines if there has been improvement in symptoms, no change, or aggravation of symptoms. The latter scenario, if transient, is
Homeopathic physicians are trained to treat a broad range of conditions in the primary care and specialty setting. In clinical practice, however, practitioners frequently treat patients with chronic conditions that conventional medicine cannot adequately address, including arthritis, allergies, autoimmune diseases, or non-life-threatening acute conditions such as viral infections or minor trauma. Parents may take their children to homeopathic physicians for recurrent conditions such as otitis media and allergies with the goal of avoiding repetitive antibiotic, corticosteroid, or long-term conventional medications.
The findings for individual randomized controlled trials on homeopathy have been contradictory. Over 180 controlled trials and over 10 reviews have been published on the effects of homeopathy compared with placebo. The majority of trials are published in non-English language journals and are frequently not listed in Medline. A few methodologically rigorous reviews have been published in English (
). The majority of systematic reviews have pooled trials on homeopathy regardless of the medical condition being treated. Many reviews have found that patient outcomes in homeopathic treatment groups were superior to placebo group outcomes. Since many of the trials do not provide
Table 42-6. Overview of English language homeopathy systematic reviews.
A 1997 systematic review identified 89 double-blind or randomized placebo-controlled trials and found the overall combined odds ratio was 2.45 (95% CI, 2.0 “2.9) favoring patients in the homeopathy-treated group. Analyses restricted to high-quality studies
A meta-analysis conducted in 2000 identified 118 randomized controlled clinical trials of which 16 satisfied inclusion criteria. Investigators reported that patients receiving homeopathic remedies compared with placebo were significantly more likely to have improved treatment outcomes (P = .00003); however, analyses limited to the five high-quality studies revealed only a trend for improvement (P = .08). Overall, there is some evidence that homeopathy is more effective than placebo; however, multiple high-quality studies of individual conditions are needed to validate these findings.
Cucherat M et al: Evidence of clinical efficacy of homeopathy: a meta-analysis of clinical trials. Eur J Clin Pharmacol 2000;56:27.
Jacobs J et al: Homeopathy for childhood diarrhea: combined results and meta-analysis from three randomized, controlled clinical trials. Pediatr Infect Dis J 2003:22:229.
Jonas W: Neuroprotection from glutamate toxicity with
Linde K et al: Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997;350:834.
McCarney R et al: Homeopathy for chronic asthma. Cochrane Database Syst Rev 2004;1:CD000353.
Reilly D et al: Is evidence for homoeopathy reproducible? Lancet 1994;344:1601.
Samal S et al: Unexpected solute aggregation in water on dilution. Chem Commun (Camb) 2001;(21):2224.
Vickers AJ: Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes. Cochrane Database Syst Rev 2004;(1):CD001957.