In the last Avenues, we wrote about strategies patients can use to improve communication with their doctors. In this article, the third in our Becoming Your Own Advocate series, we discuss the issue of letting your physician know about your use of complementary and alternative medicines, why it’s important for them to be informed, and how to communicate this to them effectively.
What are Complementary and Alternative Medicines?
Complementary and alternative medicine (CAM) is generally defined as any one or more of these modalities: acupuncture, biofeedback, chiropractic, diet, energy healing, folk remedies, herbal medicine, homeopathy, hypnosis, imagery, massage, megavitamins, relaxation techniques, self-help groups, or spiritual healing.3 This article focuses mainly on those modalities that may cause drug interactions, such as herbs and megavitamins.
How Many People are Using Complementary and Alternative Medicines?
Complementary and alternative medicines are used by an estimated 36% of the American public.2 For megavitamins specifically, their use doubled in the period between 1990 and 1997 and for herbal medicines, their use increased five-fold during the same period.3 Among some cancer patients, the use of herbal medicine and vitamins is even higher than in the general population; 64% of patients with breast cancer, for example, report including CAM as a frequent part of their self-care.6
How many patients aren’t telling their physicians?
The majority of patients do not report their use of herbal medicines and vitamins to their physicians; a nationwide survey found this number to be as high as 72%.4
Why don’t people tell their physicians?
A survey of patient-physician communications about CAM cites many contributing factors, including: the physician did not ask (55% of patients responding), the patient forgot to tell (49%), the patient feared that their physician would disapprove (15%), the physician was too busy to discuss (4%), and the patient felt the physician did not need to know (4%). In this same study, patients described how their physicians reacted when learning about their CAM use. Responses included: “physician said it was okay to continue using CAM” (71% of patients responded), “physician told me I was crazy to use CAM” (14%), and “stop using CAM” (14%).11
Why is telling your physician important?
While some vitamins and herbal medicines can increase effectiveness of drug therapies or reduce side effects,8 others can reduce their effectiveness or increase toxic interactions.7 A positive example is the combination of COQ-10 with the chemotherapy drug cisplatin, which can reduce the toxic effect of that chemotherapy drug on the heart.10 A negative example is the combination of St. John’s Wort with irinotecan (Camptosar®), which can decrease irinotecan blood levels of this cancer chemotherapy drug by as much as 50%, thus diminishing its effectiveness.9
In addition to the combinations themselves, it is also important for your physician to be aware of the specific timing of how you are combining herbal medicines and vitamins with standard therapy. It is not always necessary for drugs and vitamins to be used on the same day in order to increase benefits or reduce negative interactions. For example, a person receiving AC (Adriamycin-Cytoxan) chemotherapy for breast cancer can be provided with a protocol that specifically avoids the use of most herbal medicine and vitamins on the days when chemotherapy is given and then introduces those items during the period between chemotherapy cycles, which may enhance survival.1
Because of the potential for negative interactions, a complete description of the complementary therapies you are using helps your physician identify such interactions and also helps them understand the ways in which you are working to help yourself.
How can you help your doctor help you?
A recent survey found that a majority of physicians estimated only 15% of their patients were using CAM and that only half of these physicians routinely asked their patients about their CAM use.5 Since physicians rarely ask about patients’ use of CAM, it is important to volunteer this information yourself. Physicians use many different sources of information when evaluating a patient, so sharing information about the CAM therapies you are using will help your physician better understand the additional treatments you are receiving, tailor their own drug prescriptions to better meet your needs, and advise you about potential interactions between prescription drugs and herbal medicines or vitamins.
How can your CAM practitioner help you build better communications with your physician?
Your CAM practitioner is part of your medical care team and should be able to provide information that will be useful in your communications with your physician about complementary and alternative medicines. For each of your CAM practitioner’s recommendations, request as much information as possible, including information on potential interactions between the herbal-vitamin therapies you’re using with other medicines, prescription drugs, chemotherapy, radiation, and surgery. Requesting that this information be provided to you in writing makes it easy for you to pass it along to your physician.
Through increased communication, physicians will realize just how many of their patients are using complementary and alternative medicines and, in turn, patients will receive safer, more effective treatment protocols. The landscape of medical practice is changing rapidly and more and more physicians are becoming aware of complementary and alternative medicines. You can help accelerate these changes and help achieve potentially safer and more effective treatment outcomes by telling your physician about the complementary and alternative medicines you are using.
1. Broffman, M. and M. McCulloch (2001). “Integrative Traditional Chinese Medicine and Chemotherapy: Survival Data in Node-positive and Metastatic Breast Cancer.” San Francisco Medicine November: 29-31.
2. CDC (2004). “Complementary and Alternative Medicine Use Among Adults: United States, 2002.”
3. Eisenberg, D. M., R. B. Davis, et al. (1998). “Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.” Jama 280(18): 1569-75.
4. Eisenberg, D. M., R. C. Kessler, et al. (1993). “Unconventional medicine in the United States. Prevalence, costs, and patterns of use.” N Engl J Med 328(4): 246-52.
5. Giveon, S. M., N. Liberman, et al. (2003). “A survey of primary care physicians’ perceptions of their patients’ use of complementary medicine.” Complement Ther Med 11(4): 254-60.
6. Glass, E. L. (2004). Use of complementary/alternative therapies during chemotherapy for breast cancer. ASCO Annual Meeting, New Orleans, LA.
7. Huang, S. M., S. D. Hall, et al. (2004). “Drug interactions with herbal products and grapefruit juice: a conference report.” Clin Pharmacol Ther 75(1): 1-12.
8. Lamson, D. W. and M. S. Brignall (1999). “Antioxidants in cancer therapy; their actions and interactions with oncologic therapies.” Alternative Medicine Review 4(5): 304-329.
9. Mathijssen, R. H., J. Verweij, et al. (2002). “Effects of St. John’s wort on irinotecan metabolism.” J Natl Cancer Inst 94(16): 1247-9.
10. Takimoto, M., T. Sakurai, et al. (1982). “[Protective effect of CoQ 10 administration on cardial toxicity in FAC therapy].” Gan To Kagaku Ryoho 9(1): 116-21.
11. Rao, J. K., K. Mihaliak, et al. (1999). “Use of complementary therapies for arthritis among patients of rheumatologists.” Ann Intern Med 131(6): 409-16.
Your CAM practitioner is often your best source of specific information about the therapies they provide. Their training should include an understanding of how CAM and conventional therapies can be combined. The following questions, when asked of your CAM practitioner, should help you obtain the information you need to share with your physician.
» Do you seek information on herb/drug interactions?
» Do you incorporate this knowledge into your recommendations?
» Have you evaluated this information relative to my specific case?
» Do you plan your treatments so that they will integrate closely with my standard therapy?
» How do you evaluate the benefits and risks of treatments you suggest?
» How do you monitor the effectiveness of your treatments?
» Would you be willing to communicate directly with my physician about your treatment protocol?
Natural Medicines Comprehensive Database
Pros: A thorough review of the published evidence. Also includes some unpublished data. Clearly distinguishes interactions that have been observed in patients from those that are theoretically possible.
Cons: Cost is $92 per year.
Pros: Potential interactions identified.
Cons: Cost is $59.99 per year. Explanations much more limited than the Natural Medicines Comprehensive Database.
Institute for Traditional Medicine
Pros: Free. Clearly explains interactions between different groups of drugs and herbs. Also identifies potential benefits of herbal medicines.
Cons: Limited in scope and breadth.
Recognition and Prevention of Herb-Drug Interaction
Pros: Free. Clearly explains interactions between different groups of drugs and herbs.
Cons: Limited in scope and breadth.