MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

herbal medicine

You might remember: I have been badly misquoted in an article in THE DAILY TELEGRAPH. Based on a newly published scientific paper, the Telegraph article was about herbal medicines and their potential to interact with synthetic drugs. Towards its end, it cited me stating this:

Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said that doctors should make it clear to patients that they could not be taking herbal remedies alongside drugs.

Prof Ernst said there was no good evidence that they work and that doctors were ‘contributing to disinformation’ by turning a blind eye to the practice.

Not only did this not make any sense (I felt, it made me look like an idiot), but crucially I had never stated this nor had I even commented to a Telegraph journalist about this scientific paper. This was (27/1) when I wrote my blog-post about it.

Several friends persuaded me to file an official complaint – which I somewhat reluctantly did. Subsequently, I received an email from the paper’s ‘editorial compliance executive’ asking me to supply more details about my grievances. I complied with the request by pointing out that:

The following things are wrong with this passage:

1) I never said this.

2) I have not even been interviewed by your journalist and do not know where this quote is supposed to come from.

3) As far as I am aware, I also never stated anything like this anywhere else.

4) It is not and never has been my view that there is no good evidence that herbal remedies can never be combined with drugs.

5) It is not and never has been my opinion that there is no good evidence to suggest that herbal remedies work.

6) It is not and never has been my view that doctors were contributing to disinformation by turning a blind eye to the use of herbal remedies.

The response came swiftly:

The quoted words were recorded at a briefing at the SMC to launch your new book, More Harm than Good? The Moral Maze of Complementary and Alternative Medicine on 17th January 2018. 

We are aware that you have had correspondence with our Science Editor, Sarah Knapton who has since amended the online article to make this clear. 

We do however accept that one sentence was mistakenly attributed to you. We have therefore amended the online article and added a footnote to explain what has been updated.

This was most bizarre, I thought, because I did NOT  have a correspondence with Sarah Knapton, the author of the Telegraph article. On the plus-side, the Telegraph had indeed changed the passage in question; it now read (and did so until yesterday):

Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said there was a ‘potential for harm’.

“It’s a lazy way out of the problem,” he said at a briefing to launch his new book More Harm than Good? The Moral Maze of Complementary and Alternative Medicine. “In medicine you give treatment for a reason and if there is no reason for the homeopathic remedy why should you support it for the placebo treatment.

“As a good doctor you should be able to transmit a placebo effect any case. I just don’t see a reason, I see the potential for harm.” 

The research was published in the British Journal of Clinical Pharmacology.

CORRECTION: This article originally stated that Professor Edzard Ernst said there was no good evidence that herbal remedies work and that doctors were ‘contributing to disinformation’ by turning a blind eye to their usage. In fact, this was not said by Professor Ernst. The article has been amended.

I felt that this was a correction of one mistake by another mistake and pointed out that the briefing had been about homeopathy and NOT about herbal medicine or herb/drug interactions. Therefore I replied to the ‘editorial compliance executive’ insisting on further corrections and pointing out that such an utterly nonsensical comment might harm my reputation as an expert. I also posted a comment under the Telegraph article explainig that homeopathy is not herbal medicine.

Sadly, nothing happened.

So, a few days later, I sent a reminder to the ‘editorial compliance executive’.

And again nothing happened.

… until yesterday.

I had almost given up and was contemplating what to do next, when I received an email. It was not from the  ‘editorial compliance executive’, but from THE TELEGRAPH’s ‘Head of Editorial Compliance’. He wrote that he had listened to the tapes of the original briefing and realised that my comments were indeed made in a different context. Therefore, they had now erased all of the nonsensical stuff and replaced it with this text:

CORRECTION: This article originally stated​ ​that Professor Edzard Ernst​,​ professor of complementary medicine at Exeter Universit​y, ​had said there​ was​ ‘potential for harm’ ​in herbal remedies and ​that doctors were ‘contributing to disinformation’ by turning a blind eye to ​this.​ These comments did not in fact relate to ​interactions between herbal remedies​ and prescribed medication, and they have been removed. We apologise to the Professor for the error.   

I am pleased!

And I gratefully accept the apology.


This might be a long, convoluted and somewhat boring story, but I think it has at least two important elements to it:

  1. It may seem petty to complain, and complain, and send reminders when the complaint seems to be getting ignored (I certainly did not feel sure that I was doing the right thing). But occasionally, it is worth the effort – not because of the personal satisfaction (nice but not essential), but because the truth has a high value which should be respected.
  2. Wondering how all this mess came about, I am asking myself: Does the author of the Telegraph article perhaps genuinely not know the difference between herbal and homeopathic remedies? Obviously, I don’t know the answer to this question, but it would explain the mess she got herself (and me) into. And it would also suggest that it might be necessary to educate journalists about alternative medicine in general and homeopathy in particular (In case there is any interest, I offer to give a few informative lectures with opportunities to ask questions to London-based health writers and science journalists).

Many hard-nosed sceptics might claim that there is no herbal treatment for upper respiratory infections that makes the slightest difference difference. But is this assumption really correct?

According to my own research of 2004, it is not. Here is the abstract of our systematic review:

Acute respiratory infections represent a significant cause of over-prescription of antibiotics and are one of the major reasons for absence from work. The leaves of Andrographis paniculata (Burm. f.) Wall ex Nees (Acanthaceae) are used as a medicinal herb in the treatment of infectious diseases. Systematic literature searches were conducted in six computerised databases and the reference lists of all papers located were checked for further relevant publications. Information was also requested from manufacturers, the spontaneous reporting schemes of the World Health Organisation and national drug safety bodies. No language restrictions were imposed. Seven double-blind, controlled trials (n = 896) met the inclusion criteria for evaluation of efficacy. All trials scored at least three, out of a maximum of five, for methodological quality on the Jadad scale. Collectively, the data suggest that A. paniculata is superior to placebo in alleviating the subjective symptoms of uncomplicated upper respiratory tract infection. There is also preliminary evidence of a preventative effect. Adverse events reported following administration of A. paniculata were generally mild and infrequent. There were few spontaneous reports of adverse events. A. paniculata may be a safe and efficacious treatment for the relief of symptoms of uncomplicated upper respiratory tract infection; more research is warranted.

A. Paniculata (Burm.f.) Wall ex Nees (Acanthaceae family), also known as nemone chinensi, Chuān Xīn Lián, has traditionally been used in Indian and Chinese herbal medicine mostly as an antipyretic for relieving and reducing the severity and duration of symptoms of common colds and alleviating fever, cough and sore throats, or as a tonic to aid convalescence after uncomplicated respiratory tract infections. The active constituents of A. paniculata include the diterpene, lactones commonly known as the andrographolides which have shown anti-inflammatory, antiviral, anti-allergic, and immune-stimulatory activities. A. Paniculata has also been shown, in vitro, to be effective against avian influenza A (H9N2 and H5N1) and human influenza A H1N1 viruses, possibly through blocking the binding of viral hemagglutinin to cells, or by inhibiting H1N1 virus-induced cell death.

But our systematic review was published 14 years ago!

We need more up-to-date information!

And I am pleased to report that a recent paper provided exactly that.

This systematic review included published and unpublished RCTs. Quasi-RCTs, crossover trials, controlled before and after studies, interrupted time series (ITS) studies, and non-experimental studies were not included due to their potential high risk of bias.

Thirty-three trials involving 7175 patients with ARTIs were included. Their methodological quality was restricted as randomisation was not well documented; 73% of the trials included were not blinded; where ITT analysis were performed, loss to follow-up data were counted as no effect; and most trials were published without a protocol available.

Findings suggested limited but consistent evidence that A. Paniculata improved cough and sore throat when compared with placebo. A. Paniculata (alone or plus usual care) had a statistically significant effect in improving overall symptoms of ARTIs when compared to placebo, usual care, and other herbal therapies. A. Paniculata in pillule tended to be more effective in improving overall symptoms over A. Paniculata in tablet. Evidence also suggested that A. Paniculata (alone or plus usual care) shortens the duration of cough, sore throat and sick leave/time to resolution when compared versus usual care. Reduction in antibiotic usage was seldom evaluated in the included trials.

The authors concluded that A. Paniculata appears beneficial and safe for relieving ARTI symptoms and shortening time to symptom resolution. However, these findings should be interpreted cautiously owing to poor study quality and heterogeneity. Well-designed trials evaluating the effectiveness and potential to reduce antibiotic use of A. Paniculata are warranted.

In case you wonder about conflicts of interest: there were none with my 2004 paper, and the authors of the new review state that this paper presents independent research funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views expressed are those of the author(s) and not necessarily those of the NIHR, the NHS or the Department of Health.

Yes, the RCTs are not all of top quality.

And yes, the effect size is not huge.

But maybe – just maybe – we do have here an alternative therapy that does help against a condition for which conventional drugs are fairly useless!?!

Traditional Chinese Medicine (TCM) is popular, not least because it is heavily marketed and thus often perceived as natural and safe. But is this assumption true?

This study analysed  liver tests before and following treatment with herbal Traditional Chinese Medicine (TCM) in order to evaluate the risk of liver injury. Patients with normal values of alanine aminotransferase (ALT) as a diagnostic marker for ruling out pre-existing liver disease were enrolled in a prospective study of a safety program carried out at the First German Hospital of TCM from 1994 to 2015. All patients received herbal products, and their ALT values were reassessed 1-3 d prior to discharge. To evaluate causality for suspected TCM herbs, the Roussel Uclaf Causality Assessment Method (RUCAM) was used.

The report presents data of 21470 patients. ALT ranged from 1 × to < 5 × upper limit normal (ULN) in 844 patients (3.93%) and suggested mild or moderate liver adaptive abnormalities. A total of 26 patients (0.12%) experienced higher ALT values of ≥ 5 × ULN (300.0 ± 172.9 U/L, mean ± SD). Causality for TCM herbs was estimated to be probable in 8/26 patients, possible in 16/26, and excluded in 2/26 cases.

Compared with the large TCM study cohort, patients in the liver injury study cohort were older and contained a higher percentage of women, whereas the duration of the hospital stay was similar in both cohorts. The TCM herbs were rarely applied mostly as mixtures consisting of several herbs adding up to 35 different drugs during the patients’ four-week stay. The daily dosage was 95 ± 30 g and thus slightly higher than in the TCM study cohort. Among the many herbal TCM used by the 26 patients in the liver injury cohort, Bupleuri radix and Scuterllariae radix were the two TCM herbs most frequently implicated in liver injury, with variable RUCAM-based causality gradings. Most of the patients received one to six TCM drugs that were associated with potential liver injury as evidenced from the scientific literature, e.g., one patient (case 8) received six potentially hepatotoxic herbal TCM drugs during their hospital stay.

The authors concluded that in 26 (0.12%) of 21470 patients treated with herbal TCM, liver injury with ALT values of ≥ 5 × ULN was found, which normalized shortly following treatment cessation, also substantiating causality.

In the discussion section of the paper, the authors comment that the use of TCM is widely considered less risky as compared with synthetic drugs, although data on direct comparisons are not available in support of this view. Populations using herbal TCM, drugs, either alone, or combined experience more drug-induced liver injury (DILI) than herb-induced liver injury (HILI), possibly due to a higher use of drugs. Valid data of incidence and prevalence of HILI caused by TCM herbs are lacking, and respective data cannot be derived from the present study.

This study is most valuable, in my view. Its strength is clearly the huge sample size. Top marks for the authors for publishing it!

Having said that, we need to take the incidence figures with a pinch of salt, I think. In reality they could be much higher because:

  • other settings will not be as tightly supervised as the unusual hospital setting;
  • in most other situations the quality of the Chinese herbs might be less controlled;
  • there could be adulteration;
  • there could be contamination.

The ‘elephant in the room’ obviously is the inevitable question about benefit. Like any other treatment, TCM cannot be judged on the basis of its risk but must be evaluated according to its risk/benefit balance. I realise that this was not the subject of the present study, but it is nevertheless crucial: do the benefits of TCM outweigh its risks?

I am not aware that this is the case (but more than willing to consider any sound evidence readers might supply). More importantly, I am not aware of good evidence to show that, for any condition, TCM would be superior in terms of risk/benefit balance than conventional options. This is not a trivial issue: clinicians have the ethical obligation to apply the best (the one with the most positive risk/benefit balance) treatment to their patients.

If I am right, then TCM should not be used in therapeutic routine in or outside hospitals.

If I am right, the ‘First German Hospital of TCM‘ should close asap; it would be violating fundamental ethical principles.

If I am right, the debate about the risks of TCM is almost irrelevant because we simply should not use it.

Or did I misunderstand something here?

What do you think?

 

Herb/drug interactions are important, much-neglected and potentially dangerous. We have covered this issue several times, e. g. here. Recently, a valuable new paper has been published on the subject in a respected journal. Here is the abstract:

AIM:

The aim of this review was to assess the severity of adverse drug reactions (ADRs) due to herb-drug interactions in patients taking herbs and prescribed medications based on published evidence.

METHOD:

Electronic databases of PubMed, the Cochrane Library, Medline and Scopus were searched for randomized or non-randomized clinical studies, case-control and case reports of herb-drug interactions (HDI). The data was extracted and the causal relationship of ADRs as consequences of HDI assessed using Horn’s drug interaction probability scale (DIPS) or Roussel Uclaf Causality Assessment Method (RUCAM) scoring systems. The mechanism of interaction was ascertained using Stockley’s herbal medicine interaction companion.

RESULTS:

Forty-nine case reports and two observational studies with 15 cases of ADRs were recorded. The majority of the patients were diagnosed with cardiovascular diseases (30.60%), cancer (22.45%) and renal transplants (16.32%) receiving mostly warfarin, alkylating agents and cyclosporine, respectively.

CONCLUSION:

HDI occurred in patients resulting in clinical ADRs with different severity. Patients may poorly respond to therapeutic agents or develop toxicity due to severe HDI which in either scenario may increase the cost of treatment and /or lead to or prolong patient hospitalisation. It is warranted to increase patient awareness of the potential interaction between herbs and prescribed medicines and their consequences to curb HDI as a potential health problem.

The journal must have published a press-release, because the findings were reported in several newspapers. THE DAILY TELEGRAPH picked up the story and reported it fairly well – at least this is what I thought when I started reading it. My opinion changed when, at the end of the article, I found this:

Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said that doctors should make it clear to patients that they could not be taking herbal remedies alongside drugs.

Prof Ernst said there was no good evidence that they work and that doctors were ‘contributing to disinformation’ by turning a blind eye to the practice.

WHAT????

I was taken aback!

I had not spoken to anyone at THE DAILY TELEGRAPH about this new publication.

What’s the harm?, you might ask.

Call me pedantic, but I think it is wrong to cite someone without interviewing him (or her).

Yet, I agree that the whole thing might be seen as a triviality, if the quote had been picked up correctly elsewhere. Sadly, that is not the case in this particular instance: the words that were put in my mouth are factually incorrect and I have never said or written anything remotely like them.

It is wrong to claim that there is no good evidence that they [herbal medicines] work (as discussed repeatedly on this blog and elsewhere, there are several herbal medicines that have been shown to work for defined conditions; St John’s Wort/depression is probably the best example). And consequently, it is nonsense to state that doctors were ‘contributing to disinformation’ by turning a blind eye to the practice.

When I first saw this article three days ago, I posted a comment asking the journalist to explain the situation. This would have been the opportunity to set things straight and correct the error to everybody’s satisfaction. Unfortunately, no reaction followed.

You might still think that this is a triviality. And perhaps you are right. But I nevertheless feel it is worrying that we seem to have gotten used to even ‘respected’ newspapers misrepresenting experts and facts. If this happens in the realm of medicine, who tells us that it is not also happening in politics etc?

This survey assessed chiropractic (DC) and naturopathic “doctors”‘ (ND) knowledge, attitudes, and behaviour with respect to the pediatric patients in their practice. Cross-sectional surveys were developed in collaboration with DC and ND educators. Surveys were sent to randomly selected DCs and NDs in Ontario, Canada in 2004, and a national online survey was conducted in 2014. Data were analyzed using descriptive statistics, t-tests, non-parametric tests, and linear regression.

Response rates for DCs were n = 172 (34%) in 2004, n = 553 (15.5%) in 2014, and for NDs, n = 171 (36%) in 2004, n = 162 (7%) in 2014. In 2014, 366 (78.4%) of DCs and 83 (61%) of NDs saw one or more paediatric patients per week. Paediatric training was rated as inadequate by most respondents in both 2004 and 2014, with most respondents (n = 643, 89.9%) seeking post-graduate training by 2014. About half of DCs (51.7% in 2004, 49.2% in 2014) and one fifth of NDs (21% in 2004 and 23% in 2014) reported they received no hands-on clinical paediatric training. Only a minority of practitioners felt their hands-on paediatric training was adequate (somewhat or very) for their needs: DCs: 10.6% in 2004, 15.6% in 2014; NDs: 10% in 2004 and 19% in 2014. Respondents’ comfort in treating children and youth is based on experience and post-graduate training. Both DCs and NDs that see children and youth in their practices address a broad array of paediatric health concerns, from well child care and preventative health, to mild and serious illness.

The authors included two ‘case studies’ of conditions frequently treated by DCs and NDs:

Case study 1: colic

DC practitioners’ primary treatment focus (314 respondents) would be to use spinal manipulation (78.3%) if physical assessment suggests utility, diet changes (14.6% for child, 6.1% for mom if breast feeding), and massage (16.9%). ND practitioners (95 respondents) would assess and treat primarily with diet changes (62% for child including prescribing probiotics; 48% for mom if breast feeding), homeopathy (46%), weak herbal or tea preparations (19%), and use topical castor oil (packs or massage) (18%). In 2014, 65.9% of DCs and 59% of NDs believe (somewhat or very much) that concurrent treatment by a medical practitioner would be of benefit; 64.0% of DCs and 60% of NDs would refer the patient to another health care practitioner (practitioner type not specified).

Case study 2: acute otitis media

In 2014, almost all practitioners identified this as otitis media (in 2004, the DCs had a profession-specific question); DCs were more cautious about the value of their care for it relative to the NDs (DCs, 46.2% care will help patient very much, NDs, 95%). For treatment, DCs would primarily use spinal manipulation (98.5%) if indicated after assessment, massage (19.5%), dietary modifications (17.6%), and 3.8% would specifically refer to an MD for an antibiotic prescription. ND-preferred treatments were NHP products (79%), dietary modifications (66%), ear drops (60%), homeopathic remedies (18%), and 10% would prescribe antibiotics right away or after a few days. In 2014, 86.3% of DCs and 75% of NDs believe the patient would benefit (somewhat or very much) from concurrent treatment by a conventional medical practitioner; 81.7% of DCs and 58% of NDs would refer the patient to another health care provider.

The authors concluded that although the response rate in 2014 is low, the concerns identified a decade earlier remain. The majority of responding DCs and NDs see infants, children, and youth for a variety of health conditions and issues, but self-assess their undergraduate paediatric training as inadequate. We encourage augmented paediatric educational content be included as core curriculum for DCs and NDs and suggest collaboration with institutions/organizations with expertise in paediatric education to facilitate curriculum development, especially in areas that affect patient safety.

I find these data positively scary:

  • Despite calling themselves ‘doctors’, they are nothing of the sort.
  • DCs and NCs are not adequately educated or trained to treat children.
  • They nevertheless often do so, presumably because this constitutes a significant part of their income.
  • Even if they felt confident to be adequately trained, we need to remember that their therapeutic repertoire is wholly useless for treating sick children effectively and responsibly.
  • Therefore, harm to children is almost inevitable.
  • To this, we must add the risk of incompetent advice from CDs and NDs – just think of immunisations.

The only conclusion I can draw is this: chiropractors and naturopaths should keep their hands off our kids!

Can conventional therapy (CT) be combined with herbal therapy (CT + H) in the management of Alzheimer’s disease (AD) to the benefit of patients? This was the question investigated by Chinese researchers in a recent retrospective cohort study funded by grants from China Ministry of Education, National Natural Science Foundation of China, Beijing Municipal Science and Technology Commission, and Beijing Municipal Commission of Health and Family Planning.

In total, 344 outpatients diagnosed as probable dementia due to AD were collected, who had received either CT + H or CT alone. The GRAPE formula was prescribed for AD patients after every visit according to TCM theory. It consisted mainly (what does ‘mainly’ mean as a description of a trial intervention?) of Ren shen (Panax ginseng, 10 g/d), Di huang (Rehmannia glutinosa, 30 g/d), Cang pu (Acorus tatarinowii, 10 g/d), Yuan zhi (Polygala tenuifolia, 10 g/d), Yin yanghuo (Epimedium brevicornu, 10 g/d), Shan zhuyu (Cornus officinalis, 10 g/d), Rou congrong (Cistanche deserticola, 10 g/d), Yu jin (Curcuma aromatica, 10 g/d), Dan shen (Salvia miltiorrhiza, 10 g/d), Dang gui (Angelica sinensis, 10 g/d), Tian ma (Gastrodia elata, 10 g/d), and Huang lian (Coptis chinensis, 10 g/d), supplied by Beijing Tcmages Pharmaceutical Co., LTD. Daily dose was taken twice and dissolved in 150 ml hot water each time. Cognitive function was quantified by the mini-mental state examination (MMSE) every 3 months for 24 months.

The results show that most of the patients were initially diagnosed with mild (MMSE = 21-26, n = 177) and moderate (MMSE = 10-20, n = 137) dementia. At 18 months, CT+ H patients scored on average 1.76 (P = 0.002) better than CT patients, and at 24 months, patients scored on average 2.52 (P < 0.001) better. At 24 months, the patients with improved cognitive function (△MMSE ≥ 0) in CT + H was more than CT alone (33.33% vs 7.69%, P = 0.020). Interestingly, patients with mild AD received the most robust benefit from CT + H therapy. The deterioration of the cognitive function was largely prevented at 24 months (ΔMMSE = -0.06), a significant improvement from CT alone (ΔMMSE = -2.66, P = 0.005).

 

The authors concluded that, compared to CT alone, CT + H significantly benefited AD patients. A symptomatic effect of CT + H was more pronounced with time. Cognitive decline was substantially decelerated in patients with moderate severity, while the cognitive function was largely stabilized in patients with mild severity over two years. These results imply that Chinese herbal medicines may provide an alternative and additive treatment for AD.

Conclusions like these render me speechless – well, almost speechless. This was nothing more than a retrospective chart analysis. It is not possible to draw causal conclusions from such data.

Why?

Because of a whole host of reasons. Most crucially, the CT+H patients were almost certainly a different and therefore non-comparable population to the CT patients. This flaw is so elementary that I need to ask, who are the reviewers letting such utter nonsense pass, and which journal would publish such rubbish? In fact, I can be used for teaching students why randomisation is essential, if we aim to find out about cause and effect.

Ahhh, it’s the ! I think the funders, editors, reviewers, and authors of this paper should all go and hide in shame.

The title of this post is a statement recently made in an article by Mike Adams in ‘Alternative Medicine News’:

The cancer industry goes to great lengths to deny patients access to any information that they might use to prevent, treat or cure cancer without requiring expensive (and highly toxic) medical interventions. That’s what makes the BMJ documentation of this curcumin cancer cure so astonishing: In years past, the BMJ never would have even tolerated the publishing of such a scientific assessment. So what changed? In truth, the evidence of natural cures for cancer is now so overwhelming that even the BMJ cannot remain in a state of denial without appearing to be hopelessly out of touch with scientific reality.

The story is based on one single patient who apparently was cured of cancer using curcumin (turmeric). The case was also recently (3/1/18) featured on BBC’s ‘YOU AND YOURS’ (http://www.bbc.co.uk/programmes/b09k0ng7) in a similarly uncritical way: no expert was asked to provide an evidence-based assessment and bring some reason into the discussion. Even the DAILY FAIL reported about the story, and predictably, critical assessment had to make way for sensationalism.

So what?

We hear about such nonsense almost every day!

True, but this case is different; it is based on a publication in the highly-respected BMJ (well, actually, it was the ‘BMJ CASE REPORTS’ and not the BMJ, as reported). Here is the article:

START OF QUOTE

A woman aged 57 years was initially diagnosed with monoclonal gammopathy of undetermined significance (MGUS) in 2007 following an incidental finding of M-protein (18 g/L) during investigation for hypertension.

Within 15 months, the patient had rapidly progressed to ISS stage 3 myeloma with M-protein 49 g/L, urinary protein 1.3 g/24-hour, Bence-Jones protein 1.0 g/24-hour, Hb 9.7 g/dL and increasing back pain. She initially declined antimyeloma treatment but 6 months later, following vertebral collapse at T5 and T12, started cyclophosphamide, thalidomide and dexamethasone (CTD) treatment. However, after a week, the patient was admitted with idiosyncratic syndrome including hyponatraemia, a fall in albumin and worsening of blood counts. She received red cell transfusion and her electrolyte abnormalities were carefully corrected.

Although there was evidence of a response to CTD (M-protein 34 g/L), bortezomib and dexamethasone treatment was initiated as an alternative, but this was discontinued after three cycles due to progressive disease (M-protein 49 g/L). The patient was then treated with lenalidomide and dexamethasone with the aim of reducing disease burden prior to high-dose therapy and autologous stem cell transplantation. Treatment was frequently interrupted and dose adjusted to account for neutropenia and despite a minor response after six cycles (starting M-protein 47 g/L, finishing M-protein 34 g/L), in October 2009, she proceeded with stem cell mobilisation. However, neither cyclophosphamide nor plerixafor/GCSF priming were successful. A bone marrow biopsy revealed 50% myeloma cells and a course of CTD was restarted with cautious titration of thalidomide.

The patient achieved a partial response with CTD retreatment over the course of 17 cycles (M-protein 13 g/L) with no further episodes of idiosyncratic syndrome. However, attempts to harvest stem cells in February 2011 and again there months later, both failed. By then, her M-protein had risen to 24 g/L and the patient was too neutropenic to be considered for a clinical trial.

At this point, the patient began a daily regime of oral curcumin complexed with bioperine (to aid absorption), as a single dose of 8 g each evening on an empty stomach. A few months later, she also embarked on a once-weekly course of hyperbaric oxygen therapy (90 min at 2 ATA) which she has maintained ever since. Her paraprotein levels gradually declined to a nadir of 13 g/L, her blood counts steadily improved and there was no evidence of further progressive lytic bone disease.

Outcome and follow-up

The patient continues to take oral curcumin 8 g daily without further antimyeloma treatment. Over the last 60 months, her myeloma has remained stable with minimal fluctuation in paraprotein level, her blood counts lie within the normal range and she has maintained good quality of life throughout this period. Repeat bone imaging in 2014 identified multiple lucencies <1 cm in the right hip and degenerative changes in both hips, but these were attributed to osteoarthritis rather than the myeloma. Recent cytogenetic analysis revealed she had no abnormal cytogenetics by fluorescent in situ hybridisation.

Discussion

A small but significant number of myeloma patients consume dietary supplements in conjunction with conventional treatment primarily to help cope with the side effects of treatment, manage symptoms and enhance general well-being. Few, if any, use dietary supplementation as an alternative to standard antimyeloma therapy. Here, we describe a case in which curcumin has maintained long-term disease control in a multiply-relapsed myeloma patient. To the best of our knowledge, this is the first report in which curcumin has demonstrated an objective response in progressive disease in the absence of conventional treatment.

Curcumin is a polyphenol derived from the perennial herb Curcuma longa (turmeric) and has, for centuries, been used as a traditional Indian medicine. Several reports published over the two decades have claimed various health benefits of curcumin and this has led to its increasing popularity as a dietary supplement to prevent or treat a number of different diseases.

The biological activity of curcumin is indeed remarkable. It is a highly pleiotropic molecule which possesses natural antioxidant, anti-inflammatory, antiseptic and analgesic properties. More recently, it has demonstrated antiproliferative effects in a wide variety of tumour cells including myeloma cells and exerts its antiproliferative effects through multiple cellular targets that regulate cell growth and survival.

In vitro, curcumin prevents myeloma cell proliferation through inhibition of IL-6-induced STAT-3 phosphorylation and through modulation of the expression of NF-kB-associated proteins such as IkB〈,Bcl-2, Bcl-xL, cyclin D1 and IL-6 and apoptosis-related molecules including p53 and Bax. In other studies, curcumin was shown to circumvent resistance to dexamethasone, doxorubicin and melphalan as well as potentiate the effects of bortezomib, thalidomide and lenalidomide. Furthermore, curcumin-induced cell death was not influenced by myeloma molecular heterogeneity.

The antimyeloma effects of curcumin in the clinical setting however are less clear. Only one phase I/II study has evaluated curcumin treatment in myeloma patients. These patients were either asymptomatic, relapsed or had plateau phase disease. Treatment with curcumin downregulated the expression of NFkB, COX-2 and STAT3 in peripheral blood mononuclear cells, but no objective responses were observed in any subgroup of patients. This may be as a result of small sample size in this study, follow-up was limited to 3 months and clinical responses may have been observed with longer follow-up. However, downregulation of NFkB, COX-2 and STAT3 expression may not correlate with the clinical activity of curcumin and there may be further mechanisms of action that remain unclear, possibly through the modulation of another target. We would not be able to identify any patient-specific mechanisms of activity in this case study, as the patient has been taking curcumin for some time now and baseline bone marrow or peripheral blood samples are not available. However, in the setting of a clinical trial, it may be possible to use next-generation sequencing to help identify a mutation that may be a potential target for curcumin.

Another study examined its effects in preventing the progression of MGUS and smouldering myeloma to myeloma. The results showed that curcumin exerted a trace of biological activity with modest decreases in free light chain and paraprotein levels and a reduction in a marker of bone resorption with curcumin treatment, suggesting the therapeutic potential of curcumin in MGUS and smouldering myeloma. However, more studies are needed to address this further.

Whether such effects are observed in patients with active disease remains to be seen. The fact that our patient, who had advanced stage disease and was effectively salvaged while exclusively on curcumin, suggests a potential antimyeloma effect of curcumin. She continues to take daily curcumin and remains in a very satisfactory condition with good quality of life. This case provides further evidence of the potential benefit for curcumin in myeloma. We would recommend further evaluation of curcumin in myeloma patients in the context of a clinical trial.

END OF QUOTE

What should we make of this?

I think that much of the reporting around the story was grossly irresponsible. It is simply not possible to conclude that curcumin was the cause of the remission. It could be due to a whole host of other factors. And a case report is just an anecdote; it never can prove anything and can only be used to stimulate further research.

I fully agree with the authors of the case report: curcumin seems worthy of further investigation. But recommending it to patients for self-medication is vastly premature and quite simply dangerous, unethical and naïve bordering on stupid.

And, of course, the above-cited drivel of Mike Adams is just beyond the pale – the evidence for ‘alternative cancer cures‘ is very, very far from ‘overwhelming’; and the ‘cancer industry’ is doing what they can to determine whether turmeric or any other natural remedy can be used to treat cancer and other diseases.

If they are ever successful, the Adams of this world will shout ‘EXPLOITATION!!!’

If their endeavours are not successful, they will complain ‘CONSPIRACY!!!’

The common cold is a perfect condition for providers of alternative medicine:

  • it is prevalent (good money to be earned),
  • it is not normally dangerous,
  • it nevertheless reduces quality of life and thus patients look for a treatment,
  • there probably is not a single alternative therapy that does not claim to be effective for it,
  • it is gone after about a week, treated or not.

But is there an alternative therapy that does actually work? An article by the Cochrane Collaboration provides an excellent overview. It includes conventional as well as alternative treatments; here I have merely copied the passages related to the latter:

VITAMIN C

There was great excitement in the 1970s when Linus Pauling, (a Nobel laureate twice over), concluded from placebo-controlled trials that Vitamin C could prevent and alleviate the common cold. Further research followed and a Cochrane review, published in 2013, found 29 clinical trials, involving 11,306 participants. Unfortunately, the review did not confirm Pauling’s findings. Taking regular Vitamin C did not reduce the incidence of colds in the general population, although there was a modest reduction in the duration and severity of symptoms. The only people who appeared to derive some benefit were those who undertook short bursts of extreme exercise, such as marathon runners and skiers. In this group the risk of getting a cold was halved.

Trials looking at taking high dose Vitamin C at the onset of cold symptoms showed no consistent effect on the duration and severity of symptoms and more research is needed to clarify these findings.

ECHINACEA

Echinacea is widely used in Europe and North America for common colds. A Cochrane review (2014) showed that some Echinacea products may be more effective than placebo in treating colds but the overall evidence for clinically relevant effects was weak. There was some evidence of a small preventative effect.

INHALATIONS

Inhaled steam has been used for decades (see earlier reference to my childhood humiliation!) thinking that it helps drain away mucus more effectively and possibly destroys the cold virus. A Cochrane review (2017) of six trials with 387 participants showed no consistent benefit for this intervention.

GARLIC

A single trial with 146 participants showed that taking garlic every day for three months might prevent occurrences of the common cold but the evidence was of low quality and more research is needed to validate this finding. (Cochrane review 2014.)

END OF QUOTE

The article obviously focuses only on such therapies for which Cochrane reviews have been published. What about other treatments? As I already mentioned, if we believe the promoters of alternative medicine, the list is long. But fortunately, we do not believe them and want to see the evidence.

HOMEOPATHY

Unsurprisingly, the evidence is not good. One of my posts even expressed the fear that it might involve scientific misconduct.

CHIROPRACTIC

Yes, some chiropractors claim that their manipulations are effective for the common cold. But, as with almost all of their claims, this cannot be taken seriously; the assumption is bogus.

CHINESE HERBAL MEDICINES

A systematic review concluded that their use for common cold is not supported by robust evidence.

SAUNA

Ages ago, I published a small study with promising results:

Twenty-five volunteers were submitted to sauna bathing, with 25 controls abstaining from this or comparable procedures. In both groups the frequency, duration and severity of common colds were recorded for six months. There were significantly fewer episodes of common cold in the sauna group. This was found particularly during the last three months of the study period when the incidence was roughly halved compared to controls. The mean duration and average severity of common colds did not differ significantly between the groups. It is concluded that regular sauna bathing probably reduces the incidence of common colds, but further studies are needed to prove this.

Sadly, the findings were never replicated.

 

MY CONCLUSION

Grin and bear it!

(That is the cold as well as the myriad of false claims made by enthusiasts of alternative medicine)

 

Who could resist reading an article entitled “Is Dead Vagina Syndrome Real? Plus, 4 Ways To Boost Your Libido“?

Well I couldn’t, particularly as it came from a site promisingly called ‘ALTERNATIVE DAILY’!

And I did not regret it. Here are some excerpts:

…“Dead vagina syndrome” or DVS is used to describe a woman’s over-sensitized vagina. Some people believe that regularly using a strong vibrator can cause a woman to lose feeling in her private parts. What’s worse, it’s thought that this desensitization of the nether regions makes it almost impossible for a woman to get aroused with an actual human partner. Thus, DVS is born. The theory behind the condition suggests that using a strong vibrator regularly will ultimately damage sensitive nerves around the clitoris and in the vagina…”

[Luckily, there is help – help from all natural, herbal remedies, no less. The article recommends the following cures]

Saffron

Saffron, a culinary delicacy, has a powerful libido-boosting effect. In fact, research suggests that saffron has been used traditionally as an aphrodisiac. And a little goes a long way. All you need is one or two strands to do the trick.

Maca root

Used for centuries in Asian countries, maca root has traditionally been used for male sexuality. But a study from the Department of Psychiatry, Massachusetts General Hospital has found that it may also be helpful for women in need of a sexual boost.

Nutmeg

In animal studies, nutmeg has been found to increase sexual activity in male rats. Interestingly, nutmeg has also been used traditionally as an aphrodisiac by African women and is still used today by women of all cultures. So, what’s good for men is obviously good for women too…

END OF QUOTE

Before you get all excited and start planting your own physic garden or hurry to the next health food shop, let me tell you this: I have looked into the evidence, and to call it flimsy would be the understatement of the year. There is no good reason to believe that these herbal remedies (or any other alternative therapy) can help women increase their libido.

Thankfully, the article ends on a truthful and reassuringly positive note: “most experts agree that DVS is not a real medical concern for women.”

… nor for men, I hasten to add.

 

I have often cautioned about what I call the ‘survey mania’ in alternative medicine. Yet, once in a while, an informative survey gets published. Take this recent survey, for instance:

It was based on a design-based logistic regression analysis of the European Social Survey (ESS), Round 7. The researchers distinguished 4 modalities: manual therapies, alternative medicinal systems, traditional Asian medical systems and mind-body therapies.

In total, 25.9% of the general population had used at least one of these therapies during the last 12 months which was around one-third of the proportion of those who had visited a general practitioner (76.3%). Typically, only one treatment had been used, and it was used more often as complementary rather than alternative treatment. The usage varied greatly by country (see Table 1 below). Compared to those in good health, the use of CAM was two to fourfold greater among those with health problems. The health profiles of users of different CAM modalities varied. For example, back or neck pain was associated with all types of CAM, whereas depression was associated only with the use of mind-body therapies. Individuals with difficult to diagnose health conditions were more inclined to utilize CAM, and CAM use was more common among women and those with a higher education. Lower income was associated with the use of mind-body therapies, whereas the other three CAM modalities were associated with higher income.

The authors concluded that help-seeking differed according to the health problem, something that should be acknowledged by clinical professionals to ensure safe care. The findings also point towards possible socioeconomic inequalities in health service use.

As I said, this is one of the rare surveys that is worth studying in some detail. This is mainly because it is rigorous and its results are clearly presented. Much of what it reports has been known before (for instance, we showed that the use of CAM in the UK was 26% which ties in perfectly with the 21% figure considering that here only 4 CAMs were included), but it is undoubtedly valuable to see it confirmed based on sound methodology.

Apart of what the abstract tells us, there are some hidden gems from this paper:

  • 8% of CAM users had used CAM exclusively (alternative use), without any visits to biomedical professionals in the last 12 months. This may look like a low figure, but I would argue that it is worryingly high considering that alternative usage of CAM has the potential to hasten patients’ deaths.
  • The most frequently used CAM treatment was massage therapy, used by 11.9% of the population, followed by homeopathy (5.7%), osteopathy (5.2%), herbal treatments (4.6%), acupuncture (3.6%), chiropractic (2.3%), reflexology (1.7%) and spiritual healing (1.3%). Other modalities (Chinese medicine, acupressure and hypnotherapy) were used by around by 1% or less. The figure for homeopathy is MUCH smaller that the ones homeopaths want us to believe.
  • About 9% of healthy survey-participants had used at least one of the CAM modalities during the last 12 months. One can assume that this usage was mostly for disease-prevention. But there is no good evidence for CAM to be effective for this purpose.
  • The highest ORs for the use of Traditional Asian Medical Systems were found in Denmark, Switzerland and Israel, followed by Austria, Norway and Sweden. The highest OR for the use of Alternative Medical Systems was found in Lithuania, while manual therapies were most commonly used in Finland, Austria, Switzerland, Germany and Denmark. Moreover, Denmark, Ireland, Slovenia and Lithuania had the highest ORs for using mind-body therapies. France, Spain and Germany presented a common pattern, with relatively similar use of the different modalities. Poland and Hungary had low ORs for use of the different CAM modalities.

But by far the nicest gem, however, comes from my favourite source of misinformation on matters of health, WDDTY. They review the new survey and state this: The patients are turning to alternatives for a range of chronic conditions because they consider the conventional therapy to be inadequate, the researchers say. Needless to point out that this is not a theme that was addressed by the new survey, and therefore its authors also do not draw this conclusion.

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