MD, PhD, FMedSci, FSB, FRCP, FRCPEd

risk

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While the previous post was about seeing a traditional herbalist (who prescribe their own herbal mixtures, tailor-made for each individual patient), this post provides essential information for those consumers who are tempted to take a commercially available herbal remedy available in pharmacies, health food shops, over the Internet etc. These remedies are usually bought by consumers and then be self-administered, or (less frequently) they might be prescribed/recommended/sold by a clinician such as a doctor, naturopath, chiropractor etc. Typically, they contain just one (or relatively few) herbal extracts and are used under similar assumptions as conventional medicines: one (hopefully well-tested) remedy is employed for treating a defined condition, diagnosed according to validated and generally accepted criteria (for instance, St John’s Wort for depression or Devil’s claw for back pain). This approach is sometimes referred to as ‘rational phytotherapy’ – it is certainly more rational than the traditional herbalism referred to in my previous post. The manufacture, promotion and sale of commercial herbal remedies (in many countries marketed as ‘dietary supplements’) has grown into a multi-billion dollar industry.

Here are a few essentials you ought to know before you decide to take such an herbal remedy:

  1. Many people claim that herbal medicine is effective because many of our modern drugs are based on plants. The latter part of this claim is true, of course, but this does not necessarily mean that herbal remedies are effective. The drugs derived from plants contain one single, well-defined, extensively researched molecule (by definition, this makes them conventional drugs and not herbal remedies), while herbal remedies are based on entire (parts of) plants; thus they contain many pharmacologically active molecules. This often means that it is difficult or impossible to tell what dose of which ingredient is being administered and what pharmacological actions can be expected.
  2. Even though national regulations differ greatly, herbal remedies generally do not have to be supported by evidence for efficacy in order to be legally available. This means that a given remedy might or might not have been tested in clinical trials to determine whether it works for the condition advertised. In fact, only very few (less than 30, I estimate) herbal remedies are supported by sound evidence for efficacy; thousands do not meet this criterion.
  3. The extremely wide-spread notion that herbal remedies are by definition natural and therefore safe is nothing but a promotional myth. Plants contain many chemicals which can have pharmacological activity. This means they might be therapeutic, but it also means that they might be toxic (traditionally the most powerful poisons originated from the plant kingdom). If anyone uses the ‘natural = safe fallacy’ remind him/her of hemlock, poison ivy etc.
  4. In addition to potential toxicity of an herbal ingredient, there are other important safety issues to be considered. Most importantly, herbal remedies can interact with prescribed medicines. For instance, St John’s Wort (one of the best-studied herbal remedies in this respect) powerfully interacts with about 50% of all prescription drugs – in fact, it lowers their level in the blood which means that a patient on anti-coagulants would lose her anti-coagulant protection and might suffer from a (potentially fatal) blood clot.
  5. In many countries, including the US, the regulation of herbal remedies is so lax, that there is no guarantee that an herbal remedy which is being legally sold is safe. The regulators are only allowed to intervene once there are reports of adverse effects. This means that the burden of proof of safety is effectively reversed which obviously exposes consumers to incalculable risks.
  6. The quality of the herbal product is equally poorly regulated in most countries. A plethora of investigations in the US, for instance, has shown that the dose of the herbal ingredient printed on the label of a commercial product can range virtually from 0 – 100%. Similarly there is little safe-guard that the ingredients listed on the label correspond to the ones in the preparation. This means that it is worth purchasing not just well-researched herbal remedies but also those marketed by high quality manufacturers via respectable outlets.
  7. Any regulation of herbal remedies, even the European one that is often praised as protecting consumers adequately, is null and void once consumers go on the Internet and purchase their herbal remedies from one of the many dubious sources found there in truly alarming profusion. Bogus claims, inferior quality and even outright dangerous products abound, and it is often impossible to tell the acceptable from the fraudulent product.

Here I am not writing about herbal medicine in general – parts of which are supported by some encouraging evidence (I will therefore post more than one ‘seven things to remember…’ article on this subject) – here I am writing about the risks and benefits of consulting a traditional herbal practitioner. Herbalists come in numerous guises depending what tradition they belong to: Chinese herbalist, traditional European herbalist, Ayurvedic practitioner, Kampo practitioner etc. If you consult such a therapist, you should be aware of the following issues.

  1. Worldwide, the treatment by traditional herbal practitioners is by far the most common form of herbal medicine; it is more common than to use specific, well-tested herbs to treat specific conventionally diagnosed conditions (an approach that might best be called ‘rational phytotherapy’).
  2. Herbalists often use their very own diagnostic methods (think, for instance, of ‘tongue and pulse diagnoses’ used by Chinese herbalists) and reject (or are untrained to use) conventional diagnostic methods. The traditional diagnostic techniques of herbalists have either not been validated at all or they have been tested and found to be not valid.
  3. Herbalists usually do not recognise conventional disease categories. Instead they arrive at a diagnosis according to their specific philosophy which has no grounding in reality (for instance, energy imbalance in traditional Chinese herbalism).
  4. Herbalists individualise their treatments, meaning that 10 patients suffering from depression, for instance, might receive 10 different, tailor-made prescriptions according to their individual characteristics (and none of the 10 patients might receive St John’s Wort, the only herbal remedy that actually is proven to work for depression).
  5. Typically, such prescriptions contain not one herbal ingredient, but are mixtures of many – up to 10 or 20 – herbs or herbal extracts.
  6. Even though the efficacy of the individualised herbal approach can, of course, be tested in rigorous trials, and even though about a dozen such studies are available today, there is currently no good evidence to show that it is effective.
  7. The risk of harm through these individualised herbal mixtures can be considerable: the more ingredients, the higher the likelihood that one of them has toxic effects or that one interacts with a prescription medicine. Essentially, this means that there is no good evidence that individualised herbal treatments as used by so many herbal practitioners across the globe generates more good than harm.

Some of the recent comments on this blog have been rather emotional, a few even irrational, and several were, I am afraid, outright insulting (I usually omit to post the worst excesses). Moreover, I could not avoid the impression that some commentators have little understanding of what the aim of this blog really is. I tried to point this out in the very first paragraph of my very first post:

Why another blog offering critical analyses of the weird and wonderful stuff that is going on in the world of alternative medicine? The answer is simple: compared to the plethora of uncritical misinformation on this topic, the few blogs that do try to convey more reflected, sceptical views are much needed; and the more we have of them, the better.

My foremost aim with his blog is to inform consumers through critical analysis and, in this way, I hope to prevent harm from patients in the realm of alternative medicine. What follows, are a few simple yet important points about this blog which I try to spell out here as clearly as I can:

  • I am not normally commenting on issues related to conventional medicine – not because I feel there is nothing to criticise in mainstream medicine, but because my expertise has long been in alternative medicine. So commentators might as well forget about arguments like “more people die because of drugs than alternative treatments”; they are firstly fallacious and secondly not relevant to this blog.
  • I have researched alternative medicine for many years (~ 40 clinical studies, > 300 systematic reviews etc.) and my readers can be confident that I know what I am talking about. Thus comments like ‘he does not know anything about the subject’ are usually not well placed and just show the ignorance of those who post them.
  • I am not in the pocket of anyone. I do not receive payments for doing this blog, nor did I, as an academic, receive any financial or other inducements for researching alternative medicine (on the contrary, I have often been given to understand that my life could be made much easier, if I adopted a more promotional stance towards my alternative medicine). I also do not belong to any organisation that is financed by BIG PHARMA or similar power houses. So my critics might as well abandon their conspiracy theories and  focus on a more promising avenue of criticism.
  • My allegiance is not with any interest group in (or outside) the field of alternative medicine. For instance, I do not see it as my job to help chiropractors, homeopaths etc. getting their act together. My task here is to point out the deficits in chiropractic (or any other area of alternative medicine) so that consumers are better protected. (I should think, however, that this also creates pressure on professions to become more evidence-based – but I see this as a mere welcome side-effect.)
  • If some commentators seem to find my arguments alarmist or see it as venomous scare-mongering, I suggest they re-examine their own position and learn to think a little more (self-) critically. I furthermore suggest that, instead of claiming such nonsense, they point out where they think I have gone wrong and provide evidence for their views.
  • Some people seem convinced that I have an axe to grind, that I have been personally injured by some alternative practitioner, or had some other unpleasant or traumatic experience. To those who think so, I have to say very clearly that none of this has ever happened. I recommend they inform themselves of the nature of critical analysis and its benefits.
  • This is a blog, not a scientific journal. I try to reach as many lay people as I can and therefore I tend to use simple language and sometimes aim to be entertaining. Those who feel that this renders my blog more journalistic than scientific are probably correct. If they want science, I recommend they look for my scientific articles in the medical literature; I can assure them that they will find plenty.
  • I very much invite an open and out-spoken debate. But ad hominem attacks are usually highly counterproductive – they only demonstrate that the author has no rational arguments left, or had none in the first place. Authors of insults also risks being banned from this blog.
  • Finally, I fear that some readers of my blog might sometimes get confused in the arguments and counter-arguments, and end up uncertain which side is right and which is wrong. To those who have this problem, I recommend a simple method for deciding where the truth is usually more likely to be found: ask yourself who might be merely defending his/her self-interest and who might be free of such conflicts of interest and thus more objective. For example, in my endless disputes with chiropractors, one could well ask: do the chiropractors have an interest in defending their livelihood, and what interest do I have in questioning whether chiropractors do generate more good than harm?

In many countries, consumers seem to be fond of consulting chiropractors – mostly for back pain, but also for other conditions. I therefore think it is might be a good and productive idea to give anyone who is tempted to see a chiropractor some simple, easy to follow advice. Here we go:

  1. Ask your chiropractor what he/she thinks about the chiropractic concept of subluxation. This is the chiropractors’ term (real doctors use the word too but understand something entirely different by it) for an imagined problem with your spine. Once they have diagnosed you to suffer from subluxation, they will persuade you that it needs correcting which is done by spinal manipulation which they tend to call ‘adjustments’. There are several important issues here: firstly subluxations do not exist outside the fantasy world of chiropractic; secondly chiropractors who believe in subluxation would diagnose subluxation in about 100% of the population – also in individuals who are completely healthy. My advice is to return straight back home as soon as the chiropractor admits he believes in the mystical concept of subluxation.
  2. Ask your chiropractor what he/she thinks of ‘maintenance care’. This is the term many chiropractors use for indefinite treatments which do little more than transfer lots of cash from your account to that of your chiropractor. There is no good evidence to show that maintenance care does, as chiropractors claim, prevent healthy individuals from falling ill. So, unless you have the irresistible urge to burn money, don’t fall for this nonsense. You should ask your chiropractor how long and frequent your treatment will be, what it will cost, and then ask yourself whether it is worth it.
  3. Run a mile, if the chiropractor wants to manipulate your neck (which most will do regardless of whether you have neck-pain, some even without informed consent). Neck manipulation is associated with very serious complications; they are usually caused by an injury to an artery that supplies parts of your brain. This can cause a stroke and even death. Several hundred such cases have been documented in the medical literature – but the true figure is almost certainly much larger (there is still no system in place to monitor such events).
  4. Run even faster, if the chiropractor wants to treat your children for common paediatric conditions. Many chiropractors believe that their manipulations are effective for a wide range of health problems that kids frequently suffer from. However, there is not a jot of evidence that these claims are true.
  5. Be aware that about 50% of all patients having chiropractic treatments will suffer from side effects like pain and stiffness. These symptoms usually last for 2-3 days and can be severe enough to impede your quality of life. Ask yourself whether the risk is outweighed by the benefit of chiropractic.
  6. Remember that there is no good evidence that chiropractors can treat any condition effectively other than lower back pain (and even for that condition the evidence is far from strong). Many chiropractors claim to be able to treat a plethora of non-spinal conditions like asthma, ear infection, gastrointestinal complaints, autism etc. etc. There is no good evidence that these claims are correct.
  7. Distrust the advice given by many chiropractors regarding prescribed medications, vaccinations or surgery. Chiropractic has a long history of warning their patients against all sorts of conventional treatments. Depending on the clinical situation, following such advice can cause very serious harm.

I am minded to write similar posts for all major alternative therapies (this will not make me more popular with alternative therapists, but I don’t mind all that much) – provided, of course, that my readers find this sort of article useful. So, please do give me some feedback.

If you have diabetes, chances are that you need life-long treatment. Before effective anti-diabetic medications became available, diabetes amounted to a death sentence. Fortunately, these times are long gone.

…unless, of course, you decide to listen to the promises of alternative practitioners many of whom offer a cure for diabetes. Here is just one website of hundreds that does just that. The following is an abbreviated quote where I have changed nothing, not even the numerous spelling mistakes:

Modern medicine has no  permanent cure for diabetes but alternative medicines like yoga ,mudra,ayurveda is very useful to control and even cure diabetes.Ayurveda is an alternative medicine to cure diabetes.

Alternative medicine like ayurveda is a best to cure diabetes naturally.
A serious disorder of the glands,of pancreas to be exact,is diabetes,or madhumeha as described in ayurveda.It is one of the most insidious disorders of the metabolism and,if left undiagnosed or untreated,it may lead to rapid emaciation and ultimately death…
Ayurveda medicines to cure diabetes
In ayurveda the following medicines have been recommended for this disease
Shiljita ————————–240 mg
Nyagrodadhi churna ———3 gm
These should be given twice after meals with decoction of arni.
Vasantakusumakara rasa —120 mg
Shudha Shilajit ————–240 mg
Nag Bhasma —————–120 mg
Haldi ————————–500 mg
Amlaki Churna ————-500 mg
Twice daily with powder of rose-apple stones.Twice daily with honey.
Chadraprabha  Vati ——– 500 mg
Mudra the alternative treatment to cure diabetes naturally
Mudra is a non medical and no cost treatment to cure diabetes.You can perform mudras at any time or any position.It is an effective way of treatment you can get better result if you practice it regularly .

It goes without saying that none of these treatments would cure diabetes. A Cochrane review concluded that there is insufficient evidence at present to recommend the use of these interventions in routine clinical practice. It also goes without saying that not many patients would fall for the nonsense proclaimed on this or so many other websites. But even just one single patient dying because of some charlatan promising a cure for life-threatening diseases is one patient too many.

Here and elsewhere, I have repeatedly written about the many things that can go wrong with acupuncture. This invariably annoys acupuncture fans who usually counter by accusing me of being alarmist. Despite their opposition, I continue to think it is important to regularly point out that acupuncture – contrary to what many acupuncturists would tell us – can result in serious injury. I will therefore carry on reporting new evidence about the harm caused by acupuncture. Here is a very brief review of new (2014) articles on this important topic.

A recent study found that the incidence of any adverse events per patient was 42.4% with traditional acupuncture, 40.7% with minimal acupuncture and 16.7% with non-invasive sham acupuncture. These figures are much higher than those around 10% previously reported.

Other authors described the case of a broken off acupuncture needle in a patient’s abdomen. A very long needle was used which happily is unusual in routine practice.

Pneumothorax has been often noted as a complication of acupuncture – it is by far the most frequently reported serious complication caused by acupuncture; well over 100 instances have been described in the medical literature which, of course, reflects only the tip of an iceberg – new cases are being reported almost on a monthly basis.

Cardiac tamponade is even more dangerous but fortunately also much rarer. A case of life-threatening cardiac tamponade due to penetration of an acupuncture needle directly into the right ventricle was recently published. Cardiac tamponade can happen when the patient is unfortunate enough to have a sternal foramen, an congenital abnormality that is not normally detected by simple inspection or palpation. An investigation found that the frequency of a sternal foramen is approximately 10.5%. The authors concluded that sternal acupuncture should be planned in the region of corpus-previous CT should be done to rule out this variation. Furthermore, we strongly recommend the acupuncture technique which prescribes a safe superficial-oblique approach to the sternum.

A review from Egypt noted that acupuncture presented a significant risks for acquiring hepatitis C infections.

Other types of infections can also be transmitted by acupuncture needles, if the therapist fails to adhere to proper procedures of sterility. One report described the diagnosis, treatment and >1 year follow-up of 30 patients presenting with acupuncture-induced primary inoculation tuberculosis.

Similarly, Chinese authors reported the case of a 54-year-old woman who presented with progressive low back pain and fever. She underwent surgical decompression, with an immediate improvement of her pain. A culture of the epidural abscess grew Serratia marcescens. One year postoperatively, magnetic resonance imaging revealed the almost complete eradication of the abscess. This case is the first case of Serratia marcescens-associated spinal epidural abscess formation secondary to acupuncture.

Other authors reported a rare case of isolated unilateral hypoglossal nerve injury following ipsilateral acupuncture for migraines in a 53-year-old lady.

Finally, Greek authors published a case of severe rhabdomyolysis and acute kidney injury after acupuncture sessions. Rhabdomyolysis is a rare condition that can be caused by muscle injury and presents with muscle weakness and pain. It is characterized by myoglobinuria which, in turn, may cause acute kidney injury.

I can hear the world of acupuncture arguing that all of these events are extreme rarities and that conventional treatments are much more dangerous. This may well be true but it also ignores the following facts:

  • The frequency of such events is essentially unknown. Contrary to conventional medicine, alternative medicine has no functioning systems to monitor adverse events. Therefore the true incidence figures of acupuncture-related complications are anyone’s guess.
  • Most conventional treatments in common use are backed up by good evidence for efficacy and therefore demonstrably do more good than harm, even if they regularly cause adverse effects. This is not the case for acupuncture. In the absence of solid evidence for efficacy, even relatively rare or minor adverse effects would mean that the risk/benefit profile of acupuncture is not positive.

For these reasons, it is an ethical imperative, I think, to keep a keen eye on the harm caused by acupuncture and to inform the public about the fact that it is undeniably not free of risks.

‘Healing, hype or harm? A critical analysis of complementary or alternative medicine’ is the title of a book that I edited and that was published in 2008. Its publication date coincided with that of ‘Trick or Treatment?’ and therefore the former was almost completely over-shadowed by the latter. Consequently few people know about it. This is a shame, I think, and this post is dedicated to encouraging my readers to have a look at ‘Healing, hype or harm?’

One reviewer commented on Amazon about this book as follows: Vital and informative text that should be read by everyone alongside Ben Goldacre’s ‘Bad Science’ and Singh and Ernt’s ‘Trick or Treatment’. Everyone should be able to made informed choices about the treatments that are peddled to the desperate and gullible. As Tim Minchin famously said ‘What do you call Alternative Medicine that has been proved to work? . . . Medicine!’

This is high praise indeed! But I should not omit the fact that others have commented that they were appalled by our book and found it “disappointing and unsettling”. This does not surprise me in the least; after all, alternative medicine has always been a divisive subject.

The book was written by a total of 17 authors and covers many important aspects of alternative medicine. Some of its most famous contributors are Michael Baum, Gustav Born, David Colquhoun, James Randi and Nick Ross. Some of the most important subjects include:

  • Compassion
  • Quackademia
  • Impartiality
  • Ethics
  • Politics
  • Holism
  • Vitalism
  • Placebo

As already mentioned, our book is already 6 years old; however, this does not mean that it is now out-dated. The subject areas were chosen such that it will be timely for a long time to come. Nor does this book reflect one single point of view; as it was written by over a dozen different experts with vastly different backgrounds, it offers an entire spectrum of views and attitudes. It is, in a word, a book that stimulates critical thinking and thoughtful analysis.

I sincerely think you should have a look at it… and, in case you think I am hoping to maximise my income by telling you all this: all the revenues from this book go to charity.

Many experts have warned us that, when we opt for dietary supplements, we might get more than we bargained for. A recent article reminded us that the increased availability and use of botanical dietary supplements and herbal remedies among consumers has been accompanied by an increased frequency of adulteration of these products with synthetic pharmaceuticals. Unscrupulous producers may add drugs and analogues of various classes, such as phosphodiesterase type 5 (PDE-5) inhibitors, weight loss, hypoglycemic, antihypertensive and anti-inflammatory agents, or anabolic steroids, to develop or intensify biological effects of dietary supplements or herbal remedies. The presence of such adulterated products in the marketplace is a worldwide problem and their consumption poses health risks to consumers.

Other authors recently warned that these products are often ineffective, adulterated, mislabeled, or have unclear dosing recommendations, and consumers have suffered injury and death as a consequence. When Congress passed the Dietary Supplement Health and Education Act, it stripped the Food and Drug Administration of its premarket authority, rendering regulatory controls too weak to adequately protect consumers. State government intervention is thus warranted. This article reviews studies reporting on Americans’ use of dietary supplements marketed for weight loss or muscle building, notes the particular dangers these products pose to the youth, and suggests that states can build on their historical enactment of regulatory controls for products with potential health consequences to protect the public and especially young people from unsafe and mislabeled dietary supplements.

A new study has shown that these problems are not just theoretical but are real and common.

Twenty-four products suspected of containing anabolic steroids and sold in fitness equipment shops in the UK were analyzed for their qualitative and semi-quantitative content using full scan gas chromatography-mass spectrometry (GC-MS), accurate mass liquid chromatography-mass spectrometry (LC-MS), high pressure liquid chromatography with diode array detection (HPLC-DAD), UV-Vis, and nuclear magnetic resonance (NMR) spectroscopy. In addition, X-ray crystallography enabled the identification of one of the compounds, where reference standard was not available.

Of the 24 products tested, 23 contained steroids including known anabolic agents; 16 of these contained steroids that were different to those indicated on the packaging and one product contained no steroid at all. Overall, 13 different steroids were identified; 12 of these are controlled in the UK under the Misuse of Drugs Act 1971. Several of the products contained steroids that may be considered to have considerable pharmacological activity, based on their chemical structures and the amounts present.

The authors concluded that such adulteration could unwittingly expose users to a significant risk to their health, which is of particular concern for naïve users.

The Internet offers thousands of supplements for sale; specifically for bodybuilders there are hundreds of supplements all claiming things that are untrue or untested. The lax regulations that exist in this area seem to be often ignored completely. I think it is important to inform customers that most supplements are a waste of money and some even a waste of health.

It has been estimated that 40 – 70% of all cancer patients use some form of alternative medicine; may do so in the hope this might cure their condition. A recent article by Turkish researchers – yet again – highlights how dangerous such behaviour can turn out to be.

The authors report the cases of two middle-aged women suffering from malignant breast masses. The patients experienced serious complications in response to self-prescribed use of alternative medicine practices to treat their condition in lieu of evidence-based medical treatments. In both cases, the use and/or inappropriate application of alternative medical approaches promoted the progression of malignant fungating lesions in the breast. The first patient sought medical assistance upon development of a fungating lesion, 7∼8 cm in diameter and involving 1/3 of the breast, with a palpable mass of 5×6 cm immediately beneath the wound. The second patient sought medical assistance after developing of a wide, bleeding, ulcerous area with patchy necrotic tissue that comprised 2/3 of the breast and had a 10×6 cm palpable mass under the affected area.

The authors argue that the use of some non-evidence-based medical treatments as complementary to evidence-based medical treatments may benefit the patient on an emotional level; however, this strategy should be used with caution, as the non-evidence-based therapies may cause physical harm or even counteract the evidence-based treatment.

Their conclusions: a malignant, fungating wound is a serious complication of advanced breast cancer. It is critical that the public is informed about the potential problems of self-treating wounds such as breast ulcers and masses. Additionally, campaigns are needed to increase awareness of the risks and life-threatening potential of using non-evidence-based medical therapies exclusively.

I have little to add to this; perhaps just a further reminder that the risk extends, of course, to all serious conditions: even a seemingly harmless but ineffective therapy can become positively life-threatening, if it is used as an alternative to an effective treatment. I am sure that some ‘alternativists’ will claim that I am alarmist; but I am also convinced that they are wrong.

Cardiovascular (and most other types of) patients frequently use herbal remedies in addition to their prescribed medicines. Can this behaviour create problems? Many experts think so.

The aim of a new study was to investigate the effect of herbal medicine use on medication adherence of cardiology patients. All patients admitted to the outpatient cardiology clinics, who had been prescribed at least one cardiovascular drug before, were asked to complete a questionnaire. Participants were asked if they have used any herbals during the past 12 months with an expectation of beneficial effect on health. Medication adherence was measured by using the Morisky Scale. High adherence was defined as a Morisky score lower than 2 and a score of 2 or more was seen as low adherence.

A total of 390 patients participated in this study; 29.7% of them had consumed herbals in the past 12 months. The median Morisky score was significantly higher in herbal users than non-users. The number of herbals used was moderately correlated with the Morisky score. In stepwise, multivariate logistic regression analysis, herbal use was significantly associated with low medication adherence.

From these findings, the authors conclude that herbal use was found to be independently associated with low medication adherence in our study population.

So far, the main known risk of herbal medicine use was the possibility that there might be herb-drug interactions. To the best of my knowledge, nobody has yet studied the possibility that herbal medicine users might neglect to take their prescribed drugs. The results of this investigation are somewhat worrying but they do make sense. Some patients who buy and take herbal remedies might think that they do not need to regularly take their prescribed medications because they already take herbal medicine which takes care of their health problem. They might even have been told by their herbalist that the herbal remedies suffice.

If that is so, and if the phenomenon can be confirmed in further investigations, it should be relevant not just in cardiology but in all fields of medicine. And if that is true for herbal remedies, it might also be the case for other types of alternative medicine. In other words, alternative medicine use might be a marker for poor adherence to prescribed medication. I feel that this hypothesis merits further study.

It goes without saying that poor adherence to prescribed drugs can be a very dangerous habit. Clinicians should therefore warn their patients and tell them that herbal remedies are no replacement of prescription drugs.

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