Written by Edward Thompson
Introduction
There is no doubt that over the past 80 years many drugs have been introduced which have had profoundly beneficial and life-saving effects on our health. This includes the use of antibiotics such as penicillins in acute infections, insulin in type 1 diabetes, thyroxine in hypothyroidism and calcium channel blockers to reduce severe raised blood pressure. In the last decade however there has been an increased use of medication to reduce risk of and treat illnesses which have a major lifestyle component such as type two diabetes, obesity, high cholesterol and hypertension, with the NHS drugs bill in 2016 totalling ÂŁ9,204.9 million 1.`The use of risk scores and in particular the Q risk score in patients in the UK and the reduction to 10% as the trigger for treatment has meant that many more healthy patients are being prescribed preventative medication such as statins and blood pressure medication. At the same time mental health problems are increasing and the prevalence of obesity which is a risk factor for type two diabetes is also rising dramatically. It is creating a perfect storm for patients being on multiple drugs. Herbal medicine has an important part to play in calming the multiple medication storm, especially when combined with lifestyle change.
The rise of Polypharmacy
Polypharmacy, which can be defined as a patient being on 5 or more medicines is becoming increasingly common, especially amongst those who are 65 or older. This has arisen due to the increased use of preventative medication, and the increasing burden of chronic disease due to both longevity and the western lifestyle. Research and guidelines have focused on single diseases resulting in patients with more than one illness being started on multiple medications, all individually indicated but in combination resulting in polypharmacy. Some patients are prescribed 10 or even 15 medications and often experience marked side effects such as dizziness, indigestion, bowel problems, fatigue and falls. These patients have their symptoms controlled but they often do not have a good quality of life and donât feel well. In the UK between 2008 and 2015 the number of hospital admissions directly related to drug side effects increased by 53.4%, from 60,055 in 2008-2009 to 92,114 in 2014-2015. Every year in Europe an estimated 8.6 million unplanned hospital admissions occur as a result of drug side effects and in the US the harm resulting from medication errors is estimated at $42 billion dollars per annum 2.
Treating complex health issues
Herbal medicines have an important role to play in reducing the drug burden of the population, especially when used alongside lifestyle changes, and the deprescribing of unnecessary medication. The targeted use of herbal medicines may also help to reduce the drugs bill, adverse drug reactions and encourage self-help. Herbal medicine and humanity have enjoyed a close symbiotic relationship for millennium and today there are approximately 21,000 different plants used worldwide. Some plant medicines are very potent with their therapeutic action coming from a relatively small number of powerful phytochemicals and have often formed the basis for drug development for example Foxglove (Digitalis pupurea) and digitalis for heart failure and heart rate control, and Belladonna (Atropa belladonna) and associated alkaloids as inhalers in chronic obstructive pulmonary disease. However, many plant medicines represent a more complex range of actions containing 100s of potentially active principles which work in synergy, with it often being difficult to reliably isolate the âactiveâ ingredient. These herbal medicines are well suited to the management of more complex illnesses as they are themselves inherently complex, whilst at the same time being biologically close to us, having evolved within the natural world. Herbal medicines at this end of the spectrum have a low side effect profile, and provided they are of good quality and attention is given to potential drug herb interactions are safe.
Herbal evidence
The evidence base for herbal medicine varies from Level I evidence where a plant has had enough research to allow for a systematic review of randomised controlled trials to Level IV evidence where the knowledge of the plant is based on experience and expert consensus 3. The majority of herbal medicine evidence is empirical being at Level IV, which is seen conventionally as having a lower level of validity when compared with Level I evidence. However, the empirical basis of herbal medicine is particularly powerful as it spans centuries as opposed to decades and is also often cross cultural. A significant number of national guidelines such as NICE guidelines are partially based on Level IV expert consensus and so this can be considered an acceptable level of evidence, especially considering the low side effect profile of most plant medicines.
Three major health issues
Diabetes and in particular Type 2 Diabetes mellitus is becoming a major health issue with an 80.1% increase in the prescribing of diabetic medication in the UK in the decade leading up to 2017, the overall cost of diabetes medication in 2016-17 being ÂŁ983.7 million4. Herbal medicine has a role to play in diabetes with there being 400 herbal medicines which are believed to help diabetes 5. Plant medicines which have demonstrated an effect on diabetes in human clinical trials are Gymnema (Gymnema sylvestre) a herbal medicine used traditionally in Ayurvedic medicine 6, Fenugreek (Trigonella Foenun-graecum) which has been used in the Middle East and India 7 and Cinnamon (Cinnamomum zeylanicum)8, all of which have beneficial effects on blood glucose levels. Recent research into type 2 diabetes has also shown that a calorie restricted diet of 800 calories a day for a period of 3-5 months reversed diabetes in 46% 9, and it is likely that the addition of herbal medicines such as Gymnema, Fenugreek and Cinnamon would potentiate the effectiveness of diet in the treatment of type 2 diabetes.
Viral upper respiratory tract infections such as coughs, colds and ear infections are a common reason for patients to attend general practice, with time and patient pressures sometimes leading to unnecessary antibiotic prescribing. This increases the risk of antimicrobial resistance with there being a direct link between the amount of antibiotics prescribed in a community and antibiotic resistance. It has been estimated that increasing antibiotic resistance could lead to 10 million deaths a year worldwide by 2050, with an estimated 25,000 people dying in Europe each year as a result of antibiotic resistant infections such as MRSA and E. Coli. 10. The increased education of the public, GPs and Nurse Prescribers in the use of herbal medicines for the self-care of viral infections could lead to reduced antibiotic prescribing, with the use of herbal medicines such as Elderberry (Sambucus nigra fructus) in the treatment of viral upper respiratory tract symptoms including fever, nasal congestion, and headache 11. In addition there is evidence that Echinacea (Echinacea angustifolia/purpurea) can be used in the treatment and prevention of colds 12 and Andrographis (Andrographis paniculata) in reducing the symptoms of upper respiratory tract infections 13.
Mental health problems are increasingly prevalent in the UK population with antidepressants representing the biggest increase in prescription items in 2016. 64.7 million prescriptions for antidepressants were issued in 2015-16, with 3.7 million more anti-depressants being dispensed in 2016 than the previous year, and in 2015 anti-depressants cost the NHS ÂŁ780,000 a day 1. Herbal medicines have been used for mental health problems for centuries and can play an important role along with lifestyle changes, and psychological therapies in mild and moderate depression. St Johnâs Wort (Hypericum perforatum) has a high level of evidence (Level 1) with one meta-analysis of 29 trials showing it to be as effective as antidepressants in mild and moderate depression, and more effective than placebo in major depression, with fewer side effects than conventional antidepressants 14. A 2017 meta-analysis of 27 clinical trials came to similar conclusions when comparing St John’s Wort to Selective Serotonin Reuptake Inhibitors (SSRIs) such as citalopram 15. St Johnâs Wort however does need to be used with attention to the other medication which the patient is taking due to itâs potential interaction with medications such as the contraceptive pill and warfarin. Rhodiola (Rhodiola rosea) has also been shown to effect depression 16 and is thought to have adaptogenic effects helping the immune and endocrine system to adjust to stress. Herbal medicines can also be helpful in anxiety with 21 plants having human clinical trial evidence of efficacy such as Chamomile (Matricaria recutita), Skullcap (Scutellaria lateriflora), Passion flower (Passiflora incarnata), and Ashwagandha (Withania somnifera) 17. Ashwagandha has been shown to improve anxiety and stress compared to placebo 18 and the potential for adaptogenic herbal medicines such as Ashwagandha and Rhodiola along with others such as Reishi (Ganoderma lucidum) to help the reduce the adverse effects of stress is unique to herbal medicine and highly significant considering the prevalence of stress in the community. The humble Chamomile tea (Matricaria recutita) is available from most food stores has been shown to reduce anxiety scores and is a good example of a readily available herbal medicine with significant self-care potential19.
Conclusion
There can be no doubt that herbal medicines alongside the use of lifestyle medicine and the deprescribing of medications which are no longer indicated can play a critical role in healthcare and reducing a patientâs medication burden. Plant medicines can also play an important part in patient self-care, and the management of stress and mental health problems, as well as in preventative medicine. There is an urgent need for better education of both the public and frontline health care professionals into the possible benefits of plant medicines, as well as more appropriate research into the use of herbal medicines, especially those which are commonly used by practitioners with good empirical effect but which have not attracted research.
References
- NHS Digital, Prescriptions Dispensed in the Community – Statistics for England, 2006-2016, June 2017
- WHO, Medication Without Harm, WHO Global Patient Safety Challenge, 2017
- National Health and Medical Research Council (NHMRC). A Guide to the Development and Evaluation of Clinical Practice Guidelines. Commonwealth of Australia, Canberra, 1999.
- NHS Digital, Prescribing for Diabetes in England – 2006/07 to 2016/17, Aug 2017
- Kumar S. Mittal A. Babu D. Mittal A. Herbal Medicines for Diabetes Management and its Secondary Complications. Current Diabetes Reviews, 2021, 17, 437-456
- Baskaran K. Ahamath K, Shanmugasundaram K. Antidiabetic Effect of a Leaf Extract from Gymnema Sylvestre In Non-Insulin-Dependent Diabetes Mellitus Patients Journal of Ethnopharmacology, 30 (1990) 295 â 305
- Narsingh V. Usman K. Patel N. Arvind J. Sudhir D. et al. A multicenter clinical study to determine the efficacy of a novel fenugreek seed (Trigonella foenum-graecum) extract (FenfuroTM) in patients with type 2 diabetes. Food and Nutrition Research. Octo 2016 Vol.60 (1) p.32382-32382
- Zare R. Nadjarzadeh A. Zarshenas MM. Shams M. , Heydari MG, Efficacy of cinnamon in patients with type II diabetes mellitus: A randomized controlled clinical trial. Clinical nutrition (Edinburgh, Scotland), 2019-04, Vol.38 (2), p.549-556
- Lena ME. et al. Primary Care-led management for remission of type 2 diabetes (DiRECT): an open label cluster randomised trial. Lancet. Feb 2018 10;391 (10120):541-551
- Public Health England, Health matters: antimicrobial resistance. Dec 2015. Health matters: antimicrobial resistance – GOV.UK (www.gov.uk)
- Harnetta J. Oakes K. Carèa J. Leache M. Brown D. Cramerg H et al. The effects of Sambucus nigra berry on acute respiratory viral infections: A rapid review of clinical studies. Advances in integrative medicine, 2020-12, Vol.7 (4), p.240-246
- Jawad M. Schoop R. Suter A. Klein P. Eccles R. Wahner-Roedler D. Safety and Efficacy Profile of Echinacea purpurea to Prevent Common Cold Episodes: A Randomized, Double-Blind, Placebo-Controlled Trial. Evidence-based complementary and alternative medicine, 2012-09-16, Vol.2012, p.841315-841315
- Panel RC. Saxenaa R. Singh BP. Kumarc SC. Yadavc MPS. et al. A randomized double blind placebo controlled clinical evaluation of extract of Andrographis paniculata (KalmColdâ˘) in patients with uncomplicated upper respiratory tract infection. Phytomedicine Volume 17, Issues 3â4, March 2010, Pages 178-185
- Linde K. Berner MM. Kriston L. St Johnâs Wort for Major Depression. 2008 Cochrane Database of Systematic Reviews, Issue 4.
- Ng QX. Ventakatarayana N. et al. Clinical use of Hypericum perforatum (St John’s wort) in depression: A meta-analysis. Journal of Affective Disorders 1 March 2017, Vol 2010. Pages 211-221
- Sarris J. Panossian A. Schweitzer I. Stough C. Scholey A. Herbal medicine for depression, anxiety and insomnia: A review of psychopharmacology and clinical evidence. European neuropsychopharmacology, 2011, Vol.21 (12), p.841-860
- Sarris J. McIntyre E. Camfield DA. Plant-Based Medicines for Anxiety Disorders, Part 2: A Review of Clinical Studies with Supporting Preclinical Evidence. CNS drugs, 2013-08-01, Vol.27 (8), p.675-675
- Pratt MA, Nanavati KB. et al. An alternative treatment for anxiety: a systematic review of human trial results reported for the Ayurvedic herb ashwagandha (Withania somnifera). Journal of Alternative and Complementary Medicine 2014 Dec;20(12):901-8
- Keefe JR. Mao JJ. Soeller I. Li QS. Amsterdam JD. Short-term open-label chamomile (Matricaria chamomilla L.) therapy of moderate to severe generalized anxiety disorder. Phytomedicine (Stuttgart), 2016-12-15, Vol.23 (14), p.1699-1705
