Integrating Complementary Medicine into Pharmacy Practice
Blackmores Institute, the research and education arm of Australia’s leading natural health brand, organized its inaugural Blackmores Institute Symposium in Singapore on March 23, 2017. The institute was established to translate evidence-based science into practical resources and advisory services to improve the quality use of natural medicine, thereby improving health outcomes for the community.
The Blackmores Institute symposium is a series of international education sessions aimed at raising the knowledge on complementary medicines of healthcare professionals in the region. The symposium was held in Singapore and themed “Integrating Complementary Medicine into Pharmacy Practice”. It hosted over 200 industry leaders and healthcare professionals such as pharmacists, nutritionists and clinicians.
The symposium not only highlighted the benefits and risks of integrating health supplements and complementary medicine into pharmacy practice, but also discussed the latest research and evidence on the safety, efficacy and appropriate use of complementary medicine to optimize health outcomes.
“Considering the rapidly growing use of complementary medicine in Singapore, and the relatively unregulated claims in the market, it is imperative that we educate both medical professionals and the public on its safe and efficacious use. This must be backed by no less than rigorous research and evidence-based science,” said Dr. Braun.
APBN Interview with Dr. Lesley Braun,
Director of Blackmores Institute
Dr. Lesley Braun Dr. Lesley Braun is the Director of Blackmores Institute, Adjunct Associate Professor of Integrative Medicine within the National Institute of Complementary Medicine (University of Western Sydney), past Senior Research Fellow within the Monash/Alfred Psychiatric Research Centre and a research pharmacist at The Alfred Hospital in Melbourne.
She is a member of numerous committees/boards including the Australian Therapeutic Goods Advisory Council (ATGAC) and Advisory Committee on Complementary Medicine (ACCM). She is also the main author of the best-selling textbook ‘Herbs and Natural Supplements – an evidence based guide’, co-Editor-in-Chief of a new international journal by Elsevier entitled ‘Advances in Integrative Medicine’, a regular columnist for the Australian Journal of Pharmacy (AJP), lecturer at Monash University and RMIT and regularly presents at national and international conferences.
One of her chief areas of expertise is investigating and working at the interface between complementary and conventional medicine (medicine, surgery and pharmacy) from multiple perspectives such as efficacy, safety, patient and physician perspectives, regulation and practice.
Does ‘complementary medicine’ mean ‘supplements’ in layman’s terms?
Possibly, but note that the definition of complementary medicines is varied. You have therapeutic agents like vitamins and minerals, food concentrates, herbal medicine, fish oil, probiotics, etc. All these products are complementary medicine. Other than that, there are complementary therapies like massage and acupuncture, but we (Blackmores Institute) are focused on medicine for pharmacies to help their customers better.
Are complementary medications considered drugs?
These terminologies have certainly come a long way from what they were a few years ago. Now it depends on how they are defined by regulation authorities. From my perspective, they are not drugs because in general a drug is considered as a pharmaceutical single molecule entity, whereas the ingredients we are considering are quite complex. For instance, herbal medicine and food concentrates have many components to them and are chemically complex. Although complementary medicines do have pharmacological activity, they are different from our conventional understanding of the term “drug”. If you mean drug in the sense that they are effective, then sure – you can call them drugs.
What about the interactions between conventional medicine and complementary medicine?
I discussed three types of such interactions. The first is how pharmaceutical medicine affects our nutritional status. Some people who use medication in the long-run are at risk of nutritional deficiencies, and that’s an interaction. For example, long-term usage of blood pressure medication could increase the risk of zinc deficiency. It reduces the body’s absorption of zinc while increasing its excretion of zinc. Taking another example, more research from clinical trials shows that Metformin, a popular diabetes drug, could increase the risk of vitamin B12 deficiency. The way to address these issues is by screening for symptoms and using zinc and vitamin B12 supplements.
Another interaction is when complementary medicine interferes by either increasing or reducing drug activity. However, as I shared during my talk, there are very few kinds of herbal medicine that display clinically significant interactions. Decades ago, lots of research was done using test tube studies and lots of data was gathered through them. In the modern day, after much experimentation we found that such test-tube studies were not fully representative of real-world trials or clinical practice. Information gathered in this way, in-vitro or via experimentation of animals, are poor predictors of clinical significance in humans. Evidence from clinical trials are more accurate but these are costly and take time. In-vitro tests showed that Ginkgo had effects on metabolizing enzymes, but clinical trials showed that that wasn’t the case. Similar conclusions can be drawn from Saw palmetto and Milk Thistle. I always say that test-tube results are interesting, but not definitive. Until it’s been done clinically, solid conclusions should not be drawn. That’s the second kind of interaction.
The third kind is when you are creating a positive outcome. For example, in my Fish-oil talk I referenced a very big meta-analysis that showed that if you use Omega-3s together with anti-depressants you get a stronger anti-depressant effect. There is much more research coming through discussing such combinations. In medicine, it is not surprising that this happens, because treatments for diseases like cancer and HIV use combinations and they use the interactions for a positive effect. All we’re showing is that we can also integrate complementary medicine to achieve these positive effects on treatments.
Those are three different examples of interactions fleshed-out.
Will complementary medicine pose any potential risk that could cause them to no longer seem helpful?
Every medicine has potential risk if you are not taking the right dosage, in the right way, for the right indications. Complementary medicine is no different from any other medicine in that sense. Non-prescription medicine available in stores are generally lower risk than prescription medicine, hence the reason they need to be prescribed. What is definitely true however, is that professional advice should be taken to make a good choice with accurate dosage and timing, and to reduce risk.
If multiple supplements are taken at the same time, will the person be facing any health risk?
It depends on the situation, since as mentioned before – sometimes combinations actually work better, but sometimes they are quite pointless. In the research we shared on cardiac surgery in the hospital I worked at, we talked about how multiple ingredients were used in combination to aid surgery. If not presented in combination, individual ingredients weren’t strong enough. Therefore combinations can sometimes be very good. But of course, you need the right combination. I am taking four supplements myself.
After a point, when somebody is taking far too many in combination however, we need to take a step back and ask what they hope to achieve. What is their diet like? What is their lifestyle like? Do they need all these medications? Maybe there was a point when they thought they did, but perhaps we need to rationalize it again. It’s just good medicine management.
Most complementary medicine and drugs will be excreted from the kidney, not the liver. Most are also water soluble and won’t accumulate in the body, like vitamins B and C. This makes them different from many drugs that are mainly metabolized in the liver.
What are some common health supplements and the conditions they address?
I think multivitamins are important because normally, people are not eating 2 fruits and 4 vegetables every day, and depending on how you cook your food, the vitamin C component could be destroyed.
We’ve shown how fish oil is proven to have so many benefits, with very low risks. It is linked to reducing all-cause mortality in recent trials. If it was a mainstream drug, these clinically significant results would be remarkable. It’s very beneficial for the human heart, brain and cognitive health, and even mood; the list goes on and on.
We’re learning a lot more about probiotics in fact in the microbiome. They are complementary to antibiotics, which tend to significantly change the microbiome each time its used.
I used to get migraines a lot, and there is no standard effective drug to treat them. I found research on coenzyme Q10 (CoQ10) on its positive effect on migraine alleviation, and started to take it. The research pointed to how it effectively reduces the severity and frequency of migraines. After taking CoQ10, it showed a huge impact. My frequency of migraines reduced from two to three times per month to two to three times per year.
People use complementary medicine for all range of reasons. You can also target their use accordingly. For example, vitamin C is good for wound healing, collagen and skin health, while evening primrose oil is good for skin strength. We had a large research trial on its improvement of skin elasticity and firmness 15 years ago.
If a person is following a balanced and nutritious diet, does it mean that they need not take any complementary medicine?
I think 90% of Australians don’t eat balanced diets; I can’t comment on that situation in Singapore, but it may be similar. Three ways of using supplements could be to top up your poor diet, like taking multivitamins, using preventive medicine like folic acid for pre-pregnancy care, and also as a therapeutic agent. A good example would be high-dose fish-oil for rheumatoid arthritis – you simply can’t eat enough fish to achieve that effect. Yet another would be co-enzyme Q10 for a healthy heart. If you were to try and consume it through a regular diet with meat, you may get as little 5mg! The doses required for heart health are closer to 150mg. You simply can’t eat that much food.
Everyone has different nutritional requirements depending on their age, dietary pattern, lifestyle, etc. Smokers have a relatively high requirement for vitamin C. They are unable to get enough vitamin C from their diet, no matter how good it is, thus they need to supplement.
Do you think natural ingredients would be more effectively or easily absorbed by the body than synthetic ones?
It is difficult to make a sweeping statement about something like that. I think complementary medicine in some ways is more complicated than pharmaceutical medicine. If you look at the herbs, you will know that they are physically and chemically complicated.
Unlike pharmaceutical drugs, complementary medicine does not have to undergo clinical trial Phase 1 to 3. Keep in mind that people have been eating fish for thousands of years, so much of the evidence for efficacy is natural. These kinds of medicine are ‘evidence-based’ with all ranges of studies such as population studies, traditional evidence, scientific research (test tube studies, animal models and clinical studies), clinical acumen, patient preference and observation, culture, etc.
You are the main author of the best-selling textbook “Herbs and Natural Supplements – an evidence based guide”. Could you share insights from the book?
Sure, there are a few sections. Firstly, the book introduces complementary medicine, clinical nutrition, and different ways to use supplements. It goes on to talk about Western herbal medicine and the clinical evidence and safety issues over their ingredients. It also discusses their mechanisms of action in the body. Because of this, the book is quite popular among pharmacists, doctors, nurses and current practitioners. I do also know first-hand about members of the public who buy it.
Announcement of New Research
At the symposium, Blackmores Institute announced its first study in Singapore to gain deeper understanding of the public’s usage, perception and literacy of complementary medicine.
Based on similar studies undertaken in Australia, the Singapore research will be conducted via randomised face-to-face interviews with consumers at pharmacy outlets throughout Singapore over the next six months. It will also take into consideration the public’s expectations on the role of healthcare professionals, particularly pharmacists in addressing their queries on supplements. Ultimately, the aim is to help pharmacists grow their role in Singapore’s healthcare system, and improve primary care services in the long run.
“This piece of research is crucial to identify key demands of the modern-day consumer and with the results, we can then better equip pharmacists, who are at the first line of primary care, with the appropriate knowledge to better provide for the public,” said Dr. Lesley Braun.
Some Key Takeaways from the Blackmores Symposium’s Sessions
Pharmacists are facing increasing queries about complementary medicine and patients are expecting them to have up to date knowledge on the health products in the market to provide the best possible advice. It is therefore important to have educational workshops and panel discussions around the risks and benefits of supplementation.
Dr. Lesley Braun presented some practical tips for pharmacists to implement into their practice (e.g. some clinical evidences of CoQ10). Like drugs, complementary medicines may also have interactions and side effects. These interactions could be either negative, neutral or positive. The positive interactions help to achieve integrative medicine for improved therapeutic outcomes and reduced economic burden. When assessing interaction, we need to consider how likely the interactions are to occur and the severity of the potential consequence. Formulation and dosage are both important factors to consider, hence it is necessary to know how to read the labels carefully, especially for dosing with minerals. She highlighted some of the latest research and evidence on the safety, efficacy and the appropriate use of complementary medicine to optimize health outcomes. Additionally, many free online evidence resources are available for pharmacists to refer to, to get more information on the benefits and risks of complementary medicine.
Ms. Catherine Cooling, Asia Training Manager, Blackmores Institute Australia, another key speaker at the symposium, said that there is an issue about the lack of knowledge in pregnancy nutrition to ensure adequate nutritional support for mothers and babies. Nutrients such as iron, folic acid, vitamin C, iodine and calcium are needed in the diets of pregnant women. She spoke about the clinical signs and complications of nutrient deficiencies and the clinical guidelines for dosing and Recommended Dietary Intakes (RDIs) of nutrients in pregnancy.
At the symposium, Ms. Joy Chong, Principal Clinical Pharmacist of Watsons Singapore, presented the trends of purchasing patterns of complementary medicine in retail settings. Currently, popular complementary medicine in Singapore includes essence of chicken, nutrition drinks, multivitamin minerals, fish oil, probiotics, glucosamine and products for weight management, beauty and sports nutrition. She also shared about the challenges faced in the complementary medicine industry. One such challenge is the research and scientific evidence to support the benefit claims on the label. Community pharmacists have an increasing role to provide counsel and education to the public, including product safety, ingredients and scientific evidence that affect the pharmacists’ recommendation on complementary medicine.
The highlight of the day was the panel discussion involving Dr. Lesley Braun; Ms. Joy Chong; Ms. Evonne Lee, Senior Clinical Pharmacist at the National Healthcare Group; and Mr. Peter Fell, Pharmacist Manager of UFS Dispensaries, Australia. They exchanged ideas on how pharmacists can be better equipped to take on an expanded role in primary care.
The symposium concluded well with a speech by Ms. Veronita Rusli, Blackmores Institute Asia Manager in Singapore, who introduced the resource materials and learning modules on Blackmores Institute’s website (www.blackmoresinstitute.org). The next Blackmores Institute symposium will be held in Malaysia in May and then in China later this year.