Integrative Medicine Presents Opportunities, Poses Challenges

The uptick in dietary supplement use and integrative health and medicine practices in the United States creates both opportunities and concerns for pharmacists and health providers, who need to stay well informed to help patients avoid harmful effects. Some patients may seek vitamin or herbal supplements for health and wellness, often believing that these are safer than conventional OTC and prescription pharmaceutical products. However, so-called natural remedies come with their own set of health risks.

“Dietary supplements are very helpful and really needed when they are chosen correctly and properly,” said Farzana Kennedy, RPh, FACA, owner and president of Dalitso, an integrative pharmacy in Alexandria, Virginia. “Often, they can be harmful if not properly monitored or checked for interactions or contraindications in a patient who has preexisting conditions.”

Acting as Educators

Dietary supplement use has reached an all-time high, with 77% of Americans reportedly using these products, according to a 2019 survey conducted by the Council for Responsible Nutrition. The increased patient demand for non-pharmacologic health options has created unprecedented opportunities for pharmacists to expand their interactions with patients.

Many patients consider community pharmacies the ideal place to purchase vitamins and other dietary health supplements. Pharmacists can positively affect the patient experience by:

• Providing supplement education Making supplement recommendations

• Assessing for interactions, contraindications, and toxicities Collecting a patient’s complete medication history, including supplements

• Assessing for drug-drug, drug- micronutrient, and drug- supplement interactions

• Helping patients evaluate natural products for quality-related issues

Pharmacists can also educate patients about the potential effects of taking dietary supplements on laboratory test validity and results.

“In general, validating and interpreting laboratory test results can be key tools in helping health care professionals optimize clinical decisions related to their patients’ health,” said Cathy Rosenbaum, PharmD, RPh, MBA, CHC, CDP, a holistic clinical pharmacist and founder and CEO of Rx Integrative Solutions in Blue Ash, Ohio. “Pharmacists are uniquely poised to prospectively educate the public on any laboratory test interferences with medications, supplements, or micronutrients to minimize safety risks.”

Biotin: A Lesson in Disclosing Supplement Use

Through their frequent interaction, patients and pharmacists often build a strong rapport and a trusting relationship in which patients feel comfortable discussing supplements. Pharmacists should advise their patients to also report all dietary supplement and natural product use to physicians prior to any blood testing, Rosenbaum said.

A laboratory-testing interaction involving biotin illustrates several important ways pharmacists can help keep patients safe through counseling. Many patients who pick up a bottle of biotin, a water-soluble B vitamin, view it as a harmless supplement to enhance physical appearance (eg, skin, hair, nails). Rosenbaum warns that this assumption can be problematic because of the lack of clinical research with standardized biotin dosing to support these claims. The scientific community has long known that biotin functions in the body as a cofactor for enzymes involved in carboxylation reactions, and it plays a role in fatty acid and carbohydrate oxidation. Daily amounts of biotin needed for general health is defined in different ways because there is no standardized recommended dietary allowance or nutrient intake for this nutrient. A generally suggested intake for adults is between 30 mcg and 100 mcg a day.

OTC biotin products come in many doses that are significantly higher than the amount provided in adequate nutrition, some as much as 10,000 mcg per dose for therapeutic indications.

Several reports link high-dose biotin supplementation to falsely elevated levels of the thyroid hormones triiodothyronine and levorotatory thyroxine and falsely low thyroid-stimulating hormone levels, all used to diagnose and monitor thyroid disease. Taking supplemental biotin at 20 mg or more on a daily basis may interfere with thyroid bioassays that use streptavidin–or avidin–biotin systems.

Excessive biotin intake can lead to misdiagnosis, inappropriate treatment, or even death. For example, biotin supplementation can produce altered levels of troponin, one of the biomarkers elevated during acute myocardial infarctions. According to a November 28, 2017, FDA statement on biotin concerns, a patient who took high doses of biotin died because of complications related to falsely low troponin levels found in a test that relied on biotin technology. Because patients may be unaware of biotin interference, they may not report taking biotin supplements, and may even be unaware they are taking the supplement at all, according to the FDA.

CBD and Medical Cannabis: Countering Ads that Overpromise

The challenges of providing patient guidance in integrative medicine are not exclusive to biotin. The recent explosion of cannabis and cannabidiol (CBD) products presents more issues because these products are routinely promoted as completely safe, with no risks. Buying into this hype could have deleterious consequences for patients.

“Pharmacists providing direct patient care by providing medical cannabis or hemp-based CBD products must know and understand patient diagnoses, treatment plans, and how to monitor patients for interactions,” Kennedy told Drug Topics®.

“One big problem is that cannabis dosing is not standardized, and therefore, pharmacists should educate themselves to help patients receive optimal care regarding the product and dose that will sit well with them without [adverse] effects or other undesired feelings.”

Kennedy also stated that the ubiquitous deluge of CBD products from companies draws increasing concern about quality. She urges pharmacists to practice due diligence, vetting ingredients and confirming that there has been third-party testing for impurities, heavy metals, and other substances.

CBD products are often erroneously advertised as devoid of drug interactions. Evidence shows that CBD is well tolerated sans psychotic effects, provided doses do not exceed 600 mg. However, CBD potently inhibits CYP3A4 and CYP2D6 enzymes, which could cause higher-than-normal increases in serum concentrations of calcium channel blockers, benzodiazepines, antihistamines, antiretrovirals, statins, cyclosporine, and other drugs cleared through these enzymes.

For more information and to stay up-to-date on issues in dietary supplements and integrative health, visit FDA.gov, PubMed.gov, or ClinicalTrials.gov.