Complementary and Alternative Treatments: Worth Considering or Not?
There is an increasing body of evidence suggesting at least mild efficacy and safety of certain complementary supplements for specific conditions.
Patients in my practice will often inquire if there are natural treatments available for a certain condition, as opposed to the stronger prescription medication that I usually recommend. In fact, patients often hold the view that nonprescription treatments are safer and more effective than those typically indicated and prescribed. In addition, when reviewing patients' medication lists, I often find that I am prescribing medication in conjunction with complementary treatments initiated by the patients themselves.
It is important to inform patients that alternative or herbal remedies typically undergo less rigorous evaluation and must meet fewer safety criteria than allopathic prescription medications. Therefore, they may be more likely to contain contaminants, inaccurate ingredients, and doses, and they may even be labeled or stored in an unsafe manner. People cannot always be certain that what they are taking is exactly what is noted on the label. Also, many herbal remedies interact problematically with prescription medications and may increase toxicity, reduce efficacy, or cause adverse effects. For example, St. John's wort is a commonly purchased herbal remedy used for mild depression; however, it may affect the metabolism of multiple prescription medications—such as selective serotonin reuptake inhibitors, oral contraceptives, antiepileptic agents, and anticoagulants—when taken together.
There is an increasing body of evidence suggesting at least mild efficacy and safety of certain complementary supplements for specific conditions. I recognize that this is not necessarily a complete list; however, these are some supplements that have evidence-based support for their specific uses.
Omega-3 fatty acids, which contain >60% eicosapentaenoic acid (EPA), are considered a mildly effective supplement for depression and bipolar disorder when taken at dosages of 1000 mg to 4000 mg daily. Dosages greater than 3000 mg daily may interfere with anticoagulants and require monitoring. Regardless, patients who take omega-3 supplements in doses of 1000 mg or greater should be followed by a physician to augment prescription and behavioral treatments. Evidence is robust to suggest that dosages of 1000 mg daily or less also reduce diastolic and systolic blood pressure by an average of 4.5 mmHg. This occurs through reduction of systemic vascular resistance. Omega-3 fatty acids also reduce risk of cardiac arrhythmia, reduce triglycerides, and increase high-density lipoprotein (HDL) cholesterol when taken at higher doses. Additionally, omega-3 supplements may be associated with reduction in risk of developing dementia.
Inositol is an insulin-sensitizing agent and typically taken at a dosage of 2 g twice a day. It has been shown to be helpful with weight loss for women with polycystic ovarian syndrome or postmenopausal symptoms, and may also help reduce the risk of developing metabolic syndrome in patients taking medications proven to carry this particular risk, such as antipsychotics.
N-Acetylcysteine in dosages of 600 mg to 1200 mg twice a day have shown efficacy as an augmentation strategy for treating cannabis dependence by reducing cravings. In addition, it has been shown to reduce symptoms of excoriation and trichotillomania.
L-Methylfolate is the active bioavailable form of folic acid. It has been shown in a number of studies to provide additional antidepressant effect when used at 15 mg daily as an augmentation strategy with prescribed antidepressants. It is available either over the counter or by prescription and is covered by some insurance companies. Adult studies provide some evidence that SAMe, or S-adenosyl methionine, may be effective in the treatment of depression.
Melatonin is now well known, with good safety and efficacy data, to reduce insomnia in shift workers with associated sleep-wake cycle reversal in both adults and children.
Magnesium at doses of 250 mg to 500 mg at bedtime is effective for many patients with insomnia.
Vitamin B2 at a dosage of 400 mg daily has been shown to be an effective strategy for reduction of the number of headache days in patients suffering from migraines.
I always welcome a discussion with any patient regarding complementary and alternative supplements. I do not dismiss them as remedies, but rather continue to recommend only those supplements with a larger evidence base as augmentation strategies with other treatments or alone. This is especially important in the case of patients who have experienced intolerable adverse effects with prescription medications. I routinely inquire about supplements that my patients are taking and continue to take time to review potential medication interactions.
Increased research attention is being given to these supplements and updated information for patients and providers can be accessed on the National Center for Complementary and Alternative Medicine (NCCAM) website.