Sunday, June 16, 2019

Herbs and Nutritionals Series: The Curious Case of Echinacea

Ok people, we're back to herbs and supplements. This week: Echinacea.

This is a medicinal herb that a lot of people know about. It's supposed to be good for respiratory infections, and a web search turns up others like urinary tract infections, skin infections and so forth.

Echinaeca spp. (species, plural) commercially are mainly comprised of 3 specific species, E. purpurea, E. angustifolia and E. pallida (there are said to be 10 species altogether). Over the years I've seen various formulations of these: some contain all three species, some contain only one, with purpurea and angustifolia being the most common, and among the best studied. However, all three have pharmacological activity, especially the flowers and roots. Like many herbal products, potency varies from species to species, crop to crop, and even plant to plant. Some companies who market effective versions of this herb will use wildcrafting knowledge or domestic cultivation techniques to arrive at a harvest of material of greater potency within the natural range of the plant. Some may use post-harvest laboratory testing to validate the potency of a crop, or to survey a crop's variability so as to then blend the harvest to achieve a known potency level.

This was a technique that has been around since the late 19th Century, when mainstream medicine used a lot of herbal medicines as part of its armamentarium, for such drugs as foxglove (digitalis) and nightshade (belladonna).

Echinacea's Actions in Living Creatures
This section title should signal to the reader that a lot of this study has been done in rats and mice, but these studies help us to understand more about how it is that echinacea found its way into North American aboriginal medicine. I've pointed out that plants are complex, and this complexity can lead to two main, positive phenomena: 1) some plants can seem to treat a wide array of problems--which is counter-intuitive to our ideas about Western biomedicine in which one drug treats one thing, and has a very specific effect. 2) While there may be drug actions that predominate, other chemicals in plant medicines often modify those effects.

Echinacea contains a number of active constituents. Alkamides (AL-kam-ides) are long-chain hydrocarbons that appear to modify several immune system activities. One such action is that alkamides stimulate the activity of the "first line soldiers" of the immune system. These white blood cells (some of which actually live in tissue spaces, such as skin, rather than the blood) are the first line of defense against bacterial invaders. Alkamides boost this effect. Interestingly, alkamides also attach to CB-2 receptors--one of two receptors that marijuana products bind to--to moderate immune response by reducing the chemicals that aggravate inflammation.

Another constituent is polysaccharides--literally "many sugar" molecules. This doesn't mean white sugar or anything like it! Polysaccharides are large molecules that have many functions in both nutrition and cell structure. They include starches and cellulose, and are made up of many smaller sugar molecules. Fun fact: foreign polysaccharides are one of the things those "soldier cells" react to--thus, the invasion of bacterial polysaccharide material is one of the things that gets the immune system started. This is believed to be one way that echinacea stimulates immunity.

I'll refer interested readers to an article by Azadeh Manayi and colleagues (2015)--if you really want to get into the weeds on this subject. For now it's sufficient to say that there's real evidence that echinaceas have the ability to both enhance immunity and moderate the harmful effects of inflammation.

Echinacea's Effects in Humans
There's been a lot of study of echinacea, but much of this work is limited by a couple of factors. The first is that, because single herbal medicines are unpatentable, clinical studies have tended to be small and few. There's no money in it. Attempts to combine the results of such smaller and varied studies have led to somewhat confusing results. Researchers have also used different methods--even different preparations--to study clinical effects in people. The second factor is that there's just not as much interest in much of the world in herbal medicines, although poverty (India, Africa) and tradition (Germany, China) have fueled some research into plant-based medicine. The paper by Manayi et al. in Pharmacognosy Reviews I mentioned above was an Iranian team. There's a lot of herbal medicine study out of Iran, perhaps because economic sanctions have led to turning to Nature as a pharmacy in lieu of the easy import of regular drugs. In short: although we have a copious traditional literature about echinacea, the hard science literature is both smaller and more nuanced.

I recently gave a talk to a group of nurse practitioners, doctors, and PAs about herbal medicines, and I covered this plant, so I'll share my summary of some of that nuance here. The research is clear that echinacea modifies immunity toward activation aimed at fighting bacteria and viruses. I've read reviews that suggest that echinacea can be used--if used when symptoms first start--to reduce the duration of or abort symptoms in the common cold. I recently read a review that suggests it can't. One review concluded that it isn't effective to prevent the common cold. A more recent review says it will. Years ago it was reported that, because echinacea really does stimulate immunity, using it daily will eventually cause that part of the immune system to "burn out" and work less well. A more recent report denies this occurs, and indeed 19th Century eclectic physicians often prescribed it for daily use without ill effects in this regard. Another concern is that, because echinacea can activate the immune system, it may cause people with asthma or autoimmune diseases to suffer from aggravations of their disease.

What I've Seen in the Clinic
Echinacea works. Early on I used it strictly for the treatment of things like colds and flus, when plant medicine was desired (as opposed to regular medicines, like Tamiflu), and I have found that it works most of the time to either stop (if taken within 6 hours or so of the very first symptom) or shorten a cold (if taken at any time afterward). The longer the cold or flu has been going on, the less well it works.

Years ago I began to turn to elderberry as a first line treatment for colds and flus because it has fewer theoretical safety concerns, and because it's become very easy to get at regular retail pharmacies (because you know, people tend to get sick on evenings, weekends, and holidays!) and the quality is generally known to be good. These days I tend to use echinacea for cases of other types of early infection, such as minor skin infections, dental abscess, "stomach flu", and urinary tract infection (UTI). I do still use it sometimes for respiratory infections as well.

One problem I tend to see with it is that potency matters, and many people purchase products that are likely to be of low potency, such a dried-powdered herb in capsules. In my practice I tend to recommend either a liquid product (in alcohol or glycerine) or a standardized liquid or solid extract (in gel caps) as the approach-of-choice, as these are products that have the potency needed to achieve clinical results. You may see such products labelled as "standardized" to a certain percent by weight or milligram strength of "echinacosides", which are caffeic acids, themselves not necessarily immune-stimulating, but a marker of plant potency.

What about the downsides suggested in some reports?

Based on my clinical experience, most of these are overstated, and even authorities on this subject suggest that these concerns are more theoretical than actual. In my own practice I have seen a few cases in which mis-use of echineca led to activation of asthma and rheumatoid arthritis, and even a couple of cases in which the supposed "immune burnout" actually occurred.

This is how I view echinacea now:

  • It can be used preventively for short periods to keep from getting a cold or flu. An example of this use would be when one is preparing for air travel (commercial airplanes are basically a germ-recycling system!) or other situation in which a lot of exposures may occur. A short period would be a few days before, and then during such exposure.
  • It can be used as a treatment for colds and flus, but is best used within 48 hours of symptom onset, and is even more effective within 4-6 hours of onset of the very first symptom. I usually suggest continued use for up to 10 days, but have seen good results with even just a few days' worth of use.
  • It can be used as a treatment for various other infections such as UTIs and minor skin infections, but again, it should be used early.
  • People with asthma, rheumatoid arthritis, lupus, colitis, and other inflammatory or autoimmune conditions ought to only use echinacea under professional supervision.
  • Let the buyer beware! There's no regulation of these products, so I am skeptical of casual sources of them. There are validated, professional quality products available through a number of sources. Wellevate is one such source (disclaimer: I have an online store through Wellevate), but there are others. Amazon, Walmart, etc.--they're cheap but may or may not be what they say they are. The United States does not regulate these. Wellevate, Thorne Research, Integrative Therapeutics and others are self-policing industry outlets.
  • I never recommend daily, uninterrupted use of echinacea. I'm just not convinced this is safe or necessary.
  • Liquids (alcohol or glycerine-based) or standardized extracts are my "go-to" choices for medical use. The echinacea teas available at grocery stores are generally weak, although I have suggested--in a pinch--that using 2 or 3 teabags per cup, and letting that tea steep for 5-10 minutes can also work. 

Overall, my feeling about echinacea has changed with time. I tend to view it as a choice that should be used with professional guidance, but have also found that most people won't do themselves any harm using it on their own.

And, in the spirit of my last blog post: If you aren't getting better, and you're getting worse on something like this, seek professional assistance! Don't keep doing the same thing if it isn't working.
On that note, let me add that this article is educational and is no substitute for professional medical advice--you just have to find a professional with an open mind and a bit of experience!

Sunday, June 9, 2019

Hacks and Quacks

Sunday morning, and I'm just surfin' around on YouTube and what have you, and I ran across a video by GeneticallyModifiedSkeptic about how the quackbuster Sam Harris "beats quacks every time." Now I like this kid (real name: Drew McCoy). He's a young guy whose channel specializes in discussion of argument, belief, and reason, mostly centered on his own experience of moving from theism to atheism. He also explores the arguments of various proponents of contemporary intellectual positions like those of Jordan Peterson, religious cults, PragerU, and so on. So most of this broadly falls into the categories of general philosophy and epistemology--the "study of knowledge". His Facebook page lists one of his subspecialties as "debunks alternative medicine."

I emphasize that I like this guy, because I think he's smart and constructs his own arguments in a clear and accessible way. This blog post isn't meant to criticize him alone; rather his videos on alternative medicine--along with another bit of news I picked up on Google News this morning--inspired me to write about how we think about medicine, and why we think it.

The other bit of news comes form The Independent and concerns the sentencing for manslaughter the parents of a 7-year-old Italian boy, because his death was determined to be from the choice of homeopathic remedies for an ear infection, instead of giving him antibiotics.

This got me to thinking: what's really going on here?

Let's start with the Italian boy. I read the story. The homeopathic practitioner was said to have "underestimated the seriousness of the illness" when he persisted "despite recrudescence of the symptoms." In plain English, this means someone tried something that could have worked, and when it didn't and the kid got worse, the practitioner didn't punt to something else.

That doesn't have anything to do with homeopathy. Let me explain by analogy.

My mom was in a car accident. In the accident, her leg was pierced by an umbrella rib from a folded umbrella that was in the passenger-side door pocket. The wound got infected. She went to her doctor, who gave her an antibiotic. By the time she called me, the infection had gotten pretty bad and she told me "He gave me Keflex for a week, but that didn't clear it up so he gave me Keflex for another 10 days."

The infection was still a problem when I saw her, now more than 3 weeks into things. I lanced the wound, packed it, and changed the antibiotic to clindamycin. She was fully better in mere days.

Do antibiotics work? Of course they do, but there's this thing called "antibiotic resistance" and everyone knows about it, and why would you keep doing the same thing if it's not working?

So you can see that the real issue is clinical knowledge and clinical reasoning, not whether or not one should use antibiotics--or homeopathy, or essential oils, or prayer, or meditation, or whatever. Look, it's an axiom of clinical medicine that she might have gotten better with simple hot packs applied to the wound. Or...not, and so then we do something else. Get it?

McCoy does make one effective argument: why not just use something that has been proven to work? But that's not an epistemic question. It's still just a question of good clinical reasoning. And since he's not a clinician, I have to ask why he'd feel comfortable getting into an area that is so fraught with unknowns.

Take hypothyroidism, or low thyroid hormone levels. It's a mostly straightforward clinical problem, and the thing that cures it is T4 replacement therapy. I have not found any evidence that anything works as well as T4 for this problem. When people ask me if there's a homeopathic "cure" for hypothyroidism, I tell them "Take the drug. Think of it as food"--and technically it is, as the first treatments that effectively treated what was called "myxedema" (hypothyroidism) in the olden days was little hamburgers made out of cow thyroid gland.

Now take depression. Although there are some theories about the biological basis of depression, we really don't know what's going on. Furthermore, we don't have any good diagnostic instrument to measure depression. It's a black box. We know some general things. We know that many people improve on various antidepressants, but we can't predict which class of antidepressant will work in any given case, and we don't know what dose will work in any given case. And we don't know in any given case if antidepressants will work. I teach my students that prescribers can make general predictions: pure serotonin-focused drugs will often be somewhat sedating, so those drugs are a better first choice if the person has depression with anxiety or insomnia. Serotonin-norepinephrine focused drugs might be better if the depressed person lacks energy and sleeps too much. You get the idea.

I also teach my students that it takes time to see the effects of these drugs--regardless of category or class--and it takes time to find the right dosing. Side effects are many and often troublesome, and may lead to changing the drug as this becomes apparent. In the end, psychopharmacology is a bit of a crapshoot: it's educated guesses combined with active analysis of the ongoing case, with adjustments made ad lib based on results, or the lack thereof.

So to say that T4 works in cases of low thyroid is easy. To say antidepressants work for depression is a problem. That problem is complexity, and the difficulty I have with people who wish to "debunk alternative medicine" is that it ignores the complexity of clinical experience, clinical practice.

This is the issue I have with Harris, McCoy, or any of the many others like Edzard Ernst, David Gorsky and so on.

It is a fair intellectual exercise to experimentally inquire into the uses and effectiveness of various medical alternatives. Inquiring minds want to know--said the old ad tagline from the tabloid The National Enquirer! It is a fair exercise of political and economic policymaking to ask whether or not the costs of a thing justify public funding of its use. It is also fair to discuss the measurable harms to the public when people choose not to vaccinate. It's fair to express concern that people with low qualifications market products with broadly falsifiable claims in the hopes of bilking people out of their money while real medical problems go untreated. However, it is neither fair nor justified to spend one's time in a general enterprise "debunking" medical approaches one knows little about.

What I'll argue here today is related to something I've proposed a few previous times in this blog: These so-called skeptics have an agenda that isn't intellectual, it's psychological. I've written here before about the impulse these critics express as intellectual rectitude. It's the same "I'm right, you're wrong" attitude that affords them with a sense of superiority...or sublimates their woundedness at the harms they've seen when people make choices that don't line up with a logical positivist, materialist worldview. In the former case, it's just smug people behaving badly. In the latter case--usually among practicing doctors and nurses--it's despondency among clinicians who hate to lose patients to what sometimes prove to be bad choices.

But there's another side to this, and that side can probably be found all over South-central Pennsylvania, when some of my patients go back to see their doctors and tell them that I gave them some little white pellets and their __(fill-in-the-blank)__ got better, and stayed better. But you don't hear many doctors saying "Hmm, that's interesting. I wonder what happened there?" They shrug. Some may say something vaguely affirmative (which is at least good bedside manner!), or they may actively argue that the choice made was a poor one, and try to persuade the patient to do otherwise.

McCoy has a sharp mind and lots of promise as an interlocutor online. He--and others like him--falter when they stray into areas beyond topics like whether or not tax dollars should pay for things that have scant proof in the medical literature, or if the value of mass immunization to society exceeds its minimal harms to individuals. When he and others simplistically paint "alternative" medical approaches with a broad epistemic brush, their arguments crash on the realities of clinical experience, and the mysteries of human health and disease.