Taxonomic class

Cactaceae

Common Trade Names

Multi-ingredient preparations: Cactus Grandiflorus, Cactus-Hawthorn

Compound, Cereus Grandiflorus, Night-Blooming Cereus

Common Forms

Available as liquid extract and tincture.

Source

Active components are derived from the stems and flowers of Selenicereus grandiflorus, which is native to tropical and subtropical America , including the West Indies .

Chemical Components

The plant contains a digitalis-like glycoside, either cactine or hordenine (N,N -dimethyl -4- hydroxy-beta - phenethylamine). Other reported components include betacyanin, isorhamnetin-3-glucoside, narcissin, rutin, cacticine, kaempferitrin, grandiflorine, hyperoside, isorhamnetin-3-beta­galactosyl- rutinoside, and isorhamnetin- 3-beta- xylosyl- rutinoside.

Actions

Night-blooming cereus is thought to elevate arteriolar tension by increasing the muscular energy of the heart and causing arteriolar contraction. This theory has not been confirmed by human data. Early research with commercial preparations of the active compound proved it to be physiologically inert. More recently, in studies with rats and dogs, hordenine showed a positive inotropic effect on the heart, with increased systolic and diastolic blood pressures and peripheral blood flow volume . Flavonoids and their derivatives (rutin, rutinoside, and kaempferitrin) are thought to improve capillary function by decreasing abnormal leakage .

Reported Uses

In Europe , the liquid plant extract has been used to treat angina pectoris, irritable bladder, kidney congestion, nervous headache, palpitations, and prostatic diseases. The herb has been used as an antirheumatic and a cardiotonic in Cuba . Other indications for its use include cystitis, dyspnea, edema, endocarditis, and myocarditis. Anecdotal reports claim that the herb is valuable as a cardiac stimulant and a partial substitute for digitalis in heart disorders related to anemia, dyspepsia, Graves’ disease, neurasthenia, and tobacco toxicity.

Dosage

Traditional uses suggest the following dosages:

Liquid extract: 0.7 ml (12 minims) P.O. every 4 hours.

Tincture: 1 to 1.8 ml (15 to 30 minims) P.O. every 4 hours.

Adverse Reactions

EENT: burning sensation in the mouth.

GI: diarrhea, nausea, vomiting.

Interactions

ACE inhibitors, antiarrhythmics, beta blockers, calcium channel blockers, cardiac glycosides: May increase effects of these drugs. Avoid administration with night-blooming cereus.

Contraindications and Precautions

Night-blooming cereus is contraindicated during the first trimester of pregnancy.

Special Considerations

Monitor the patient’s heart rate and blood pressure if the is also taking prescription cardiac drugs.

Encourage the patient with a CV disorder to be evaluated by a health care provider and, if necessary, receive prescribed cardiac drugs. Because the use of night-blooming cereus as a substitute for digitalis has not been confirmed by human clinical trials, it should not be used by itself for heart-related disorders.

Urge the patient to immediately report heart-related adverse effects (blood pressure changes, increased heart rate, and palpitations) to his health care provider.

Instruct women to report planned or suspected pregnancy.

Advise women to avoid using night-blooming cereus during pregnancy or when breast-feeding.

Commentary

Although night-blooming cereus contains a digitalis-like glycoside, its use as a substitute for digitalis preparations (digoxin or digitoxin) or for treating heart-related disorders has not been evaluated in humans. Patients with such conditions should strongly be encouraged to seek professional medical advice. Also, patients who are taking prescription digitalis or other cardiac drugs should avoid concurrent use of this herb.

Taxonomic class

Caricaceae

Common Trade Names

Papaya Enzyme, Papaya Enzyme with Chlorophyll, Papaya Leaf

Common Forms

Tablets: 5 mg

Tablets (chewable): 25 mg

Also available as a tea.

Source

Components are usually extracted from the leaves, seeds, pulp, and latex of Carica papaya, which is native to Mexico and Central America but also grows in other tropical areas.

Chemical Components

Papaya is composed primarily of proteolytic enzymes, including papain and chymopapain. Papain (also know as vegetable pepsin) occurs in the leaves and fruit latex. The alkaloid carpaine has also been isolated from the leaves. The seeds contain the glycosides caricin and myrosin.

Actions

Meat, seeds, and plant pulp of unripe papaya have demonstrated antioxidant properties and exerted weak bacteriostatic activity in vitro.

Latex from papaya sap has inhibited the growth of Candida albicans in culture .

Reported Uses

Papain is classified as a debriding agent for necrotic tissue. Chymopapain is approved for intradiskal injection in patients with herniated lumbar intervertebral disks who do not respond to conventional therapy.

Papaya was used for athletic injuries and showed improved anti­inflammatory response and speedy recovery . It was also helpful in reducing postoperative edema and ecchymosis after nasal plastic surgery. In patients who had undergone head and neck surgery, papaya reduced postoperative edema slightly .

Papain is claimed to be useful as an anthelmintic and in treating digestive disorders. The latex has been effective against intestinal nematodes in mice.

Dosage

For inflammation, clinical trials suggest 10 mg P.O. q.i.d. for 7 days.

Adverse Reactions

CNS: decreased CNS activity (carpaine), paralysis.

CV: decreased heart rate.

GI: perforation of the esophagus and severe gastritis (with ingestion of excessive papaya or papain).

Skin: carotenemia, dermatitis.

Other: anaphylactic shock (reported after injection of chymopapain), hypersensitivity reactions (plant parts, extracts).

Interactions

None reported.

Contraindications and Precautions

Avoid using papaya in pregnant or breast-feeding patients; effects are unknown. Use cautiously in patients with a history of atopy or in those who are prone to contact dermatitis reactions from the herb.

Special Considerations

Monitor the patient with hypersensitivity for reactions to papaya.

Caution the patient against prolonged use because of the risk of severe gastritis and hypersensitivity reactions. Explain that the latex in the plant may induce dermatitis.

Advise Women to avoid using papaya during pregnancy or when breast -feeding.

Points of Interest

Papaya is a source of flavoring used in candies and ice cream.

Papain is used in Some facial creams to soften skin and as a meat tenderizer.

Commentary

Human clinical trials suggest that papaya may be useful in treating inflamation caused by trauma or surgical procedures. In vitro studies have documented bacteriostatic effects against enteropathogens, but human clinical trials need to be conducted to verify these claims. Because allergic reactions have been caused by plant parts and extracts, papaya should be used cautiously in patients with a history of hypersensitivity reactions.

Taxonomic class

Rosaceae

Common Trade Names

Alvita Teas Hawthorne Berry, Cardio Health Hawthorne Berry #6 Syrup, Cardiplant, Gaia Herbs Hawthorn Berry A/F, Gaia Herbs Hawthorn Berry Solid, Gaia Herbs Hawthorn Supreme, Gaia Herbs Hawthorn Supreme SFSE, Hawthorne Berry, Hawthorne Formula, Hawthorne Heart, Hawthorne Phytosome, Hawthorne Power, Heart Foods Company Hawthorne plus, Heart Foods Company Power Caps Hot Cayenne with Hawthorne and Ginger, Herbalist and Alchemist Hawthorn-Cactus Extract, Herbalist and Alchemist Hawthorn­Fruit/Flower Extrac, Natrol Hawthorne Berry Capsules, Nature’s Answer Hawthorne Berry Low Alcohol, Nature’s Answer Hawthorne C+ Combo, Standardized Full Potency Hawthorne Berry Extract Vegicaps

Common Forms

Available as biological extracts (4 mg/ml of vitexin-2-0-rhamnoside); capsules of berries (510 mg) or leaves (80 mg) standardized to 15 mg of oligomeric procyanidines; and extended-release capsules (300 mg of 1.8% vitexin-2-rhamnoside and hyperoside).

Source

Active ingredients are extracted from the berries, flowers, and leaves of

Crataegus species, commonly C. laevigata, C. monogyna, or C. folium. More than 300 Crataegus species are found in the temperate regions of North America, Asia, and Europe.

Chemical components

Hawthorn is composed primarily of proanthocyanidins and flavonoids (quercetin, hyperoside, vitexin, vitexinrhamnoside, rutin); other constituents include catechin and epicatechin.

Actions

Studies on animals and in vitro models have suggested CV actions that

include ACE inhibition, beta-blocking activity, dilation of coronary arteries, hypotensive effects, and negative and positive inotropic effects. The high bioflavonoid content in some hawthorn species may show antioxidant activity and be cardioprotective in experimental ischemic animal models; the extracts decreased myocardial oxygen consumption and left ventricular work . Prophylactic antiarrhythmic potential has also been shown in rabbits that received aconitine. Mild CNS depressant effects have been documented for the hawthorn flower extract.

Reported Uses

Claims for hawthorn surround its use in arteriosclerosis, Buerger’s disease, heart failure, hypertension, and paroxysmal tachycardia. It may be therapeutically useful in the treatment of New York Heart Association (NYHA) functional class II (mild to moderate) heart failure. Patients with this class of heart failure who received a daily dose of 600 mg of hawthorn extract showed significant clinical improvement over an 8­week period .

Hawthorn, either alone or with coenzyme Q10, was found to be beneficial and also compared favorably to captopril for patients with heart failure. Other studies have noted the herb’s usefulness in patients with stable angina pectoris .

Dosage

A dose of 160 to 900 mg of a standardized extract containing 2.2% flavonoids or 18.75% oligomeric procyanidines given P.O. b.i.d. or t.i.d. The amount of flavonoid (calculated as hyperoside) is 3.5 to 19.8 mg and that of procyanidins (as epicatechin) is 30 to 168.7 mg.

Adverse Reactions

CNS: fatigue, sedation (with high doses).

CV: arrhythmias and hypotension (with high doses).

GI: nausea.

Respiratory: respiratory failure (in animals).

Skin: sweating.

Interactions

Antihypertensives, nitrates: Increased risk of hypotension. Monitor blood pressure closely.

Cardiac glycosides: Increased effects of these drugs. Use cautiously.

CNS depressants: May cause additive effects. Use cautiously.

Contraindications and precautions

Hawthorn is contraindicated in patients who are hypersensitive to other members of the Rosaceae family and in pregnant or breast-feeding patients.

Special considerations

Monitor the patient for adverse CNS effects.

Instruct the patient to use hawthorn only under medical supervision.

Caution the patient to avoid hazardous activities until hawthorn’s CNS effects are known.

Inform the patient that other proven therapies for heart failure should be pursued before taking hawthorn.

Urge the patient to seek emergency medical treatment if he becomes short of breath or if pain occurs in the heart region and spreads to the arm, lower jaw, or upper abdomen.

Urge the patient who chooses to self-medicate to seek medical advice if symptoms continue for longer than 6 weeks.

Points of Interest

Germany’s Federal Institute for Drugs and Medical Devices has approved the use of hawthorn leaf with flower extracts in the treatment of NYHA functional class II heart failure. The extract of berries has not been approved because efficacy has not been shown.

Berry preparations are commonly advertised as a supplement to strengthen and invigorate the heart and circulatory system.

Commentary

Hawthorn has long been used for heart failure in Europe. Several foreign studies suggest that it may be effective in treating NYHA functional class II heart failure. Long-term studies using hawthorn that demonstrate prolonged survival are lacking. Future studies should focus on evaluating improvements in NYHA heart failure class, hospital admission rates, quality of life measurements, and whether hawthorn extracts have an effect on mortality.

Taxonomic Class

Rutaceae

Common Trade Names

Multi-ingredient preparations: Jaborandi, Origin Hair and Scalp Therapy, Wonder Gel, X-Tablets

Common Corms

The leaves from the jaborandi tree are available as essential oil, fluidextract, a powder, and tincture. Combination products are found as gels and tablets. Pilocarpine, the main active ingredient, is available in many prescription products:

Ocular insert: 20 mcg, 40 mcg

Ophthalmic gel: 4%

Ophthalmic solution: 0.25%, 0.5%, 1 %,2%,3%,4%,5%,6%,8%, 10%

Tablets: 5 mg

Source

Pilocarpus, or jaborandi, consists of the leaves of Pilocarpus jaborandi (Pernambuco jaborandi), Pilocarpus microphyllus (Maranham jaborandi), or Pilocarpus pinnatifolius (Paraguay jaborandi). The plant is native to the northern and northeastern parts of Brazil.

Chemical Components

Three alkaloids are found in jaborandi: pilocarpine, pilocarpidine, and isopilocarpine. Also reported are jaborine, pilosine, volatile oils (including dipentene), and jaboric, pilocarpic, and tannic acids.

Actions

When applied topically to the eye, pilocarpine stimulates muscarinic receptors; this causes the pupil to constrict and the ciliary body to contract, thus improving the outflow of aqueous humor. Muscarinic alkaloids, when administered orally, stimulate the smooth muscles of the GI tract, increasing motility and tone. The tone and motility of other organs or organ systems (such as the ureter, bladder, gallbladder, and biliary ducts) may also be increased. Pilocarpine causes increased sweating and salivation in humans. It acts on the CV and respiratory systems as well (decreases blood pressure, heart rate, and vital capacity). In cats, pilocarpine has caused cortical stimulation .

Jaborine, a component found in the leaves, may actually be antagonistic to pilocarpine. Tannic acid has local astringent properties that act on the GI mucosa and has shown anti ulcerative and antisecretory effects within the GI tract.

Reported Uses

Although jaborandi has several reported uses, pilocarpine is usually extracted and used to stimulate saliva secretion or as a diaphoretic or myotic . Pilocarpine is primarily used to treat glaucoma or xerostomia. Other reported uses of the jaborandi plant include treatment of Bright’s disease, deafness, diabetes, edema, intestinal atony, jaundice, nausea, nephritis, pleurisy, psoriasis, rheumatism, syphilis, and tonsillitis. A decoction of the leaf applied locally has been used as a treatment for baldness.

Dosage

For glaucoma, 1 or 2 gtt applied t.i.d. or q.i.d. Refer to package insert for pilocarpine for specific dosing information.

For xerostomia, 15 to 30 mg P.O. daily; a dose of 100 mg P.O. is considered fatal.

The following daily doses have been suggested: powdered leaves, 5 to 60 grains (0.324 to 3.9 g); fluidextract, 10 to 30 gtt; tincture, Y, to 1 dram (1.75 to 3 ml).

Adverse Reactions

CNS: headache.

CV: bradycardia.

EENT: increased salivation, lacrimation, visual changes.

GI: nausea, vomiting.

Skin: sweating.

Interactions

Anticholinergics (atropine, ipratropium, scopolamine, other belladonna­type alkaloids): May decrease effects of these drugs. Avoid administration with jaborandi.

Beta blockers: May cause conduction problems. Monitor the patient.

Glycosides, iron-containing compounds, other alkaloids: Tannic acid may interact with these drugs. Do not use together.

Other prescription products containing pilocarpine, other muscarinic agonists (arecoline, methacholine, muscarine), cholinesterase inhibitors (do­nepezil, edrophonium, physostigmine): May have additive effect when used concomitantly. Use cautiously to avoid toxicity.

Contraindications And Precautions

Jaborandi is contraindicated in patients who are hypersensitive to pilocarpine and in those with uncontrolled asthma, acute iritis, and angleclosure glaucoma. Avoid use in pregnant or breast-feeding patients. Avoid large doses of jaborandi because hepatic injury can occur, especially in patients with preexisting hepatic disease. Use cautiously in patients with significant CV disease, biliary tract or urogenital abnormalities (cholelithiasis, nephrolithiasis), and preexisting cognitive or psychiatric disorders.

Special Considerations

Monitor intraocular pressure in patients at risk for glaucoma.

Monitor liver transaminase levels; if they increase, the product should be discontinued immediately.

Inform the patient that excessive sweating may lead to dehydration if fluids are not replenished.

Alert Signs of pilocarpine toxicity include exaggerated muscarinic effects. Extreme cases may lead to severe bronchospasm, hypotension, pulmonary edema, and shock. Treatment consists of atropine administration and general support of the CV and respiratory systems to counteract the effects from pulmonary edema .

Urge the patient to immediately report symptoms associated with pilocarpine toxicity (excessive sweating, lacrimation, increased salivation, nausea, vomiting, hypotension, and bradycardia) or hepatic dysfunction (fever, jaundice, and pain in right upper quadrant). Instruct him to discontinue use of the product if they occur.

Caution the patient that pilocarpine may cause visual changes, especiallyat night, which may impair his ability to drive.

Advise the pregnant or breast-feeding patient not to use jaborandi.

Commentary

The jaborandi tree is regarded as a source for pilocarpine. Much information exists about the use of pilocarpine for treating glaucoma and xerostomia. No human studies are available that support the use of jaborandi leaves for any medicinal purpose. Patients with glaucoma, xerostomia, or other potentially treatable conditions should seek medical advice because self-medication with jaborandi is not advised.

Type of Drug:

Long-term (less than 5 years), reversible birth-control system; progestin­containing contraceptive system.

How the Drug Works:

Levonorgestrel appears to prevent pregnancy by preventing ovulation. It also causes changes in the inner lining of the uterus, preventing implantation should fertilization occur.

Uses:

To prevent pregnancy for up to 5 years. The implants should be removed by the end of the fifth year; new implants may be inserted at that time if continuing contraceptive protection is desired. Approximately 0.2 (patients weighing less than 110 Ibs) to 8.5 (patients weighing 154 Ibs or more) of 100 women using levonorgestrel implants become pregnant. The effectiveness of this method is not dependent on proper use, but does appear to vary in accordance with body weight.

Precautions:

Contact lens wearers: If you develop changes in vision or lens tolerance, contact your eye care specialist. Consider temporarily or permanently stopping contact lens wear.

Delayed follicular atresia: If the development of an ovarian follicle occurs, growth beyond the size attained in a normal cycle may occur. These enlarged follicles cannot be distinguished clinically from ovarian cysts. Usually they will spontaneously disappear; rarely, they may twist or rupture, possibly requiring surgery.

Ectopic pregnancy: Ectopic pregnancies have occurred among levonorgostrel implant users, although studies have shown no increase in the ringleader yom CIS With users of no method of contraception or of intrauterine progesterone (IUDs).

Impaired liver function: If jaundice (yellowing of skin or eyes) develops, removal of the implants should be considered. Steroid hormones may be poorly metabolized in patients with impaired liver function.

Fluid retention: Steroid contraceptives may cause fluid retention. There­fore, they should be used with caution in patients with conditions that might be aggravated by fluid retention (eg, high blood pressure, heart failure).

Pregnancy: Do not use during pregnancy. The risk of use in a pregnant woman clearly outweighs any possible benefit.

Breastfeeding: Levonorgestrel appears in breast milk. Consult your doctor before you begin breastfeeding.

Children: Safety and effectiveness have been established in women of reproductive age. Safety and effectiveness are expected to be the same for postpubertal adolescents 16 years of age or younger. Use of this product before the onset of first menstruation is not indicated.

Drug Interactions:

Tell your doctor or pharmacist if you are taking or if you are planning to take any over-the-counter or prescription medications or dietary supplements with levonorgestrel implants. Doses of one or both drugs may need to be modified or a different drug may need to be prescribed. The following drugs and drug classes interact with levonorgestrel implants:

• Carbamazepine (eg, Tegretol)
• Phenytoin (eg, Dilantin)
• Rifampin (eg, Rifadin)

Side Effects:

Every drug is capable of producing side effects. Many levonorgestrel implant users experience no, or minor, side effects. The frequency and severity of side effects depend on many factors including duration of therapy and individual susceptibility. Possible side effects include:

Insertion site reactions: Pain; swelling; bruising; infection; blistering; ulceration; itching; skin sloughing; excessive scarring; discoloration; arm pain; numbness and tingling; nerve injury; removal difficulties; vein inflammation.

Urinary and Reproductive Tract: Change (typically a decrease) in menstrual flow; spotting; lack of menstrual bleeding; breast pain; breast discharge; inflammation of the vagina or cervix; vaginal discharge; enlarged ovarian follicles; prolonged, frequent, or irregular menstrual bleeding.

Digestive Tract: Nausea; vomiting; appetite changes; stomach ache. Nervous System: Headache; anxiety; ­tives monograph in this chapter.

Guidelines for Use:

• Carefully read the patient package insert available with this product.
• Capsules will be inserted beneath the skin of the upper arm.
• Capsules should be implanted or removed only by a health care professional thoroughly instructed in the insertion and removal technique.
• Pregnancy must be ruled out prior to insertion. Conduct pregnancy tests whenever pregnancy is suspected. If pregnancy occurs, the implants must be removed.
• Insertion of the levonorgestrel implants should be performed during the first 7 days after the beginning of menstruation or immediately following an abortion. If performed at any other time during the cycle, a non­hormonal contraceptive method (eg, condom, diaphragm) should be used for the remainder of that cycle. Insertion is not recommended until 6 weeks after childbirth in breastfeeding women.
• Removal of the implants should be considered in women who will be immobilized for a prolonged period of time due to surgery or illness.
• Implants must be removed at the end of the 5-year period. If new implants are not inserted at the same time, the patient’s previous level of fertility will return and pregnancy can occur at any time.
• Some change in menstruation patterns can be expected, especially during the first year.
• Notify your doctor if you experience stomach or pelvic pain, persistent headache, visual disturbances, depression, or yellowing of the skin or eyes.
• Diabetic patients - Levonorgestrel implants may alter glucose tolerance. Monitor your blood glucose closely.
• Bruising may occur at the implant site during insertion or removal. Darkening of the skin over the implant site may occur in some women but is usually reversible upon removal.
• Levonorgestrel implants do not protect against HIV infection (the virus that causes AIDS) or any other sexually transmitted diseases.

Taxonomic class

Parmeliaceae

Common Trade Names

Iceland Moss, Juvinol Cell and Tissue Formula

Common Forms

Available as capsules, creams, and throat lozenges.

Source

Cetraria islandica, a lichen that grows in the Northern hemisphere, is common in the mountains and heathlands of Iceland. The single-cell green algae are enclosed in a web of fungal hyphae (root filaments). The lichen may be gathered throughout the year, but it seems to be most abundant between May and September. It should be freed from attached impurities and dried in the sun or shade. The entire plant, or lichen, is used for extraction.

Chemical components

C. islandica is bitter and mucilaginous. Constituents include about 50% water-soluble polysaccharides, including lichenin, a linear cellulose-like polymer of beta-D-glucose, and isolichenin, a linear starchlike polymer of alpha-D-glucose. Iceland moss also comprises galactomannans; an acidic, branched polysaccharide containing D-glucose and D-glucuronic acid units; and trace amounts of iron and calcium salts. Other constituents are bitter-tasting lichen acids, including the depsidones fumarprotocetraric acid and protolichesterinic acid . Iceland moss has a high fiber content.

Actions

Protolichesterinic acid from Iceland moss was found to have antibacterial properties against Mycobacterium tuberculosis, Streptococcus pyogenes, and Staphylococcus au reus. It has also exhibited antitumorigenic activity against solid type carcinoma in mice and been potent in vitro in inhibiting activity against the DNA polymerase activity of HIV type 1 reverse transcriptase . Protolichesterinic acid was shown to be antiproliferative and cytotoxic to T-47D and ZR-75-1 cell lines cultured from breast carcinomas and to K-562 from erythro­leukemia. Significant inhibition of 5-lipoxygenase may stimulate these activities and contribute to protolichesterinic acid’s reported anti­inflammatory actions .

Because of their antibacterial properties, the extracts hqve been studied for use in pharmaceutical and cosmetic products. The lichen extracts appear to be safe for use as preservatives without interfering with proprietary ingredients.

Extracts of Iceland moss were found to suppress the growth of Helicobacter pylori, the organism thought to contribute to the cause of gastritis and gastric and duodenal ulcers .

Reported Uses

C. islandica has been used in European medicine to treat asthma, GI disorders such as gastritis, minor ailments (such as throat irritation and cough), and tuberculosis. Cough drops for sore throats and laxative and tonic formulations are available in European pharmacies. In a random­ized trial, Iceland moss was found to prevent dryness and inflammation of the oral cavity in patients who had undergone surgery of the nasal septum and were subjected to prolonged mouth breathing after surgery. Emollient effects were noticeable with daily use of 0.48 mg of Iceland moss lozenges .

The polysaccharides are thought to form a soothing, protective, mucilaginous layer on upper respiratory tract mucosa. In an open clinical trial, 100 patients with bronchial ailments, laryngitis, or pharyngitis were treated with lozenges containing 160 mg of an aqueous extract of Iceland moss. The results were determined to be positive in 86 cases, with good gastric tolerance and lack of adverse effects .

In Iceland, the plant has also been used for symptomatic relief of gastric and duodenal ulcers . Studies of the antitumorigenic and immunostimulating properties of the polysaccharides found comparable carbon clearance assay results as those for the fungal polysaccharide lentinan, which is used clinically in adjuvant cancer therapy in Japan .

Dosage

A decoction can be made by mixing 1 tsp of shredded moss in 1 cup of cold water, which should then be boiled for 3 minutes and taken P.O. b.i.d. Alternatively, 1 to 2 ml of the tincture can be taken P.O. t.i.d.

Of significance, powdered material must be soaked in lye for 24 hours or filtered through ash to properly extricate lichen acids. Studies demonstrate that poorly prepared Iceland moss may contain toxic levels of lead .

Cough drops and laxative and tonic formulations are also available.

Adverse Reactions

GI (with large doses or prolonged use): hepatotoxicity, indigestion, nausea.

Interactions

None reported.

Contraindications And Precautions

Avoid using Iceland moss in pregnant or breast-feeding patients; effects are unknown. The bitterness of Cetraria is detectable in breast milk.

Special considerations

Inform the patient that Iceland moss cannot be recommended for any use because of insufficient data.

Advise the patient to watch for signs of toxicity (abdominal pain; bleeding; change in color of urine, stool, or skin; diarrhea; nausea; vomiting).

Advise the patient to consult a health care provider before using herbal preparations because a treatment that has been clinically researched and proved effective may be available.

Points of Interest

Iceland moss has been exported from Iceland and is used abroad to manufacture herbal medicines (particularly in Germany). Because Iceland is regarded as one of the least polluted countries in the world, the purity of the plants growing in Iceland is desirable. The wild plants are grown organically; fertilizers are not used in the highlands, where many of these plants are found.

Lichens lack roots and derive their energy and nutrients from their surroundings. They are susceptible to contamination by radioactivity and heavy metals. After the Chernobyl accident, the fallout contaminated the lichen in most of Europe, but in Iceland the radioactivity level was almost negligible.

Commentary

Iceland moss derivatives show promise as immunomodulating and antitumorigenic agents, and someday they may find a role in the treatment of H. pylori infections. Further research in human subjects is needed before any conclusions can be drawn. Definitive applications and clinical efficacy are not known. Although the lichen extracts appear to be relatively safe in small amounts, therapeutic application cannot be recommended.

Type of Drug:

Enzyme inhibitors; androgen hormone inhibitors.

How the Drug Works:

Dutasteride and finasteride inhibit the production of androgen, a hormone that is a major cause of prostate growth. By reducing the amount of androgen, dutasteride and finasteride help relieve urinary symptoms often associated with overdevelopment or enlargement of the prostate (benign prostatic hyperplasia [BPH]).

By inhibiting the production of androgen, finasteride interrupts processes that lead to male pattern baldness (hair loss on the crown of the head or the front scalp area).

Uses:

Doutasteride, Proscar: To treat symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate to improve symptoms, reduce the risk of acute urinary retention, and reduce the risk of the need for prostate surgery. Not indicated for use in women or children.

Propecia: To treat male pattern hair loss (vertex and anterior midscalp).

Effectiveness with other types of hair loss has not been determined. Not indicated for use in women or children.

Unlabeled Uses: Finasteride is being investigated in combination with flutamide as therapy following radical prostatectomy. Other potential uses include prevention of the progression of first-stage prostate cancer, treatment of acne in women, abnormal hair growth.

Precautions:

Pregnancy: Do not use during pregnancy. The risk of use in a pregnant woman clearly outweighs any possible benefit. Not indicated for use in women. Women who are pregnant or may become pregnant should not handle broken or crushed tablets or capsules because of the potential for absorption and potential risk to a male fetus. Similarly, when a male patient’s sexual partner is or may become pregnant, the patient should either avoid exposing his partner to his semen or discontinue therapy.

Breastfeeding: It is not known if these drugs appear in breast milk; they are not indicated for use in women. Consult your doctor before you begin breastfeeding.

Children: Safety and effectiveness have not been established; not indicated for use in patients younger than 18 years of age.

Lab tests may be required during and following treatment. Tests include prostate cancer screenings and urinary flow and volume monitoring.

Drug Interactions:

Tell your doctor or pharmacist if you are taking or planning to take any over­the-counter or prescription medications or dietary supplements with these drugs. Drug doses may need to be modified or a different drug pre­scribed. Ritonavir (Norvir) interacts with dutasteride.

Side Effects:

Every drug is capable of producing side effects. Many patients experience no, or minor, side effects. The frequency and severity of side effects depend on many factors including dose, duration of therapy, and individual susceptibility. Possible side effects include impotence, decreased sex drive, decreased amount of ejaculate, testicular pain, and breast tenderness and enlargement.

Guidelines for Use:

• Read the patient information insert before beginning therapy.
• Dosage is individualized. Take exactly as prescribed.
• Do not stop taking or change the dose, unless instructed by your doctor.
• Male pattern baldness - In general, three months of daily treatment is necessary before benefit is observed. Continued use is recommended to sustain benefit. Stopping treatment can reverse results within 12 months.
• Benign prostatic hyperplasia (BPH) - Six to twelve months of treatment may be necessary to determine response.
• Take without regard to meals.
• Swallow dutasteride capsules whole.
• Dutasteride long-term treatment - The incidence of most drug-related adverse events (eg, impotence, decreased sex drive, ejaculation disorder) will decrease with duration of treatment. The incidence of drug­related breast tenderness and enlargement may remain constant during therapy.
• Women who are pregnant or may become pregnant should not handle broken or crushed tablets or capsules because of the potential for absorption and potential risk to male fetus. Similarly, when a male patient’s sexual partner is or may become pregnant, the patient should either avoid exposing his partner to his semen or discontinue therapy.
• The amount of ejaculate may be decreased. This should not interfere with normal sexual function. However, impotence (erectile dysfunction) and decreased sex drive may occur .
• Men treated with dutasteride should not donate blood until at least 6 months have passed following their last dose to prevent pregnant women from receiving dutasteride through blood transfusion.
• Lab tests may be required during and following treatment. Be sure to keep appointments.
• Store at room temperature (59° to 86°F). Protect from light and moisture. Keep container tightly closed.