Do pharmacists know enough about supplements and traditional medicines?

In the traditional sense of the words, a pharmacy is a place where medicinal drugs are sold and pharmacists are the healthcare professionals who dispense those drugs.

September 11, 2016 Health, Wellness

By TAN SHIOW CHIN

While pharmacies in hospitals and clinics usually adhere strictly to this traditional definition, most retail or standalone pharmacies tend to sell far more products than just prescription and over-the-counter medicines.

According to a study conducted by Taylor’s University School of Pharmacy associate dean (learning and quality) Penny Wong Pei Nee, nearly three out of five Malaysian pharmacies (59%) stock a large variety of complementary medicines (CMs).

Only 1% say they don’t stock any CMs at all, while the remaining 40% report that they offer a limited variety of such products.

Wong showing the Meditag hologram decoder that helps to differentiate between real and fake holograms on medicines and supplements. Photo: The Star/Rohaizat Darus

This finding is probably due to the fact that over 90% of the pharmacists participating in the study agreed or strongly agreed that such products are an important part of a retail pharmacy’s finances.

They also agreed or strongly agreed that:

• Customers now expect more information about CM products from their pharmacist compared to five years ago;

• Pharmacists have a professional responsibility to counsel customers about CM products; and

• Pharmacists should play a greater role in providing customers with safety and drug interaction information about CM products.

Over 80% also thought that pharmacists should play a greater role in recommending CM products to their customers.

Complementary medicine in this study was defined as “herbal medicines, vitamin and mineral supplements, and other nutritional supplements” that “can be bought in a supermarket, pharmacy, health-food store, on the internet, from a mail-order company or from a T&CM (traditional and complementary medicine) practitioner”.

Local usage of CM

Says Wong: “The use of complementary medicines in Malaysia generally has three purposes for consumers.

“The first one is general health maintenance, like multivitamins; (the second is) treatment and prevention of minor ailments, such as when someone has a cold or flu and are recommended echinacea or vitamin C just to boost up the immune system; and for specific serious and chronic diseases, (for example) saw palmetto, black cohosh and things like that.”

She adds that while there are no specific statistics for CM, the Health Ministry’s Health Expenditure Report 1997-2013 published last year, estimated the sales of traditional and complementary medicines to be about RM1.7 billion in 2013.

“And this is only 7% less than pharmaceutical products,” she says.

According to Wong, CM products are regulated by the ministry’s Pharmaceutical Services Division and need to be registered with the Drug Control Authority.

“A registered product would be given a hologram, and also, a registration number.

“So, all CM products will have a registration number starting with MAL, and ending with the letter T or N – T represents traditional and N represents supplements (nutritional),” she says.

She adds that most pharmacies should have the Meditag hologram decoder issued by the ministry, which can help differentiate between a genuine hologram and a fake one on all registered CM and pharmaceutical products.

image: http://www1.star2.com/wp-content/uploads/2016/09/sfitx_anr_1109_top5CM.PDF.jpg

Knowledge on CM

Sponsored by the Blackmores Institute, the study called Survey of Integration and Usage of Complementary Medicines in Pharmacy was conducted between last April and December, and involved 453 community pharmacists from around the country.

Around 47% of them were from large-chain pharmacies (i.e. consisting of more than 10 outlets, like Guardian, Watsons and Caring), 41% from pharmacy chains with less than 10 outlets, and the remainder were from independent pharmacies.

More than half of them (54%) received their bachelor’s degree locally, while the rest graduated from a mix of both Asian and Western countries, especially the United Kingdom (26%) and Australia (12%).

Wong notes that the respondents mostly agreed that pharmacists need to provide integrative care, i.e. the combination of allopathic and complementary medicines.

Around 93% of them agreed or partly agreed that their personal practice of pharmacy centred around integrative care.

The factors that prevented the remaining 7% from practising integrative care included lack of sufficient knowledge, lack of information sources, limited opportunity or insufficient time to talk to customers, the ineffectiveness of the product, and because the promotion of CM products is the responsibility of other colleagues.

Three-quarters of the pharmacists learnt about CM products on their own, 60% through seminars from the product manufacturer, 37% each through seminars from a professional association and lectures during their undergraduate course, and 7% through formal studies like certificate or postgraduate courses.

Six percent said they had no training whatsoever about CM products.

image: http://www1.star2.com/wp-content/uploads/2016/09/sfitx_anr_1109_drugcminteraction.PDF.jpg

The study also found that the top three information sources about CM products used by pharmacists were the manufacturer or brand owner’s own material or training (59%), the World Wide Web (49%), and professional seminars, conferences or lectures (43%).

The top three factors that pharmacists consider when assessing information about CM products are: whether it has a scientific basis (68%), whether it contains both traditional and scientific information (49%), and whether it has been endorsed by a professional or educational organisation (46%).

The information they provide to customers is usually sourced from books or leaflets (65%); their own knowledge (63%); textbooks, journals and the Web (59%); manufacturers or brands (50%); and feedback from other customers (42%).

Explains Wong: “So, to ensure safe use of complementary medicines or conventional medicines, when customers present with a prescription, a brief medical history should be taken by the community pharmacist to see what medications they are taking so that safe drugs can be recommended.”

The study found that nearly three-quarters of pharmacists (74%) always or often ask their customers if they take CM when they present their drug prescriptions.

Fourteen of the pharmacies also currently employ a T&CM practitioner, while a similar number said they would consider employing one.

A T&CM practitioner in this study is defined as one who is registered with the Health Ministry. However, Wong cautions that registration for such local practitioners is currently voluntary, although compulsory for foreign practitioners.

While 17% of the respondents said they would definitely not employ a T&CM practitioner, the top three factors considered most important in employing such a practitioner for those considering doing so were tertiary qualifications (65%), increasing product sales (49%) and being a member of a professional association (43%).

Advice for patients

Wong says that the most important factors for those thinking of taking a CM product are ensuring that it is a registered product and knowing how to use it.

“It is a collaborative effort between pharmacist and patient.

“We know that the pharmacist has their professional role (in educating and providing information), but sometimes, customers need to know what kind of questions they need to ask,” she says.

Some of these questions should include the optimum dose of the product (in order to achieve the optimum effect), whether it is genuine or not, and whether it will interact with whatever medications they are currently taking.

Wong says that customers should also go back to their pharmacist and report if they have any adverse effects from the CM product they consume.

http://www.star2.com/health/wellness/2016/09/11/do-pharmacists-know-enough-about-supplements-and-traditional-medicines/

Vitamin K2 Deficiency Is a Significant Cause of Cardiovascular Disease

You may be watching your vitamin D and calcium to "grow strong bones," but inadvertently be placing yourself at higher risk for cardiovascular disease. If you take these medications or eliminate this from your diet, you could be raising your risk.

July 13, 2016 

Story at-a-glance

• Warfarin and statins may reduce your absorption of vitamin K2, leading to an increased risk of heart disease, stroke, osteoporosis and cancer
• Although necessary for your overall health, vitamin D without vitamin K2 may increase your risk of atherosclerosis, heart disease and stroke
• Vitamin K2 is found in fermented foods, fermented cheeses and grass-fed meats and dairy products

By Dr. Mercola

Your body is a complex organism, dependent upon the interactions and interrelationships of organs, enzymes, vitamins and hormones. Anytime you take a nutritional supplement, especially at high doses, you affect the balance of others.

For instance, if you take a zinc supplement, you must be wary of a copper imbalance in your body. These two nutrients balance each other, meaning you may suffer from either zinc or copper toxicity if they get out of balance.

The same is true for vitamins K and D. When the ratio between these two is not balanced, it can increase your risk for cardiovascular disease (CVD), stroke and heart attacks.

But vitamin supplements are not the only thing that can cause an imbalance. In a recent review, researchers found a link between medications used to lower cholesterol levels and treat type 2 diabetes and an inhibition of absorption of vitamin K from food.1

The 2 Forms of Vitamin K

In this video, Dr. Kate Rhéaume-Bleue discusses the differences between vitamins K1 and K2 and how they interact with vitamin D, calcium and other nutrients.

Vitamin K was discovered in 1929 as part of an experiment and was associated with blood coagulation, or how your blood clots.2 There are two main forms of the vitamin. Phylloquinone (K1) is found in leafy green plants and menaquinone (K2) is found in animal meat and fermented foods. Your body can also synthesize K2 in your gut.

Vitamin K2 can be divided into subtypes. The two we understand to be important today are MK-4 (short-chain) and MK-7 (long-chain bacterial derived).

Both vitamins K1 and K2 have important functions in your body. K1 is an integral factor in blood clotting and K2 activates proteins that regulate where calcium ends up in your body.3

The importance of vitamin K2 relates to the interaction it has with calcium. How and where calcium is deposited and used by your body has an impact on your dental health, bone health, cardiovascular system and renal (kidney) health. Each of these bodily systems depend upon the correct balance of calcium.4

Your body has limited storage capacity for vitamin K2, but can recycle the vitamin so it can be used multiple times.5 The functions of the vitamin are unique and necessary throughout all your life stages.

Many Drugs Reduce Vitamin K2 Absorption

The review paper associated medications used to treat cardiovascular disease (CVD) and type 2 diabetes with an inhibition of vitamin K2 processes. These negative effects may increase your risk for CVD, diabetes, chronic kidney disease, bone loss and even mental disorders, as a result of poor K2 absorption.6

The research found a shared mechanism between the blood thinner warfarin, statin medications and vegetable oils in the inhibition of vitamin K dependent processes.7The blood thinner warfarin works to reduce coagulation through an antagonistic effect on vitamin K.

This was the design of the drug. Even eating foods with vitamin K can reduce the effectiveness of warfarin. Research has also found that:

• Anti-tuberculosis medications or anticonvulsant medications, taken when you are pregnant, may place your newborn at increased risk of vitamin K deficiency8
• Use of broad-spectrum antibiotics may alter your gut microbiome and thus reduce the effectiveness of your gut to synthesize vitamin K2. Drug classes associated with this alteration include cephalosporins and salicylates9
• Statin medications, developed to reduce cholesterol levels, also have a negative impact on your vitamin K2 absorption and inhibit CoQ10,10 both necessary for a healthy cardiovascular system.

Dr. Hogne Vik, chief medical officer with NattoPharma, a leader in vitamin K2 research and development, says:11

"We are not only finally seeing recognition that vitamin K2 is woefully insufficient in the diet, but there is a growing body of evidence that pharmaceuticals further exacerbate the problem of our limited vitamin K2 status, delivering potentially dangerous consequences for human health."

Interaction Between K2 and Your Cardiovascular System

A significant risk factor in the development of CVD is calcium buildup in your arterial system.12,13 Plaque formation on the walls of your arteries may lead to small pieces breaking off, causing clot formation. This is one of the more common reasons for a heart attack or stroke.14

Calcification of these plaque formations occurs as atherosclerotic disease progresses, which may predict your risk for future cardiovascular events.

A meta-analysis of 30 studies, including over 218,000 participants, found calcification in the arteries was associated with a 300 to 400 percent increased risk of a cardiovascular event (such as a heart attack) or death.15

Vitamin K2 regulates arterial calcification through protein modulation. In one study, those who had the highest amount of vitamin K2 were 52 percent less likely to experience calcification in their arteries and 57 percent less likely to die from heart disease over a seven to 10 year period.16

Insufficient vitamin K2 in your diet may also lead to suboptimal carboxylation and biologically inactive matrix carboxylated glutamate protein (MGP), both leading to lower protection of your cardiovascular system from calcification of the arterial system.17

Vitamin D and Vitamin K2 Need Balance

Vitamin D influences or plays a significant role in dozens of conditions, including:

Eye health	Preventing macular degeneration	Preventing dry eye
Immune system health	Preventing bowel disease	Reducing effects of rheumatic diseases
Reducing effects of multiple sclerosis	Reducing effects of lupus	Fighting HIV/AIDS
Reducing depression	Reducing potential for childhood asthma	Reducing the risk of certain cancers
Reducing the signs of aging	Prevention of dementia	Prevention of heart disease

Deficiency in vitamin D may also contribute to a number of different health conditions, all of which increase your risk of heart disease. These conditions include high blood pressure, type 2 diabetes, atherosclerosis and increased inflammation in your body.18

However, like most other vitamins and nutrients, no one nutrient operates independently of others. For instance, most pasteurized milk is fortified with vitamin D. Manufacturers recognize they have effectively eradicated the natural vitamin D in the milk, necessary for absorption of calcium, and so they add it.

While vitamin D helps you absorb calcium, vitamin K2 directs your body to deposit the calcium in the appropriate places. In other words, it's the vitamin K2 that tells your body to deposit calcium in your bones and teeth, and not in your organs, arteries, muscles or soft tissue.

An effective analogy is that vitamin D is your gatekeeper, allowing the admission of calcium, and vitamin K2 is the traffic cop, telling the calcium where to go. With vitamin D and calcium you'll have the traffic, but without vitamin K2 you'll have a traffic jam and calcium being deposited exactly where you don't want it — in your arteries.

With the push for vitamin D and calcium to "grow strong bones," you may be at risk for CVD if your diet isn't rich in sources of vitamin K2. As an added risk, you may be taking medication or have an altered gut microbiome, reducing the absorption of vitamin K2.

Role of K2 in Osteoporosis

Osteoporosis causes more than 8.9 million fractures worldwide. This means a fracture due to osteoporosis happens every three seconds.19 Worldwide, 1 in 3 women and 1 in 5 men over the age of 50 will experience a fracture related to osteoporosis.

The strength of your bones is related to several factors. Both the density of the bone and formation of the bone are related to the strength of the bone. When you have density without proper formation, your risk of fracture may actually increase. Your body needs several nutrients to build strong bones.20

Vitamin K2, working together with vitamin D, magnesium, phosphorus and calcium, helps your body develop strong bones and may reduce your risk of osteoporosis. This is because nutrients in your body are interconnected in the way they function.

Vitamin K is essential to the proper development of several bone-related proteins, including osteocalcin, MGP and periostin. Vitamin K is also a cofactor in the production of gamma-glutamyl carboxylase (GGCX). Recent research links low levels of GGCX and/or vitamin K2 to bone mineralization defects.21

This means that without vitamin K2 your body produces bone with defects, reducing the strength of the bone and increasing your risk of bone mineralization fractures.22,23

Vitamin K2 Is Also Important for Your Teeth and Cancer Prevention

Vitamin K2 also plays a significant role in the health of your teeth and in preventing cancer. You teeth, like your bones, are storehouses of calcium, which supports the structure and hardness of the teeth.24 The way calcium is deposited in your teeth will either increase the hardness of your tooth or make it more brittle.

Vitamin K2 once again acts like the traffic cop, telling calcium where and how to be used in your teeth. Working together with vitamin D, it also promotes a reduction in tooth decay or cavities.25 The process of depositing calcium in areas of the body where it is not normally found may act like sand in the gears of a machine. In fact, inappropriate calcium distribution may contribute to the development of:

Gallstones	Colon cancer
Liver cancer	Ovarian cysts
Bone cancer	Breast cancer
Prostate cancer	Lung cancer
Dementia	Leukemia
Varicose veins	Macular degeneration

German doctors evaluating the effect of vitamins K1 and K2 on the development and treatment of prostate cancer found that those who consumed the greatest amount of K2 had a 63 percent reduced incidence of advanced prostate cancer.26,27

Vitamin K2 has demonstrated the ability to induce cell destruction in leukemia cells outside the body.28 The vitamin also demonstrated inhibitory effects on myeloma and lymphoma. Following treatment for liver cancer, those who took K2 supplements experienced a 13 percent relapse of the cancer while those who did not experienced a 55 percent relapse rate.29,30

Enjoy the Benefits of K2

How do you know if you're deficient in vitamin K2? According to Rhéaume-Bleue, there are several questions you can ask yourself, and depending upon the answers, you'll have a good idea if you are deficient. Estimates suggest up to 85 percent of Americans are vitamin K2 deficient.

•Do you suffer from health conditions associated with vitamin K2 deficiency? Some of these conditions are listed above.

•Do you eat meats, dairy or cheeses from grass-fed sources? Grass-fed beef and the dairy products from these animals are higher in vitamin K2 and healthier for you.

•Do you eat fermented foods? The bacteria in the fermentation process produce vitamin K2 in the food. Natto (fermented soybeans), is one of the best sources of vitamin K2. I ate it for a while, but the flavor is a bit of a challenge and probably isn't well accepted by the Western palate.

Other fermented foods like kimchi also contain vitamin K2. My favorite way of getting K2 is to ferment my own vegetables using a special starter culture designed with bacteria that produce K2.

•Do you eat Brie or Gouda cheeses or consistently eat liver pate? Fermentation in the cheese produces vitamin K2. Fermented dairy products will provide about one-third the amount per serving of natto. Ideally, I recommend fermented cheeses from raw milk. It is important to note that raw milk in and of itself does not contain K2. The vitamin is produced during the fermentation process.

If these foods aren't a regular part of your diet, then you are likely deficient in vitamin K2 and you may benefit from using a supplement. At this time, there are no reliable tests to determine your level of vitamin K2. However, while it is a fat-soluble vitamin, there is no known toxicity at any dose.

It is important to take your supplement with foods containing healthy fat to increase absorption. Of the two forms of vitamin K2, MK-4 and MK-7, the latter is the more effective supplement to use.

MK-4 is a synthetic product, having a very short biological half-life of about one hour, making it a poor candidate as a dietary supplement. After reaching your intestines, it remains mostly in your liver, where it is useful in synthesizing blood-clotting factors. MK-7 is a newer agent with more practical applications because it stays in your body longer. Its half-life is three days, meaning you have a better chance of building up a consistent blood level. MK-7 is extracted from the Japanese fermented soy product, natto.

http://articles.mercola.com/sites/articles/archive/2016/07/13/vitamin-k2-deficiency-cardiovascular-disease.aspx

Grapefruit not only food that can affect medication

Michelle Healy, USA TODAY4:26 p.m. EST January 22, 2013

Healthwise

From grapefruit to calcium to licorice, some foods and their nutrients can interfere with the way your medicines work.

(Photo: Scott Olson, Getty Images)

STORY HIGHLIGHTS

• Food and beverages can delay, decrease or enhance absorption of medication
• Dietary supplements, including vitamins and herbs, can also interact with medications
• Ask your physician and pharmacist what you should avoid when given a new prescription

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From milk and cookies to chocolate and peanut butter, some foods make a tasty combination. But attention to medical labels, and not your taste buds, is needed when combining certain foods with medications.

Milk and other calcium products, for example, can block the absorption of certain antibiotics. And eating large quantities of chocolate while taking some antidepressants can cause a sharp rise in blood pressure. Even some licorice can reduce the effects of certain blood pressure drugs and diuretics.

A recently published review in the Canadian Medical Association Journal that found an increasing number of prescription drugs could have potentially dangerous interactions with grapefruit and grapefruit juice highlights the importance of consumers being aware of possible food and drug interactions.

It's been known for some time that grapefruit juice can "both increase or decrease the absorption of a small number of drugs," says Hartmut Derendorf, chairman of pharmaceutics at the University of Florida College of Pharmacy. Derendorf was not involved in the Canadian review.

"If the drug is metabolized in the gut wall to a large extent and this metabolism is blocked, then the concentrations in the blood will go up. An example is the lipid-lowering drug simvastatin (Zocor)," says Derendorf. "For other drugs such as the antihistamine fexofenadine (Allegra), grapefruit juice blocks the uptake into the bloodstream and the concentrations in blood will go down."

In all such cases there are alternative medications available that will not interact with grapefruit and the other citrus fruits that contain furanocoumarins, the culprit behind the "grapefruit juice effect," Derendorf says. These include Seville oranges (often used in marmalade), limes and tangelos, a cross between tangerines and grapefruit. Sweet oranges, such as navel and Valencia, do not contain furanocoumarins.

There's more attention than ever before being paid to reducing interactions between food and drugs, Derendorf says, and researchers are focused on finding safe alternatives, removing the chemical compounds that cause interactions, and in some cases, changing the genetic makeup of foods so that they do not interfere with medications.

In December, a team at the University of Florida's Citrus Research and Education Center published a paper about ongoing efforts to create a grapefruit hybrid with significantly reduced interaction risk.

Concerns about the interactions between foods and drugs are not limited to prescription medications. Dietary supplements (which also include vitamins, minerals and herbs) can likewise interfere with how some medications work.

"Often, people think that herbal supplements are benign and don't have interactions, and that's absolutely false," says Christine Gerbstadt, a registered dietitian and spokesperson for the Academy of Nutrition and Dietetics. "Most supplements have the exact same chemicals and ingredients as pharmaceutical drugs but simply in a naturally occurring form or lower dose," she says.

Drugs, of course, can have negative interactions with other drugs, and the same can be true of supplements. Calcium supplements, for example, may decrease the absorption of dietary iron, which is why people at high risk for iron deficiency are encouraged to take calcium supplements at bedtime, instead of with meals.

When being prescribed any medication it's important to inform your physician of all medications you're currently taking — prescription, over-the-counter and dietary supplements — to read the patient information material that comes with the medication and to ask about potential interactions, Gerbstadt says.

"Your pharmacist and registered dietitian can also provide a wealth of information," she says. "No one person can know it all, but huge databases are available to help professionals get access to this information."

A sampling of the potential interactions between foods and medications, including some supplements, according to the Food and Drug Administration:

-- Grapefruit juice: Some statin drugs to lower cholesterol, such as simvastatin (Zocor), atorvastatin (Lipitor), and pravastatin (Pravachol); some blood pressure-lowering drugs, such as Nifediac and Afeditab ; some organ transplant rejection drugs, such as Sandimmune and Neoral (both cyclosporine); some anti-anxiety drugs, such as BuSpar (buspirone); some anti-arrhythmia drugs, such as Cordarone and Nexterone (both amiodarone); some antihistamines, such as Allegra (fexofenadine); the anti-malaria drugs Quinerva or Quinite (quinine); and Halcion (triazolam), a medication used to treat insomnia.

-- Licorice: The sweetening compound glycyrrhizin in black licorice may reduce the effects of some blood pressure drugs or urine-producing drugs including Hydrodiuril (hydrochlorothiazide) and Aldactone (spironolactone). It may increase the toxicity risks from Lanoxin (digoxin), used to treat congestive heart failure and abnormal heart rhythms.

-- Chocolate: Antidepressant Monoamine Oxidase (MAO) inhibitors (such as phenelzine (Nardil, Nardelzine) and tranylcypromine (Parnate) are just one category of drugs that shouldn't be consumed with excessive amounts of chocolate and other caffeinated foods. Caffeine can also interact with stimulant drugs such as Ritalin (methylphenidate), increasing their effect, or by decreasing the effect of sedative-hypnotics such as Ambien (zolpidem). Using bronchodilators with caffeinated foods and drinks can increase the chance of side effects, such as excitability, nervousness, and rapid heart beat.

-- Potassium-rich foods (such as bananas, oranges, and green leafy vegetables): Can add to high potassium levels in the body caused by ACE (Angiotensin Converting Enzyme) inhibitors including captopril (Capoten) and enalapril (Vasotec) prescribed to lower blood pressure or treat heart failure. Too much potassium can cause an irregular heartbeat and heart palpitations.

-- St. John's Wort (Hypericum perforatum): Can reduce concentrations of medications in the blood, including digoxin (Lanoxin), used to treat congestive heart failure and abnormal heart rhythms; the cholesterol-lowering drug lovastatin (Mevacor and Altocor), and the erectile dysfunction drug sildenafil (Viagra).

-- Vitamin E: Taken with a blood-thinning medication such as warfarin (Coumadin) can increase anti-clotting activity and may cause an increased risk of bleeding.

-- Ginseng: May increase the risk of bleeding when taken with anticoagulants (blood thinners such as warfarin and heparin). Can also increase the bleeding effects of aspirin and non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, and ketoprofen. Combined with MAO inhibitors such as Nardil or Parnate may cause headache, trouble sleeping, nervousness and hyperactivity.

-- Ginkgo biloba: High doses can decrease the effectiveness of anticonvulsant therapy in patients taking seizure-control medicines Tegretol, Equetro or Carbatrol (carbamazepine), and Depakote (valproic acid).

For more information:

-- Download Avoid Food-Drug Interactions, an online guide by the U.S. Food and Drug Administration and the National Consumers League

-- Download What You Should Know About Your Medications, an online guide by the University of Florida, Institute of Food and Agricultural Sciences

-- View the list of medications that might interact with grapefruit cited in the Canadian Medical Association Journal article

http://www.usatoday.com/story/news/nation/2013/01/20/food-drug-interactions/1827229/

Other articles of interest:

http://healthticket.blogspot.my/2012/10/grapefruit-interferes-with-medication.html

http://healthticket.blogspot.my/2012/11/grapefruit-with-some-prescription-drugs.html

http://healthticket.blogspot.my/2014/08/grapefruit-not-only-food-that-can.html