Wisdom Wednesday: Rates of Two Nerve Conditions on the Rise

Two particular types of neuropathy have been increasing as more and more people develop diabetes in the United States. An expert says.

Autonomic and small fiber neuropathy were once rare conditions. Both occur when small blood vessels supplying the nerves are damaged by diabetes because they don’t get enough oxygen and nutrients, said Dr. Divpreet Kaur, a neurologist at Penn State Health Milton S. Hershey Medical Center.

Diabetes is one of the main causes of neuropathy, and about 30 million Americans currently have diabetes, Kaur said. More commonly, people with diabetes have nerve damage that causes numbness in the feet and toes. This is called peripheral neuropathy, according the American Diabetes Association.

Autonomic neuropathy affects involuntary bodily functions such as blood pressure, digestion, sexual function, urination, temperature control and sweat regulation.

“The most common symptom is light-headedness, especially when standing up. The blood pressure drops so much when they stand up that they feel like they are going to pass out,” Kaur said in a Penn State news release.

People with small fiber neuropathy often have burning pain in their feet that eventually progresses up their legs. Their hands can also be affected. “People don’t know about it or recognize the symptoms, and they keep going to different physicians without receiving a diagnosis,” Kaur said.

“It isn’t that every patient who has these symptoms will definitely have such a neuropathy. Once common things have been ruled out by their primary care physician, they can be referred to the neuromuscular clinic for consultation or the autonomic laboratory for further testing,” she said.

Wisdom Wednesday: Neuropathy

Neuropathy or nerve pathology is a term used to describe damage to a nerve as opposed to pain and inflammation. The signs of neuropathy are numbness, tingling and/or loss of strength but often these symptoms are overshadowed by pain.

Think of neuropathy as a loss of nerve function. If the damage is to the afferent nerve (signals going to the brain) supply, then the loss is sensory. If the efferent nerves (signals coming from the brain) are damaged, then a loss of motor control ensues.

Let’s look at sciatica, where the pain runs from the spine down the back of the leg. True sciatica effects approximately 5% of the population but many physicians continue to call all leg pain “sciatica”. When the nerve is just inflamed, treatment is fairly straight forward – correction of all injury reflexes, reduction of inflammation with supplementation and spinal/pelvic manipulation will resolve most cases is a couple of weeks.

However, if the sciatic neuralgia (nerve pain) is complicated by neuropathy, the prognosis is less favorable. In addition to the treatment described above, the nerve must also heal. Unfortunately, peripheral nerves are the slowest healing tissue in the human body.

The most common cause of neuropathy is diabetes. Over 50% of all Americans are either diabetic or pre-diabetic. About half of that number are developing neuropathy but currently are asymptomatic. The other half are well aware of their neuropathy symptoms.

It is said that all diabetics develop sciatica and are never cured. While that statement is certainly not true there is some truth in that statement.

I rely on two herbs and a former B vitamin to support healing from neuropathy. If a sciatic patient has no objective findings of neuropathy, I prefer to concentrate on reducing inflammation. However, once the inflammation is under control, if the patient is not responding well, it’s time to consider treating for neuropathy even if all the findings are symptomatic.

Wisdom Wednesday: Treatment Before the Diagnosis?

This is an abbreviated case history to illustrate some of the unique features of the QA (Quintessential Applications) protocol.

A 34 four-year-old female came to my office with a chief complaint of severe pain under her left jaw. She had been to her primary care physician who thought it was a salivary gland but found no evidence of infection.

On palpation I could elicit pain but not from the salivary gland but actually from a small area just adjacent to a salivary gland. The area did not feel inflamed or abnormal in any sense, except she reacted to the pain.

Chiropractors are very good at palpation. It’s skill that is honed in school by palpating a hair through pages of Gray’s Anatomy. With practice, you can feel the distortion through about 80 pages of text. Now add 38 years of practice, palpating spines all day long.

So I was just as confused as her PCP. I could not identify the tissue from palpation.

Using the QA protocol, I looked for an injury reflex. However, Autogenic Facilitation was intact (any weak muscle strengthened when the nerve supply to that muscle was stimulated) eliminating an injury.

TL (therapy localization) to the jaw was active – if she placed her hand on the location of pain, any weak muscle became strong. Now I had a tool to evaluate her symptoms.

Next I checked to see what inflammatory pathway might be active. She was negative for prostaglandins but positive for both leukotrienes and cytokines. These pathways stimulate the immune system and when both are active can be autoimmune in nature. Typically, such cases will not respond favorably to ginger or boswellia, requiring a supplement that modulates the immune system.

St. John’s Wort vs Prozac

Researchers at Adelaide University compared the reported adverse drug reactions to St. John’s wort, an herbal treatment for depression, with fluoxetine, a prescription antidepressant which includes Prozac.

It found both can cause serious side effects such as dangerous increases in body temperature and blood pressure. Both treatments also caused side effects such as anxiety, panic attacks, dizziness, vomiting, amnesia and aggression.

“There is a common belief that because something is natural and can be purchased from a health food shop without a prescription, it’s safe,” says researcher Claire Hoban.

“People need to start thinking of St. John’s wort, and other herbal medicines, as a drug and seek advice from a qualified healthcare practitioner to be sure they use it safely,” she says.

Between 2000 and 2013, there were 84 reports of adverse reactions to St. John’s wort and 447 to fluoxetine, [notes] the study published in Clinical and Experimental Pharmacology and Physiology.

Fewer people use St. John’s wort and adverse reactions for herbal medicines largely go unreported because they are not considered drugs, say Hoban.

There were more severe reactions to St. John’s wort, 11.9% of reports compared to 6.7% for Prozac.
The big concern is using St. John’s wort and prescription antidepressants together because this can lead to serotonin syndrome inducing gastrointestinal upsets, hemorrhage, confusion, inattention and even death, she said.

Evidence Based Herbal Therapy

When consulting with a traditional physician about a common patient, the most common question is “What are your credentials?” I explain that I am board certified in nutrition and that my studies were at the University of Miami, Miller School of Medicine.

I think my answer surprises most physicians and they can’t use my lack of education to dismiss my nutritional therapies. A resistant doctor will then ask for the evidence based research to support my treatment. Even when I provide the research studies, a few physicians refuse to accept nutritional therapy as valid and strongly object to their patient taking any OTC supplements.

The most amusing aspect of this stance is that the chemistry of most prescription drugs is poorly understood and the mode of action is often just a theory.

Recently I spent some time on PubMed. PubMed is online resource for published medical research. It is sponsored by the National Institutes of Health (NIH), the source for a vast majority of my blogs. NIH sends me a daily E-mail that summarizes recent research. Of late, I have found the topics lacked interest or were repetitive. So I decided to visit the source – PubMed.

The problem with PubMed is the sheer volume of information. There are hundreds or even thousands of research articles published daily. I limited my search to complimentary medicine and then plugged in some of my favorite herbs. What follows is a very short list showing the herb, the number of peer review published papers and one study title for your review:

• Gymnema – 143 papers “Anti-Obesity Effect of Gymnema sylvestre Extract on High Fat Diet-Induced Obesity in Wistor Rats”
• Echinacea – 1016 papers “Echinacea Reduces the Risk of Recurrent Respiratory Tract Infections and Complications: A Met-Analysis of Randomized Controlled Trials”
• Boswellia – 268 papers “A Randomized, Double Blind, Placebo Controlled, Crossover Study to Evaluate the Analgesic Activity of Boswellia serrata in Healthy Volunteers Using the Mechanical Pain Model” (This type of study is the “gold standard” in research demonstrating the efficacy of Boswellia by any standards)
• Ginger – 1925 papers “A Novel Component from Citrus, Ginger and Mushrooom Family Exhibits Antitumor Activity on Human Meningioma Cells through Suppressing the Wat/Beta-catemin Signaling Pathway” (Virtually every herb I reviewed had favorable studies on cancer treatment)
• Ashwaganda - 641 papers “Effects of Withania somnifera (Ashwaganda) Root Extract on Amelioration of Oxidative Stress and Autoantibodies Production in Collagen-induced Arthritic Rats”
• Tribulus - 211 papers “Tribulus terrestis for Treatment of Sexual Dysfunction in Women: Randomized Double-Blind Placebo-Controlled Study”
• Turmeric – 3179 papers “Curcumin Inhibits Apoptosis and Brain Edema Induced by Hypoxia-Hypercapnia Brain Damage in Rat Models”
• St. John’s Wort -2343 papers “Hypericum performatum Reduces Paracetamol-Induced Hepatotoxicity and Lethality in Mice by Modulating Inflammation and Oxidative Stress”

The Bottom Line:
The next time someone tells you that herbal therapy is unscientific folklore, just refer them to this blog or PubMed. Of note is that a vast majority of these studies were conducted outside the U.S. as the rest of the world is advancing herbal therapy rather than scoffing at it.

Dangerous Dietary Supplements Return to Store Shelves

The FDA frequently recalls dietary supplements that are found to contain banned substances. But a new study suggests that many of these products return to store shelves months later with the same dangerous ingredients.

The study, published in JAMA, the Journal of the American Medical Association, found that out of more than two dozen supplements that were pulled from shelves after that were found to contain anabolic steroids or powerful prescription drugs, roughly two-thirds were back on the market a year later with the same illicit ingredients.
Most of the supplements were marketed for weight loss, exercise and sexual enhancement, and they were sold across the country at convenience stores, in health food shops and over the Internet. They were found to contain steroids and prescription drugs like Viagra and Prozac, an antidepressant.

The study also found that several of the weight-loss products contained Sibutramine, an amphetamine-like drug that was removed from the market in the US, Asia and Europe after a clinical trial showed it increased the risk of heart attacks and strokes.

In recent years, research has shown that herbal supplements such as echinacea, Ginkgo biloba and St. John’s wort are frequently mislabeled or diluted with cheap fillers like powdered rice.

Jennifer Dorren, a spokeswoman for the FDA, said that supplement companies “are legally responsible for marketing a safe product that is not adulterated.” But because companies do not need approval to sell their products, she said, the agency cannot identify tainted supplements before they reach consumers.

Mixing Supplements with Medications

One in three adults in the US are taking both prescription medications and dietary supplements, creating a risk for dangerous interactions, according to a new study.
April 30, 2014 (Reuters)

Multivitamins with added ingredients like herbs and fish oil were the most common form of supplement mixed with medications, researchers found. “Multivitamins are commonly assumed to be safe, but our analysis suggests multivitamins, which may include multivitamin ‘plus’ combination products, can also contain botanical and herbal ingredients that have the potential to interact with prescription medications.” Harris Lieberman told Reuters Health. Lieberman, the study’s senior author, a researcher with the Military Nutrition Division of the US Army Research Institute of Environmental Medicine (USARIEM) in Natick, Massachusetts.

For their study, Lieberman and his colleagues, used information taken from the 2005-2008 National Health and Nutrition Examination Survey (NHANES), which represents the entire national population. The researchers focused on 10,480 adults (4,934 women who were not pregnant and 5,016 men) who answered survey questions about their dietary supplement and prescription medication use, as well as whether they had any of the following conditions: asthma, arthritis, congestive heart failure, coronary heart disease, angina, heart attack, stoke, high blood pressure, high cholesterol, emphysema, chronic bronchitis, cancer, weak bones or problems with the liver, thyroid or kidneys.

The researchers found that 47% of participants diagnosed with any of those medical conditions used both supplements and prescription medications. That compared to about 17% of adults who didn’t have those conditions, but were taking prescription medications for other reason, such as birth control pills or antidepressants. Overall, 34% of the participants – representing some 72 million people in the US – were taking some kind of dietary supplement along with a prescription medication. Cardiovascular medications were most likely to be used along with dietary supplements, followed by central nervous system agents, hormones, metabolism-related drugs, psychotherapeutic agents and antibiotics or antivirals.

Multivitamins containing other ingredients were more common that standard multivitamins. The ingredients most often added to the enhanced multivitamins included fish oil, botanicals, herbs, probiotics, fiber, enzymes, antacids and glucosamine and chondrotin.

Supplement use was most common among people with diagnosed osteoporosis, followed by those with thyroid, cancer, arthritis, cardiovascular, kidney, diabetes, respiratory and liver conditions.

The authors call the finding “concerning” because some herbal supplements are known to alter the way the liver metabolizes drugs, and can increase or weaken the potency of a medication. “Patients, especially those taking medications or given new prescriptions, should always inform their doctors about what dietary supplements they are taking, and doctors can help patients by asking about their supplements,” Lieberman said.

MY TAKE:
Drug – herb interactions are common, so common that I have a 700 page textbook on herbal safety. I am constantly looking for potential interactions in my patient population. The herbs are really quite safe, when taken properly; it’s the way in which they react to many drugs that is at issue.

Honestly, drug – drug interaction is a much bigger issue. For example, lovastatin, commonly prescribed to lower cholesterol (currently taken by 49% of the population over the age of 60) has 214 known drug interactions, representing 632 band and generic drugs on the market.

The average American takes four prescription medications with little or no knowledge about how these drugs interact. It is estimated that a third of all cases of senile dementia in our country are from overprescribed medications.

The multivitamin is not really an issue. Recent studies have found they have little if any value in human health. The “plus” combinations in many multiple supplements contain so little content that they are neither helpful nor harmful. As noted in an earlier blog, herbal quality in the US in non-existent. Contamination is a bigger issue in the “proprietary blend” of herbs noted on the label.

Silymarin (milk thistle), St. John’s Wort and Black Cohosh will either increase or decrease drug clearing time through the cytochrome P450 liver pathway. This is a common metabolic pathway for many prescription drugs. However there are alternatives when medications prevent safe use of these herbs.

Ginkgo is a potent blood thinner and should not be used with other blood thinners, like Coumadin. The blood thinning effects of fish oil are generally overstated.

THE BOTTOM LINE:
You should review all the "drug to drug" and "drug to herb" interactions of any prescription medications you take. Throw that multiple vitamin away, it’s worthless anyway. Please do not take herbs without consulting a qualified nutritionist. They are potent and can be harmful it not taken properly.

I believe people who take supplements with medications are just looking for help. The drugs don’t restore their quality of life and they just hope that supplements will be of some benefit.

Can Coffee Treat Liver Disease?

Findings show there may be benefits to drinking coffee.
April 14, 2014 (Medscape)

More that 2.25 billion cups of coffee are consumed each day throughout the world. Although coffee consumption varies from country to country, most Americans drink coffee daily. Despite early concerns about the damaging effects of coffee on health, contemporary studies suggest that coffee is beneficial for many medical disorders, including Parkinson disease, diabetes, symptomatic gallbladder disease, stroke, and chronic liver disease.

Coffee contains caffeine that is also found in tea and other plants. The quantity of caffeine present in each cup varies, but in general, approximately 85mg of caffeine is absorbed in the stomach and small bowel. It is metabolized through the liver by cytochrome P450. The half-life of caffeine is 4-6 hours.

Current studies suggest that caffeine binds to adenosine receptors and reduces the development of hepatic fibrosis from liver injury by limiting stellate cell activation and the secretion of connective-tissue growth factors and collagen.

Coffee appears to have a significant effect on all-cause mortality. The National Institutes of Health- American Association of Retired Persons Diet and Health Study involving 229, 119 men and 173,141 women demonstrated an inverse relationship between coffee consumption and mortality. In other words, coffee drinkers had a reduction in mortality compared with non-coffee drinkers.

Alcohol consumption and cigarette smoking can increase gamma-glutamyl transferase (GGT) levels. Coffee appears to reduce circulating levels of GGT. Green tea had no effect of GGT levels.

Alcoholic liver disease develops with excessive alcohol intake; women are at greater risk for alcoholic hepatitis at lesser quantities of alcohol-containing beverages than are men. Fatty liver is common in patients with excessive alcohol intake and cirrhosis develops in 10%-20% of those with chronic alcoholism.

Alcoholics who also drank coffee had a significant reduction in the risk for alcoholic cirrhosis. For alcoholics who also had hepatitis B or hepatitis C, the risk of developing advanced liver disease was also reduced if they also consumed coffee on a daily basis.

For patients with chronic HCV (viral hepatitis), coffee drinkers and those consuming caffeine-containing beverages are more likely to maintain normal aminotransferase (SGPT) levels or to reduce SGPT levels than are those with lower caffeine intake. No chronic HCV-infected patient drinking decaffeinated coffee had improvement of SGPT levels.

Primary liver cancer is the third leading cause of death in the world; more than 600,000 new cases develop annually, with a survival rate of 3%-5%. Hepatocellular carcinoma (HCC) risk factors include cirrhosis, HBV and HCV, alcohol, and cigarette smoking. Coffee consumption appears to reduce the risk for HCC in those at elevated risk.

Daily consumption of coffee appears to have a preventative effect on developing fibrosis in some liver diseases, especially alcoholic liver disease and NASH (non-alcoholic sterato-hepatitis). However, coffee consumption had no apparent effect of the development of NASH. In addition, some reduction in fibrosis was noted in all liver disease with daily consumption of coffee.

Although many treatments are available for chronic liver disease, alcoholics and patients with NASH who are unable to control their associated causal factors might benefit from drinking 2 or more cups or regular coffee daily.

MY TAKE:
This article contained a lot of research data that I eliminated. There were also forty references for sited material. If you would like to read the full article, please visit Medscape.com.

Regardless of its potential health benefits or issues, coffee is here to stay. As a coffee drinker, it is nice to find support for one of “my vices”. I have long advocated the use of organic coffee rather than decaf. I limit myself to one cup in the morning. To be honest, I don’t feel any “lift” from drinking it or any fatigue if I skip it. I do really enjoy the ritual of brewing a cup for my wife and myself, then sipping it as we share a couple of minutes each morning before going off to work.

The nerve synapes in your brain produce norepinepherine, a neurotransmitter, which normally stimulates other nerves and then is chemically dismantled. This whole chemical process takes place repeatedly in less than a second. Caffeine actually prevents the norepinepherine from being dismantled so the neurotransmitter continues to stimulate. I tell my patients that caffeine is not like pressing the gas pedal on a car, it more like not letting you use the brakes.

Much like other herbs (yes, I consider coffee an herb) the best use is based on scientific research. When there is little research (approximately 80 of the 1500 herbs used medicinally have had significant research), I depend on traditional use. If something has been used for thousands of years, it probably has merit. Coffee certainly fits in this category.

Liver dysfunction is almost universal in my practice. If I have a patient complete a symptom survey, liver shows up as the most common cause of symptoms virtually 100% of the time. I believe it is the hundreds of thousands of man-made chemicals in our environment that damages our livers.

The SGPT and GGT are enzymes that elevate in the blood stream when the liver is inflamed and liver cell death escalates. These enzymes are measured on the complete metabolic profile (CMP) that I routinely run in the office. Frequently these enzymes are elevated. NASH, hepatitis C, alcohol and drug abuse are common issues.

Often prescription drugs are the culprit. Statin drugs commonly elevate liver enzymes so these blood tests are run every six weeks on patients taking statins to reduce cholesterol. For patients who can not or will not discontinue these medications, coffee may reverse some of the negative effects of medication.

I believe the influence of caffeine on the cytochrome P450 pathway in phase 1 liver detoxification is responsible for much of the benefit associated with drinking coffee. Many drugs are processed through this important pathway. Coffee, like silymarin (milk thistle) and St. John’s Wort, support this pathway and have hepatorestorative (liver healing) effects.

THE BOTTOM LINE:
If you are a coffee drinker, then rejoice, the benefits seem to outweigh any negative issues. I highly recommend you drink organic coffee to avoid all those chemical additives. The additives in decaffeinated coffee are even worse, so just avoid it. If you have a liver issue, talk to your physician about drinking coffee. It may be of significant benefit for you. If you take any prescription medications, please review any possible conflict between coffee and the metabolism of your meds. You can visit www.drugs.com and review your medications. Check to see if the drug is metabolized through the cytochrome P450 pathway. If so, you might have an issue.