As the saying goes, ‘You’ve got to know when to hold ’em, and know when to fold ’em.’
Complementary medicines may also be called ‘traditional’ or ‘alternative’ medicines and include items such as vitamins, minerals, herbal products, aromatherapy and homoeopathic products. Many of the products available in pharmacies, supermarkets or health food outlets have limited evidence of efficacy. There is some evidence of efficacy for some complementary medicines, however this may be formulation and dose dependent, and health practitioners are encouraged to seek this information before recommending such products.
For these reasons, the PSA provided advice to pharmacists about complementary medicines in its Choosing Wisely recommendations that were released last year.1 The recommendation made was:
‘Do not recommend complementary medicines or therapies unless there is credible evidence of efficacy and the benefit of use outweighs the risk.’
Just because something is natural doesn’t mean it’s safe, and just because something has been used for centuries doesn’t mean it works. These are just two ideas that consumers often hold dear to their hearts which can cause dilemmas for pharmacists. Unfortunately, it is not always clearcut. Whilst one branch of these medicines, homeopathy, has been discredited as ‘sham’ medicines by several bodies including Australia’s National Health and Medical Research Council,2 other complementary medicines do have therapeutic uses, and proven clinical benefits. These discrepancies can make this area hard for pharmacists to know what works, what might work, and what doesn’t work at all.
The pharmacy board states: When complementary and alternative medicine is provided at a pharmacy, pharmacists should provide products of proven safety and quality. Relevant accompanying advice should be offered to assist patients in making a well-informed choice regarding treatment with a complementary or alternative medicine, which should include available information on the potential benefits and harms, and whether there is sufficient evidence to support its proposed use. Where appropriate, pharmacists should incorporate details of the supply of complementary and alternative medicines in the dispensing record and, where possible, in the patient’s health record.3
A recent systematic review pertaining to the role of the pharmacist outlined the following seven major roles of pharmacists: 1) to acknowledge the use; 2) to be knowledgeable about the products; 3) to ensure safe use of complementary products; 4) to document the use of these products; 5) to report adverse reactions to products; 6) to educate others about complementary products and; 7) to collaborate with other healthcare professionals.4
How can pharmacists find out what does work and what doesn’t?
NPS MedicineWise has a set of listed websites that may be useful for consumers and health professionals to use to search for more information about complementary medicines.5 These include:
- MedlinePlus – www.medlineplus.gov/
- myDr – www.mydr.com.au/
- National Centre for Complementary and Integrative Health (US) – www.nccih.nih.gov/
- Healthdirect – www.healthdirect.gov.au/complementary-therapies
In addition to web searches, most pharmacists will head to the monographs contained in the Australian Pharmaceutical Formulary and Handbook (APF).6 These provide a handy summary of commonly used herbs, as well as listing any evidence surrounding the products as well as listing side effects and specific precautions.
With respect to vitamins and minerals, again, there is conflicting evidence surrounding their regular use, with experts stating that if one has a balanced diet, then they should not require supplementation with these vitamins and minerals.7 With vitamins that are fat soluble (A,E,D and K), people need to be careful with respect to dose, as these are more likely to accumulate and be harder to excrete. Water-soluble vitamins on the other hand are generally excreted through the kidneys and are less likely to cause issues.
There are however some groups of people that are lacking in specific vitamins and minerals that may need supplementation, and at certain times of one’s life, supplementation may also be necessary – during pregnancy, for example. In fact, all women thinking of having a baby should have folic acid supplements and continue these at least up to week 12 of pregnancy. Folic acid has been proven to prevent neural tube defects such as spina bifida.8
Another example of a supplement that may be recommended is vitamin D. This vitamin is mainly acquired from the sun, but for those who are frail and housebound, or cover most of their skin due to religious reasons, may need to supplement.9
There are numerous examples of when it is okay to take a complementary medicine, as well as many instances where they will be contraindicated, e.g. echinacea in asthma, or St John’s wort with other antidepressant medicines. On top of this, there are some parts of the plants that contain more active constituents than others (such as the root versus the leaves), providing further complexity to the formulations available.
For these reasons, the lists of what to use and what not to use are vast and constantly changing as new available evidence comes to hand. Therefore, it is outside the scope of this article to list all of the complementary therapies, and their pros and cons.
Instead, the take home message is to be aware of the risks and benefits of the product, and to provide products when you can be assured that you are practising within the ethical framework and that we follow Care principle 1: A pharmacist makes the health and wellbeing of the patient their first priority. And Integrity principle 1: A pharmacist acts with honesty and integrity to maintain public trust and confidence in the profession.10
See PSA’s six recommendations to the Choosing Wisely initiative at:
- Pharmaceutical Society of Australia. 5 Things Clinicians and Consumers should Question 2018 At: psa.org.au/wp-content/uploads/2018/12/PSA Recommendations-v4-jg-121218-ACC.pdf.
- National Health and Medical Research Council. NHMRC Statement: Statement on Homeopathy 2015. At: file:///C:/Users/rebekahm/Downloads/nhmrcstatement-on-homeopathy.pdf.
- Pharmacy Board of Australia. Pharmacy Board Guidelines on Practice Specific Issues: 5. Complementary and alternative medicines. 2015. At: https://www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2F17693&dbid=AP&chksum=wRUYxmjLkeSpBGRiCUgJlQ%3D%3D
- Ung COL, Harnett J, Hu H. Community pharmacists responsibilities with regards to traditional medicine/ complementary medicine products: A systematic literature review. Research in Social and Administrative Pharmacy. 2017;13(4):686–716. At: https://www.ncbi.nlm.nih.gov/pubmed/27671273
- NPS Medicinewise. Complementary medicines-explained 2016 At: nps.org.au/consumers/complementary-medicines-explained
- Sansom LN. Australian pharmaceutical formulary and handbook. 24th ed. Canberra: Pharmaceutical Society of Australia; 2018. At: https://www.psa.org.au/media-publications/australian-pharmaceutical-formulary/
- Harvard Health Publishing. Do you need a daily supplement? 2018 At: health.harvard.edu/staying-healthy/do-you-need-a-daily-supplement
- Laurence KM, James N, Miller MH, Tennant GB, Campbell H. Double-blind randomised controlled trial of folate treatment before conception to prevent recurrence of neural-tube defects. Br Med J (Clin Res Ed). 1981;282(6275):1509-11. At: At: https://www.ncbi.nlm.nih.gov/pubmed/6786536
- Do I need vitamin suplements? At: www.nhs.uk/common-health-questions/food-and-diet/do-i-need-vitamin-supplements/
- Pharmaceutical Society of Australia. Code of ethics for Pharmacists 2017 [28.03.2019]. At: psa.org.au/wp-content/uploads/2018/07/PSA-Code-of-Ethics-2017.pdf
BY PSA CHOOSING WISELY WORKING PARTY: CHRIS CAMPBELL, AMY PAGE, SUE EDWARDS, REBEKAH MOLES, KENNETH LEE, ALYSSA PISANO, SHANE JACKSON & CHRIS FREEMAN