HERB MEDICATION

OF
HYPERTENSION








Cikra Ikhda Nur H. S., S. Farm., M. Sc., Apt.

HERB MEDICATION
OF
HYPERTENSION
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2
Definitions
As per JNC VII and ISH (WHO) 2004
1. What is normal B.P ?
2. What is pre hypertension ?
As per JNC VII and ISH (WHO) 2004
Normal SBP < 120 and DBP < 80
Pre HT SBP 120 to 139 mm Hg
DBP 80 to 99 mm
Hg
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3
Definitions
1. What is stage 1 HT ?
2. What is stage 2 HT ?
Stage 1 SBP 140 to 159
DBP 90 to 99
Stage 2 SBP 160 and more
DBP 100 and more
4
JNC VII Classification
Category SBP (mm Hg) DBP (mm Hg)
Normal < 120 < 80
Pre hypertension 120-139 80-90
Hypertension
Stage 1 140 159 90 99
Stage 2 160 and above 100 and above
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5
Definitions
Are the values same for Diabetics , CKD?
No, for DM, IHD and CKD the
criteria
are more stringent
The cut off values are 10 mm
lower
Stage 1 SBP 130 to 149
DBP 80 to 89
Stage 2 SBP 150 and more
DBP 90 and more
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6
Global Risk Profile and HT
25)
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7
HT combined with other CHD RF
Framingham offspring study, subjects aged 17 84
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Diseases Attributable to Hypertension
Hypertension
Heart failure
Stroke
Coronary heart disease
Myocardial infarction
Left ventricular
hypertrophy
Aortic aneurysm
Retinopathy
Peripheral vascular disease
Hypertensive
encephalopathy
Chronic kidney failure

Cerebral hemorrhage

Adapted from: Arch Intern Med 1996; 156:1926-1935.
All
Vascular
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9
Atherosclerosis Time line
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10
Endothelial NO Balance
NO
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11
Target Organ Damage - Assessment
Routine Tests
Electrocardiogram, Echocardiography
(desirable)
Urinalysis for proteinuria, Microalbuminuria
Blood glucose (F and PP), and Hematocrit
Serum Na and K, Creatinine or GFR,
Calcium
Lipid Profile complete, Eye examination,
ABI
Optional tests
X-Ray Chest PA
24 hr. urine albumin excretion or ACR
More extensive testing is not generally
indicated
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Normal weight 350 to 450 g
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13
Progression of HT to LVH to HF
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TODAYS PARADIGM
Herb medication
Nature product
Back to nature
Why is it so?
14
Herb
medication
Complementer
Theraphy
(CAM)
HEALTH
SYSTEM

AKSELERASI UPAYA INTEGRASI PELAYANAN
KESEHATAN TRADISIONAL KEDALAM
PELAYANAN KESEHATAN NASIONAL
16
Dr.Abidinsyah Siregar,DHSM,Mkes
(Direktur Bina Yankes Tradkom)

PARADIGMA BARU PELAYANAN
KESEHATAN DI INDONESIA

PELAYANAN KESEHATAN
KOMPLEMENTER DAN ALTERNATIF
Pada saat ini kedalam
pelayanan kesehatan
komplementer dan
alternatif termasuk pula
pelayanan kesehatan
tradisional
Pelayanan kesehatan
komplementer adalah
pelayanan kesehatan yang
melengkapi pelayanan
kesehatan konvensional
Pelayanan kesehatan alternatif
adalah pelayanan kesehatan
yang mengganti pelayanan
kesehatan konvensional
Contoh pelayanan
kesehatan komplementer
dan alternatif yang telah
masuk pelayanan kesehatan
tradisional
Chiropractic
Osteopathy
Homeopathy
Naturopathic
Acupuncture
Herbal
Massage
Manipulation
Breathing exercise
Yoga
TCM



JEJARING ORGANISASI TRADKOM
DINKES PROV
BKTM/LKTM
18
18
SP3T
Koordinator Bin-was
Yankestrad di wil Provinsi
TUGAS
Pemantauan & evaluasi
yankestrad

FUNGSI
a. Menyusun renc dan eval
b. Pemantauan & evaluasi
c. Melaksanakan kemitraan
d. Melaksanakan diklat,
e. Melaksanakan urusan
ketata usahaan

1. Melakukan Penapisan
yankestrad (alat/teknologi
/metode, pengobat, obat)
2. Melakukan diklat
3. Memberikan pelayanan
Kestrad sbg model
4. Koordinator JID
DINKES KAB/KOTA
1. Memberikan STPT/SIPT
2. Koordinator bin-was
a. Membina battra :
sarasehan, KIE, Pelatihan
b. Memantau pekerjaan
battra/kunj. langsung
3. Membina , mengemb. TOGA
& selfcare secara Trad
4. Pencatatan, pengumpulan
data & pelaporan
KEMKES
REGULATOR/
POLICY MAKER
RUMAH SAKIT

PUSKESMAS


BATTRA SWASTA
DAN
BATTRA ASING


UKMB
DAN
MASYARAKAT


TRADITIONAL INDONESIAN HERBAL
MEDICINE (TIHM)

IS
A SECRET WEAPON !!!

(China is an excelent example)
INTERNATIONAL PATIENT TRADING
Types of Herbal and Alternative
Medicines
Crude dried herbs *
European Phytopharmaceuticals
extracts
standardized extracts *
Traditional Chinese Medicines*
Ayurvedic Medicines
Homeopathic Medicines*
Functional Foods/Nutraceuticals *
Probiotics **
other dietary supplements (e.g. melatonin)
Top 20 Selling Herbals for 2007- Mass Market
HerbalGram 2008;78:61-62
Product M $ % change rank in 2006
1. soy 25 -17 1
2. cranberry 24 +24 3
3. garlic 20 -13 2
4. ginkgo 18 +12 5
5. saw palmetto 17 - 6 4
6. echinacea 16 - 9 6
7. black cohosh 09 -0.5 8
8. milk thistle 09 -0.4 7
9. ginseng 08 + 3 10
10. St. Johns wort 08 - 6 9
11. Green tea 05 - 7 11
12. Evening primrose oil 04 - 9 12
13. valerian 03 - 9 13
14. Horny goat weed 02 - 2 14
Red indicates risk for drug interactions
Top 20 Selling Herbals for 2007- Mass Market
HerbalGram 2008;78:61-62
Product M $ % change rank in 2004
15. bilberry 02 - 9 15
16. grape seed 02 - 9 16
17. Yohimbe 01 -15 17
18. red clover 01 -13 18
19. Horse chestnut seed 01 -21 19
20. ginger 0.7 -20 20

Total (all herbs) 268 +7.6
Red indicates potential risk for drug interactions
Note: total herbal sales are estimated at $4.7 billion
The above figures include only sales from food stores, drug stores, and
mass market retailers but with Wal-Mart figures not included. It does
not include warehouse buying clubs (Costco), convenience stores,
natural foods stores, multilevel marketers, health professional sales,
mail order or internet sales.


Kaufman et al. JAMA 2002;287:337-344
Useful Herbal Products
(some evidence in support of uses)
Echinacea immune stimulant
Saw Palmetto BPH
Ginkgo circulation
Milk Thistle liver
Ginger nausea
Chamomile indigestion
Fever Few migraine
St. Johns Wort mild/mod depression
Hawthorn heart/circulation
Soy menopause symptoms
Kava anxiolytic
Black cohosh menopause symptoms
Green tea stimulant (antioxidant)
Cranberry UTI prevention
Possibly Useful Herbal Products
(less evidence or conflicting evidence)
pycnogenol vision, antioxidant
uses
ginseng adaptogen, tonic
grape seed vision, antioxidant
uses
Evening primrose dysmenorrhea, other
Bilberry vision, antioxidant
uses
Garlic hyperlipidemias,
hypertension, heart
yohimbe erectile dysfunction
Valerian sleep

Popular Herbs
The Herbs

Garlic (Allium sativum)
Uses
Lower cholesterol
anti-thrombotic
lower blood pressure
anti-microbial agent
Strengthen heart muscle
Reduce platelet clumping
and clotting
Stabilize blood sugar levels
Garlic
Some concern about use if bleeding is of
concern
Odor
Large amounts can great gas
Potential decreased platelet aggregation

Garlic
Contains alliin in intact garlic bulb
Alliin allicin (crushed)
600 900 mg of dried powder (1.3% allicin)

Garlic - Evidence
German Commission E
elevated blood lipids
prevention of age-related vascular changes
25 studies between 1979-1998 with 2,920
people
Mixed results highly dependent on type of
garlic preparation
Garlic - Evidence
2 Meta-analyses
garlic lowered total cholesterol between 9-12%
Meta-analysis
Anti-hypertensive - 10% reduction
Double blind RCT - 152 subjects for 4 years
garlic reduced development of atherosclerosis
GATU KOLA
(Centella asiatica)

Triterpenoid, saponin, asiaticoside,
centelloside, madecassoside. And asiatic acid
Ginkgo biloba
Most ancient tree known
Uses: cerebral insufficiency, Alzheimers Ds,
intermittent claudication, tinnitis
Powdered
leaves
Tincture or
infusion


Ginkgo
Increases vascular flow
diabetic peripheral vascular disease
Raynauds syndrome
Other circulatory benefits fro varicose veins,
hemorrhoids, eye disorders
Affinity for cerebral circulation
Inhibits platelet activity factor



Ginkgo
Used to relieve tension, anxiety, elevate mood
Contains flavanoids, terpene lactones,
ginkgolides A, B, and C, bilobalide, quercetin,
and kaempferol.
ginkgolides control allergic inflammation,
anaphylactic shock and asthma
antioxidant
What to watch for
Can increase blood flow
Discontinue before surgery
Do not use with menstrual flooding
Do not use with other bleeding problems
(ulcer, bruising, etc.)
Not suggested with blood thinners, aspirin, etc.


Gingko biloba & Dementia
52 week RCT, double
blind, multi-center
Outcomes in 309 pts
(ITT):
Pt cognition: tx no
change, placebo worse
(p=0.04)
Caregiver assess: tx
slight improve, placebo
worse (p=.004)

Dose: 120 mg/d of EGb
761
Safety: side effects
equal
Problems: high dropout
rate (50% tx, 62%
placebo)
Ginkgo & Claudication
Meta-analysis of Egb 761
5 placebo controlled trials
Moderate to large effect (0.75 Cohens d) on
pain-free treadmill walking distance
Schneider B. Arzneimforsch 1992;42(4):428-436
Ginkgo - Toxicology
Adverse events
GI complaints
bruising & spontaneous bleeding
Avoid if taking warfarin, heparin, or NSAIDs
Can increase insulin levels
May increase sedation with trazodone
St. Johns Wort
Hypericum Perforatum
Used as tincture, extract in pill form,
topically as oil or salve

Popular as anti-depressant.
Also used for muscle aches, nerve pain,
nerve regeneration, for herpes
outbreaks, bruising


St. Johns Wort
P450 Cytochrome system
Can interfere with effectiveness of other
medications
Possible rash from exposure to sun (sheep and
cows)
Use with other mood altering drugs of concern
Use by people with manic depressive and other
psychological conditions of concern
St. Johns Wort & Depression
Meta-analysis: 23 studies, 1757 pts
Mild-mod depression
Superior to placebo, rrr =2.67 (1.78-4.01)
As effective as TCAs , rrr=1.10 (0.93-1.31)
Fewer side effects than TCAs
Dose: 0.4-2.7 mg Hypericin (standardized extract)
Multi-center trial vs. SSRIs at Duke
Linde K, et al. BMJ 1996;313:253-8
St. Johns Wort and Zoloft
Randomized controlled trial
St. Johns wort vs. Zoloft vs. placebo
effects
Side effects
Placebo < SJW < Zoloft (p= 0.000
St. Johns Wort - Toxicology
Side effects
Theoretical risk - sunburn
Herb-drug interactions
Studies - digoxin, protease inhibitors, TCAs
Case reports - cyclosporine, warfarin, oral
contraceptives, theophylline, SSRIs
Theoretical - iron
Facts & Comparisons Review of Natural Products, Dec 2000.
Rauwolfia Serpentina
(pule pandak)
Ginger Zingiber officinale
Used for nausea
Helpful for colds and
flu
Warming herb
Many other folkloric
uses

Ginger for Nausea &
Vomiting of Pregnancy
2 trials show efficacy compared to placebo
excess Yang (excess Qi)
N not in AM, N worse p eating, N improves p
vomiting
ginger is too hot, use peppermint
excess Yin (deficient Qi)
N in AM, N better p eating, N worse p
vomiting
ginger will be helpful
Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196
How to take ginger
Dose 3-9 grams fresh (or dried) peeled ginger
root
Tea made from grated fresh root
Commercially available capsules
NOT ginger biscuits or ginger beer
Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196
Ginger Root Safety?
6-gingerol is mutagenic in
vitro at high doses
Other compounds in ginger
are anti-mutagenic
Widely used in Traditional
Chinese Medicine
No contraindication in
Pharmacopoeia of the
Peoples Republic of China
(1995)
May increase miscarriage Contraindicated in
German Commission E
Echinacea spp.
E. pallida purpurea angustifolia
Use: prevention and treatment of
colds, flu
One of most popular herbs in US
German Commission E
supportive for colds, chronic
URI, UTI
UK - GSL
Echinacea
Stimulating dose not advised with autoimmune
and some systemic diseases
Can interfere with immune suppression during
chemotherapy treatment
Stimulating dose should be short term (3-4
days) only
No known side effects
Concern with steroid treatment - depends on
use
Echinacea - Human Evidence
26 controlled trials (many open label)
3 blinded RCTs on URI
1 showed dose dependent decrease in symptoms
and duration of flu
2 showed 13-20% relative risk reduction of
acquiring URI
Dose: 30-60 gtts 1:5 (g/ml) tincture TID
Echinacea Systematic Review
16 randomized or quasi randomized trials
Echinacea preparation vs. no treatment or
placebo
8 trials on prevention, 8 trials on treatment
3396 patients involved
Majority with positive results
Cannot say which preparation is best
Melchart, D. et al. Cochrane Database Syst Rev 2000;2.
Black Cohosh (Cimicifuga
racemosa)
Fresh root tincture or dried
root infusion
Remifemin, used in
Germany since 1950s
Used for hot flashes and
night sweats
German Commission E:
Premenstrual discomfort
Dysmenorrhea
Menopausal
neurovegetative symptoms
Black Cohosh - Mode of action
Steroidal terpenes? isoflavones? others?
Methanol extracts bind estrogen receptors
Inhibits estrogen dependent breast tumor cell lines

Lowers LH in rats and women, no effect on FSH
a

Stimulatory effect on endometrium
b,c


Actein may be beneficial in hypercholesterolemia and
peripheral arterial disease
a. Duker 1991; b. Stoll 1987; c. Warnecke 1985
Black Cohosh - Clinical Trials
5 RCTs in literature
Randomized, head to head trial
60 pts, < 40 yr. old with hysterectomies
Estriol vs. conjugated estrogens vs.
estrogen-gestegen sequential vs. black
cohosh extract
Outcome: Kuppermans Menopausal Index
Black cohosh equal to other treatments
Lehmann-Willenbrock, et al. Zentralblatt fur Gynakologie 1998;110:611-8
similar findings: Warnecke, 1985
Black Cohosh Update
Recent RCT
85 breast cancer survivors
59 were on tamoxifen
40 mg/d Remifemin vs. placebo x 2 months
No benefit for hot flashes

On-going trial at Columbia Univ
RCT, 1 year duration
hot flashes, endometrial thickness, bone metab,
cognitive effects
Jacobson JS, et al. J. Clin. Oncol 2001;19:2739-45.
Black Cohosh - Toxicology
Overdose: nausea,
dizziness, nervous system
disturbance
Mice - spread of breast
CA
Large doses may cause
miscarriage.
Contraindicated in
pregnancy
Long term safety
unknown
INDONESIAN HERB
HYPERTENSION EFFECT
Mentimun
Seledri
Kumis kucing
Mengkudu
Bawang putih
Bawang merah
Alpokat
Sambiloto

Belimbing wuluh
Pegagan
Curcuma
Ginseng
Daun wungu
Bunga Rosela
Pule pandak
Daun salam

Why ??
The answer is..
1. Phytochemical
a) Alkaloid
b) Flavonoid
c) Fenolik
d) Terpenoid
e) Glikosida
f) Saponin
g) Atsiri
2. Pharmacologycal effect
Mechanism of act

Antioxidant effect,
So,

CHEMICAL
MEDICATION

HERB
MEDICATION
SIDE EFFECT, BENEFITS, COST AND
QUALITY OF LIFE
L/O/G/O