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ImageEpilepsy and Complementary and Alternative (natural) medicine. Feature article

Complementary and alternative medicine, known as CAM for short, is a term that refers to various healthcare approaches developed outside the Western or “conventional” medicine.  These treatments are known by other names as well, including holistic medicine, integrative medicine, naturopathic medicine, etc.  

How do you understand complementary and alternative medicine (CAM)? 

We have all heard these terms on the television or the internet, but it is difficult to accurately define them because they can mean different things to different people. According the National Institutes, Alternative medicine is used in place of Western medicine and complementary medicine is used in combination with conventional treatments.  A large percentage of the population uses health care approaches that are outside conventional, mainstream Western medicine for general health and for specific disease conditions.  In fact, it is estimated that some 4 out of 10 Americans use some kind of CAM and the use of CAMs has been on the rise.  Some examples of CAMs are natural remedies (herbs and supplements), and mind and body techniques such as deep breathing, massage therapy, yoga, meditation, acupuncture, and diets.  In this article we will be addressing natural remedies rather than the many mind-body techniques that exist.

What are the most common reasons for using CAMs in people with epilepsy? What are a few examples of CAM that are used in epilepsy?

A proportion of people with epilepsy do not find seizure control with conventional anti-epilepsy drug (AED) therapy. Hence, for epilepsy, <10% of people use CAMs for seizure control, a vast majority of people (>70%) use them for general health purposes, and around 20% of people use them to control other symptoms such as problems with memory and sleep or depression.  Natural and herbal remedies for epilepsy include herbs like St. John’s wort, melatonin, gingko biloba, garlic and black cohosh. 

What percentage of people with epilepsy use CAMs? How many of these people share this information with their doctors? 

Studies in the US and the UK have found that up to 1 in 3 persons with epilepsy use CAM; most of them do not discuss this with their doctors. 

Are CAMs regulated by some federal agency? What are the repercussions of a lack of regulation by a federal agency? 

In order to be prescribed in a clinical setting, conventional therapies have gone through double-blind studies (i.e. studies where neither the doctor nor the patient knows what medication is active and which on is inactive or a placebo). CAMs are rarely subject to such rigorous testing, hence it can be difficult to tell exactly how effective they are, or what is their side-effect profile. For herbal remedies, it is important to remember the following points - 

- They are not required to be produced under Good Manufacturing Process standards, like drugs. 

- No government agency (eg, FDA) independently verifies the quality/production. 

- They could be contaminated with microbes, pesticides, toxic metals, or adulterated (eg. herbs or drugs). 

- Potency and amount per pill/capsule may vary significantly within the same bottle or from batch to batch, or from one branded product to another. 

- They can interact with medications prescribed by the doctor.

However, DSHEA (Dietary Supplement and Health Education Act) has put forth the these regulations for herbal remedies - 

- Manufacturers are responsible for the truthfulness of labeling claims. 

- No government agency independently reviews and verifies the claims and supporting evidence, but 

- Only manufacturers control product quality and verify safety   

Why is it difficult to standardize herbal remedies?

The label of a conventional anti-epileptic drug may say ‘carbamazepine 200 mg’, and we know what the drug formulation contains. This is not so easy with herbal products because - 

- The active ingredient(s) is usually not known. 

- The amount of the assumed active ingredient may vary from pill to pill and product to product. 

- It is usually not possible to measure levels in the blood to guide dosage

A case in point is St. John's wort, which is standardized by its content of hypericin, but hypericin has never been confirmed as the active ingredient. 

Can you list examples where CAMs have been detrimental in epilepsy? 

Kava Kava and ginseng can both cause generalized tonic-clonic seizures, gamolenic acid and ginseng can lower seizure threshold, high doses of a drug called Skullcap can cause confusion and convulsions. St. John’s wort can lower carbamazepine levels, and formulation called Shankapulshpi can decrease the half-life of phenytoin, hence decreasing its efficacy. Hence, it is extremely important to share with your physician all substances you may be taking, so potential interactions like these can be stopped before they occur. 

Could you talk about ‘natural=safe’ theory that people have for CAMs? And why it may not be true or scientifically sound?

A common misconception that exists in society is that anything that is natural is safe, whereas anything that is synthetic is unsafe. This is not necessarily true, as poisonous mushrooms and hemlock are deadly plants! Hence, natural does not equal safe. This is especially important to remember in epilepsy, as herbs and herbal preparations may contain many other compounds in addition to the active ingredient. For example, Black cohosh can cause miscarriage via uterine stimulation, and lobelia can cause respiratory paralysis and death. 

What is the take-home message according to you regarding CAMs in epilepsy? 

I would emphasize that in any given person natural remedies may be helpful, but in many they may not. In a person with epilepsy, herbs may worsen seizures and can definitely affect levels of the anti-epileptic drugs (AEDs) in a detrimental way. Good, rigorous studies haven’t been performed to test the efficacy of CAMs in epilepsy, but if you are thinking about CAMs for your condition, have an open discussion with your doctor. 

 

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