Peri-operative anticoagulation

Peri-operative anticoagulation

Complementary therapies Matthew A Bartlett, M.B., B.Ch., BAO Assistant Professor of Medicine General Internal Medicine Department of Internal Medicine 2014 MFMER | slide-# Disclosures Relevant financial relationships: None Off label usage: Everything

I am not a liver or PSC specialist 2014 MFMER | slide-# Objectives Discuss CAM/Integrative Medicine use in U.S. Very brief overview of common CAM therapies Develop practical approach to assessing risks/benefits of CAM (and other!) therapies Discuss how CAM can be incorporated in patients with PCS

2014 MFMER | slide-# Why am I here? Complementary therapies are common 1 in 3 adults use some form of alternative medicine 20-60% of patients with IBD $28.3 billion spent in the US in 2012 One of the fastest growing fields in healthcare Clinical practice is moving much faster than research NCHS, National Health Interview Survey, 2012

2014 MFMER | slide-# Complementary and alternative medicine therapies 2014 MFMER | slide-# Types of complementary therapies Mind-body therapies Herbs and dietary supplements

Manipulation and touch Energy therapies Alternative medical systems Martial arts 2014 MFMER | slide-# Mind-body approaches Expressive therapy Pet therapy

Art therapy Meditation/Relaxation Journaling Meditation Paced breathing Hypnosis

Sensory therapy Spirituality Aromatherapy Other Guided imagery Biofeedback

Music therapy Yoga 2014 MFMER | slide-# Herbs and dietary supplements Typically products that you take by mouth Often micronutrients aimed towards Correcting a deficiency

Increase body function (e.g. immune booster) 2014 MFMER | slide-# Manipulation and touch Chiropractic Osteopathy Massage

Rolfing Acupressure Acupuncture Healing touch Reiki 2014 MFMER | slide-# Alternative medical systems Complete systems of theory and practice make up alternative

medical systems Ayurveda Traditional Chinese medicine Naturopathy Homeopathy 2014 MFMER | slide-# Practical approach to CAM therapies 2014 MFMER | slide-#

Practical approach to CAM therapies Our approach to any CAM intervention (or any therapy!) A. Safety first B. Suggestion of Benefit C. Worth Trying D. Determination of Benefit E. Continuation F. Healthy lifestyle as the ultimate therapy 2014 MFMER | slide-#

Practical approach to CAM therapies A. Safety first. Are there concerns overall or specific to the condition treated? Is the product considered high-quality & free of contaminants? https://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/ https://well.blogs.nytimes.com/2015/02/12/107141/ 2014 MFMER | slide-#

Our Therapeutic approach B. Suggestion of Benefit. Is it scientifically plausible that intervention will have a benefit? (reliable sources) Are there formal studies for the conditions and symptoms the patient is facing? 2014 MFMER | slide-# Our Therapeutic approach C. Worth Trying

The patient and provider weigh Risks Benefits Costs Inconvenience Opportunity costs (trying one thing versus another) 2014 MFMER | slide-# Our Therapeutic approach D. Determination of Benefit

Set SMART goals to determine if therapy is "working Specific Measurable Attainable Relevant Timely Example Lower Alkaline phosphatase by 30% by 3 months Improve sleep by 15% (ie. sleep one hour longer) by 3 mo 2014 MFMER | slide-#

Our Therapeutic approach E. Continuation? Once product is tried Did we achieve goals? Any safety concerns? It is worth it? 2014 MFMER | slide-# Our Therapeutic approach

F. Lifestyle as the therapy Supplements are truly only supplements Cannot replace a healthy lifestyle 2014 MFMER | slide-# CAM and PSC 2014 MFMER | slide-# No alternative medicine treatments have been

found to treat primary sclerosing cholangitis. But some complementary and alternative therapies may help you cope with the signs and symptoms of the disease. 2014 MFMER | slide-# A. Safety first Supplements account for 20% reported hepatotoxicity Tripled in the last decade

Products most commonly associated with liver damage: Herbal products (16%): Green tea extract, kratom, black cohosh, Garcinia Botanic mixtures (8%): Ayurvedic medcations Vitamins and minerals (8%): Niacin, multivitamins Others (68%): Glucosamine chondroitin sulfate? Navarro V, Khan I, Bjrnsson E, et al. Liver Injury from Herbal and Dietary Supplements. Hepatology. 2016. doi: 10.1002/hep.28813. 2014 MFMER | slide-#

B. Suggesting of benefit? Clear role for dietary supplementation in the context of malabsorption or bone loss Follow the advice of your liver specialist Commonly used supplements in PSC/Liver disease Curcumin / Turmeric Milk thistle Antioxidants 2014 MFMER | slide-#

Curcumin Yellow-colored molecule derived from the turmeric plant Used in traditional Asian medicine to treat upset stomach, arthritic pain, & "low energy." Promising results in other liver diseases such as nonalcoholic fally liver disease (NAFLD) 2014 MFMER | slide-# Conclusion: While curcumin was well tolerated, it was not associated with significant improvements

in cholestasis or symptoms. Moreover, this study also illustrates that a low SAP is common among those with PSC. Scandinavian Journal of Gastroenterology: https://doi.org/10.1080/00365521.2019.1611917 2014 MFMER | slide-# Milk thistle Plant native to Europe, brought to the US by colonists Used for over 2 millennia, liver/gallbladder disorders

Safe Safely used in studies lasting 3 months 4 years Watch for medication interactions Benefits: Studies inconclusive spanning several liver diseases 2014 MFMER | slide-# Antioxidants Free radicals - byproduct of natural cell function Found in environment: sunlight, pollution, tobacco

Trigger cell and tissue damage through oxidation Antioxidants believed to minimize effects of free radicals Unknowns Test tube benefit = Human benefit? Antioxidant supplements = Antioxidant foods? Unclear what role antioxidants play in PSC Safety Vitamin E? 2014 MFMER | slide-# Supplements Take home points

Very little research on supplements in PSC Legitimate concern about risks All supplements need careful scrutiny If a supplement is considered Discuss with your primary care clinician or liver specialist and consider the ABCDE approach Ensure that the supplement has had some outside quality assurance 2014 MFMER | slide-#

So what can I do? Integrative medicine therapies can be helpful for common issues seen with chronic medial illness Stress Insomnia Pain 2014 MFMER | slide-# CAM therapy for stress, insomnia and pain + efficacy/ low risk

+/- efficacy/ low risk

Acupuncture Massage Biofeedback Hypnosis Meditation Guided imagery Qi gong

Tai chi Yoga 2014 MFMER | slide-# Back to the basics A healthy lifestyle is always going be beneficial Balanced, whole-food, plant-based diet Physical activity Regular mindfulness practice Social support

2014 MFMER | slide-# 2014 MFMER | slide-# 2014 MFMER | slide-# 2014 MFMER | slide-# Back to the basics A healthy lifestyle is always going be beneficial

Balanced, whole-food, plant-based diet Physical activity Regular mindfulness practice Social support 2014 MFMER | slide-# Conclusion

No complementary therapy found to treat PSC As part of integrative management program, may: Reduce stress Reduce insomnia Reduce muscle tension and pain 2014 MFMER | slide-# Thank you! 2014 MFMER | slide-#

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