Alternative Medicine: Putting It In Its Place

Non-traditional treatments are gaining traction with patients. Here’s what you can tell them.

BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR

Between “Dr. Google” and Dr. Oz, today’s patients are exposed to information about alternative medicine as never before. While much of the information is about improving overall health rather than strictly ocular-related health, it’s quite likely you have had the experience of patients coming into your office and asking about the latest non-traditional treatments and sometimes ancient therapies from Asia.

How should the busy doctor respond? Too dismissive and you risk alienating patients — and getting egg on your face if they try the therapy anyway and it turns out to work for them. Too “non-judgmental” and you risk abdicating your responsibility as their physician. This article looks at how to strike the delicate balance of tact, open-mindedness and hardheaded empiricism when confronting your patients’ proclivities for non-traditional medicine.

Mostly, It’s About Nutrition

The lion’s share of patient inquiries are about nutritional supplements, clinicians told Ophthalmology Management: vitamin C and other antioxidants, bilberry, omega 3 oils, goji berries and more. Not all questions pertain to if and how these can improve an ocular condition. “Patients are searching for a way to feel better,” says Helen K. Wu, MD, assistant professor at Tufts University and director of the Refractive Surgery Service, New England Eye Center, Boston. Many of the inquiries she hears are not specifically about the eye, but about how to improve general health.

That nutrition plays a significant role in ocular and overall health is increasingly accepted. But just how big a role does it play, and which nutrients matter? What are the optimal dosages? Because these questions remain largely unanswered, finding the right response can be tricky — especially given that nutrition doesn’t get a lot of attention when doctors are learning medicine.

“I think doctors learned about two nanoseconds worth of nutrition in med school; now they learn maybe three nanoseconds of nutrition,” says Karl Stonecipher, MD, director of Southeastern Eye Laser and Refractive Center in Greensboro, N.C. Because ophthalmologists spend most of their time treating eyes rather than getting up to speed on nutritional news, it’s possible your patients are more aware of the latest headline-making study than you are.

Supplements and Your Oath

Physicians are famously admonished to do no harm, and as John R. Samples, MD, former professor of ophthalmology at Oregon Health and Sciences University and presently at Rocky Vista University points out, most nutritional therapies do no harm. That said, though, he maintains the physician must make clear when the data for a given nutrient is on the weak side. The goal of these therapies in glaucoma, he notes, is largely to benefit the optic nerve with the presumption that antioxidants are helpful (not all antioxidants are, he cautions). “Make clear the nutrients have varying amounts of evidence, but the evidence is not strong enough to rise to a high level of clinical significance,” Dr. Samples says. “No one is ever going to pay any money to study these things because it costs too much to do it.”

If you are putting a patient on a systemic medication, however, you need to go a step further, Dr. Wu says. Be proactive in asking the patient what vitamins or supplements she or he is taking. In her practice in Boston’s Chinatown, nearly everyone goes to an herbalist. “Patients won’t tell you unless you ask them, because they don’t even consider these preparations medicine,” she says.

Not knowing what patients are taking could be a problem, points out Uday Devgan, MD, a private practitioner in Los Angeles and chief of ophthalmology at Olive View UCLA Medical Center. Some supplements may have an unintended ocular side effect. Some patients, for example, take saw palmetto for their prostate. “It acts kind of the same way that Flomax (tamsulosin) does, just not as strongly,” he explains. However, “that can affect their iris tone and cause floppy iris syndrome in cataract surgery.” He urges patients to consult with their internists about the supplements they are taking as well.

“If I don’t see a negative, it doesn’t interfere with any of their other medicines and it doesn’t worsen the disease process, I am totally neutral about it,” Dr. Stonecipher says. “Because if the patient believes in it, nine times out of 10 it is going to help them, whether it’s mentally or physically.”

Not Outside Your Job

Discussing patients’ diets is something that, until recently, few ophthalmologists would have considered their responsibility. Recent findings of diet’s role in ocular health, though, have caused some to change their minds. Dr. Stonecipher likes to cite to patients the book The China Study, by T. Colin Campbell, PhD. The book presents what many regard is a formidable array of evidence demonstrating that a diet based predominantly on plant protein is more beneficial than one based on animal protein.

Dr. Stonecipher also recommends patients get their nutrients from food — an important reminder given society’s incessant quest for a quick fix in the form of a pill. “I tell patients it’s much better to have a glass of red wine and get your resveratrol that way than go buy the pills,” he says. “But a pill form is better than nothing.”

Dr. Wu makes a point of discussing diet with patients if they or a family member has macular degeneration or some form of inflammatory disease. In those cases, she recommends an anti-inflammatory diet, such as the one feature in the popular book The Perricone Prescription, by dermatologist Nicholas Perricone. “It’s about eating foods high in omega-3s, and how not all fruits and vegetables are the same, that some are more inflammatory or have higher levels of antioxidants,” she explains.

Dr. Wu does not regard such discussions of nutrition as outside the mainstream, however. “I don’t even view that as alternative medicine, I view that as common sense supported by research.”

The Medical Marijuana Issue

As many ophthalmologists are learning, medical marijuana for glaucoma therapy is popular with patients. “Patients take endless delight in asking about marijuana now that it’s legal for non-medical use in both Colorado and Washington,” where he practices, says Dr. Samples. In California, where medical marijuana is legalized, Dr. Devgan also frequently fields patient inquiries.

What’s worrisome, both physician say, is that glaucoma patients often want to smoke marijuana instead of taking IOP-lowering drops. What these patients do not realize, Dr. Devgan says, is the large amount of marijuana that would be required to achieve a significant IOP reduction. “You have to explain to patients, ‘Well, you’re going to smoke this marijuana, what percentage of it is going to get from your lungs to your blood, what percentage is going to get from your blood to the eye, and what percentage of that is going to finally have this effect that we want in your eye? Wouldn’t it be easier to just put a drop in your eye and have this direct effect,’” he asks.

Because delaying aggressive, reliable treatment can result in permanent vision loss, he feels this is one alternative therapy where doctors need to be vocal in their opposition.

Dr. Samples educates patients about another of marijuana’s shortcomings as a glaucoma treatment. In modern glaucoma thinking, he notes, it is either the greatest pressure or large amounts of fluctuation in IOP that cause optic nerve damage.

“If you do lower your pressure with marijuana, unless you are stoned all the time, you sort of subject the optic nerve to this fluctuation, which is probably bad for the glaucomatous optic neuropathy,” he explains to patients.

Questions About Herbal Remedies

Dr. Wu’s patients’ enthusiasm for herbalists also presents some potential problems. While traditional Chinese medicine has been around for thousands of years, Dr. Wu cautions about the possible downsides. As with nutritional supplements, herbal blends are not regulated by the FDA or any other agency. Her patients who travel to and from China often have eye drops meant to slow the progression of cataract. “I don’t know what’s in them,” Dr. Wu says.

Further, Chinese herbal medicines can be “cut” with other things, such as aspirin or acetaminophen. “You think it’s the herbs that are making you feel better, but it’s actually the acetaminophen,” she says. Sterility is another concern. Blends are mixed in herbalists shops, Dr. Wu says, so sterility is questionable. She keeps that in mind if patients come to her with an ocular problem.

Not that Dr. Wu is automatically critical of herbal blends or other staples of traditional Chinese medicine. “I’ve had a lot of herbal medicine in my life and it does help with symptoms,” she says. “Frankly, I think in Western medicine, there are huge gaps in knowledge in what we can treat and what we know.”

Acupuncture and Yoga

Dr. Wu also sees patients who are curious about acupuncture or have already tried it. When a colleague told her that acupuncture was one of only two options that provided him relief from his terminal illness, she began recommending the alternative medicine center where he’d received treatment to interested patients. She has seen people undergo acupuncture for various reasons, including chronic pain, low energy, headaches and infertility. “I recommend it when their Western-style courses of treatment aren’t doing the trick for them,” Dr. Wu says.

Yoga is the subject of many discussions as well. Can it cure, or even reduce the severity of any maladies, much less those of an ocular variety? Again, conclusive evidence is lacking, but Dr. Stonecipher tends to believe the discipline is beneficial overall. It reduces stress, he notes. He cites a patient who had significant arthritis and dry eye. “She had trouble even moving, but one day she decided to try something different and went to a hot yoga class. She did what she could, which wasn’t a lot,” he says “She came in recently more spry than I’ve ever seen her before. Two thousand years of yoga or acupuncture, they have to have some value,” he says.

Caveat Emptor

While acknowledging the possible efficacy of alternative therapies, you must still be on the lookout for patients’ misconceptions. Among them:

■ Patients often believe the alternative treatment can do more than it really can. For instance, Dr. Devgan says some of his patients, having read that vitamins such as C and E are antioxidants that catch free radicals, which in turn cause oxidation of the lens, want to take very high doses of vitamin C to avoid cataract surgery. “I explain to them that the cataract they’ve developed didn’t occur because of the sun exposure they got at age 66; it’s because of the sun exposure they’ve been receiving since age 16. Massive amounts of antioxidants won’t reverse damage that’s been building over a lifetime.”

Dr. Stonecipher reports similar experiences, but he has found a way to put a positive spin on it. When the later-stage AMD patient comes in and says, “Doc, I’m going blind. What can I do?” He tells the patient the truth: The vitamin supplement will not reverse the disease process. The patient’s family, however, may still be helped. Children will have probably inherited the gene for AMD; getting started on an AREDS-based supplement now, in addition to common-sense precautions such as avoiding sun exposure and starting an exercise program, could help them avoid AMD later. “That puts them on a positive spin, rather than in a negative tail spin,” Dr. Stonecipher explains.

■ Impress upon patients the strength of the data behind proposed alternative therapy. These clinicians typically let patients go ahead with their alternative therapy if they see no harm in it, but they do so with a disclaimer. “It’s always important to tell patients that the evidence is largely animal-based,” says Dr. Samples. Though he likes the antioxidant CoQ10 for his glaucoma patients, he is sure to inform patients that the scientific posters he reviewed for it, while suggestive, were inadequately powered. Similarly, when he recommends goji berries, telling patients that one well-executed study suggested they protect the optic nerve, he also states that more studies are needed to prove their value.

■ Buyer beware. This is how Dr. Stonecipher tells patients to beware of claims that sound too good to be true, of companies that “cut” their product with non-therapeutic, or even harmful, ingredients, and of expensive fad products. Keep in mind also that the quality of products will vary. Dr. Stonecipher, who recommends omega 3 oils to his patients, has a list of products he has researched for quality and purity.

■ Alternative treatments are a supplement, not a substitute. The most dangerous misconception to nip in the bud is that patients often believe it’s a matter of choice between a course of conventional medicine and alternative treatments. “That really needs to be hammered home really hard,” Dr. Samples says. “Whether it’s medicine, laser or surgery, none of these alternative therapies takes the place of those.”

Postponing established medical treatment to go the nutritional route, for instance, could result in irreversible damage, Dr. Devgan points out. “With cataracts, does it really make a difference if they wait six months or a year before they go ahead with the cataract surgery?” he asks. “Well, 99% of the time, it doesn’t. All you’ve lost is that much time of good vision. You can still get back the normal vision once you do the cataract surgery.” However, with many other ocular conditions, such as glaucoma or retinal disease, that isn’t the case — a fact enthusiastic patients tend to overlook.

Dr. Stonecipher emphasizes to patients that while he sees value in nutritional supplementation and holistic medicines, he believes they work best in conjunction with conventional medicine.

Making Your Case to Patients

Combining respect for the unknown — or at least, the not-yet-proven — with clear-eyed knowledge wins the day with most, patients, Dr. Devgan says. But be sure your bedside manner is working with these things. It’s important to listen to your patients when they come in asking about these therapies. “I won’t interrupt them,” Dr. Devgan explains. “They may come across something that is really cool that I’ve never thought of before. So I give them the benefit of the doubt. I’ll respond, ‘That’s interesting. There may be some validity to that.’ Then I say, ‘But here’s one of the issues: What about this?’ If they are making a serious mistake with their choices, I want to educate them and I give them any easy out.”

After all, ancient lore may turn out, one day, to be backed up with cold hard facts. “There are tons of things in the Amazon jungle that still haven’t been discovered and are going to cure something, I’m sure,” Dr. Stonecipher says. Until then, proceed cautiously when talking with patients about alternative medicine and non-traditional cures. OM

Reference

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