Herbal Therapy in Epilepsy

Joan A. Conry, MD and Phillip L. Pearl, MD

The use of complementary and alternative medications (CAM) in the United States has skyrocketed in the past decade. A 1998 study in the Journal of the American Medical Association estimated that the use of herbal medications increased from 2.5% to 12.1% in the adult population between 1990 and 1997, and that 18% of all prescription drug users were also taking herbal remedies or high-dose vitamins (1). The clinical benefit of CAM is largely unproven, because of a paucity of rigorous clinical trials evaluating safety and efficacy. Patients tend to underreport their use of alternative medicines to physicians, and physicians may discount their significance even when their use is presented. Substantial risks, however, are associated with the use of these interventions. These risks involve the direct toxicities of the alternative preparations as related to their intended ingredients, possible adulteration by other compounds, and interactions that we call "herb-drug interactions." Herb-drug interactions are related to the effects on the metabolism of standard antiepileptic drugs (AEDs) as well as factors related to AED absorption from the gastrointestinal tract and transport into the brain. This chapter presents an overview of the general principles for using alternative medicines in epilepsy and specific information on their potential effects and interactions in epilepsy patients. Data for the efficacy of these agents for use in epilepsy are also presented.

Alternative therapy may be defined in various ways. The Epilepsy Foundation (EF) recognizes different categories of alternative therapy for epilepsy:

• Excellent efficacy and excellent tolerability—example: pyridoxine (vitamin B6) in the rare neonatal syndrome of pyridoxine dependent epilepsy

• Excellent efficacy but poor tolerability—example: ACTH in West syndrome (infantile spasms)

• Promising but not proven efficacy—example: IVIG in Landau-Kleffner syndrome (acquired epileptic aphasia)

• Unproven efficacy but little evidence of side effects—examples: herbal remedies, vitamin supplements, and acupuncture

The position of the EF is that alternative therapies are acceptable as long as the patient also continues with traditional therapies, and the alternative and traditional therapies do not conflict. Although this position appears reasonable, its premise depends on evidence for efficacy of alternative therapies in the treatment of seizures and their acceptable safety without excessive toxicity. This standard applies to all therapies in medicine and should not be abrogated on behalf of alternative medicines.

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