MHRA has updated Traditional Herbal Registration (THR) provisions following the Windsor Framework. New UK-wide licensing arrangements for medicines came into effect January 2025. Always check current BNF interactions for St John's wort and report adverse reactions via Yellow Card scheme.
Alternative Medicine for GPs: Your Survival Guide
Navigating the herbal highway without getting lost in the weeds
Date Updated: December 12, 2024
Executive Summary: CAM in Primary Care
Focus: Common CAM approaches and products that UK GPs are likely to encounter in routine primary care, with emphasis on evidence and safety. This curriculum is selective, not exhaustive. It focuses on complementary and alternative medicine (CAM) that GPs in the UK are likely to see in everyday practice.
What This Page Covers:
- • Scope & rationale for CAM in general practice
- • Learning outcomes for GP trainees
- • Suggested teaching structure (5 modules)
- • High-yield modalities with evidence summaries
- • Comprehensive herb-drug interaction table
- • Key resources for ongoing learning
Quick Facts at a Glance:
Key Resources for Trainees
Essential Web Resources
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NHS – Herbal Medicines
Overview of herbal medicines, cautions, and how to report side effects via the Yellow Card scheme.
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National Center for Complementary and Integrative Health (NCCIH)
Evidence-based fact sheets on individual herbs and therapies, including safety and interaction information.
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UK Specialist Pharmacy Service (SPS)
Professional guidance on complementary products and herb–drug interactions for pharmacists and prescribers.
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Cochrane/NIHR Evidence
High-quality reviews on acupuncture and other CAM therapies, particularly in chronic pain.
Quick Reference Tools
Downloads
path: COMPLEMENTARY MEDICINE
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.listing
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acupuncture.ppt
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alternative medicine.pdf
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complementary and alternative medicine - an overview.ppt
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complementary medicine - information for primary care groups.pdf
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complementary medicine - why bother.ppt
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complementary medicine and the evidence.pdf
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complementary therapies in cancer care.pdf
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herbal medicine.ppt
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herbs and spices in alternative medicine.doc
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homeopathy - a comprehensive guide for gps.pdf
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homoeopathy - the evidence for.pdf
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homoeopathy.ppt
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osteopathy - introduction.pdf
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osteopathy vs chiropractic.doc
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Brainy Bites: Golden Rules & Red Flags
Key Questions for CAM History
Red Flags - What Not to Miss!
1. Learning Outcomes
- • Understand the scope and prevalence of CAM use in the UK
- • Recognize high-yield CAM modalities encountered in primary care
- • Identify evidence levels for common CAM therapies
- • Know major herb-drug interactions and contraindications
- • Understand regulatory frameworks (MHRA, THR)
- • Assess safety profiles of common CAM products
- • Recognize high-risk combinations and contraindications
- • Know when to advise stopping CAM before surgery
- • Understand reporting mechanisms for adverse events
- • Identify vulnerable patient groups requiring extra caution
- • Take comprehensive CAM histories without judgment
- • Communicate evidence-based advice respectfully
- • Navigate patient autonomy vs. safety concerns
- • Access reliable CAM information sources
- • Collaborate with CAM practitioners when appropriate
2. Suggested Teaching Structure
- • CAM prevalence and patient demographics
- • Regulatory landscape: MHRA, THR, licensing
- • Evidence hierarchy and quality assessment
- • Communication strategies and shared decision-making
- • St John's wort: efficacy and major interactions
- • Echinacea, ginkgo, garlic: evidence and safety
- • Turmeric, valerian, chamomile: clinical considerations
- • Ayurvedic medicines: contamination risks
- • Acupuncture: evidence base and NHS availability
- • Homeopathy: evidence assessment and patient communication
- • Traditional Chinese Medicine: safety considerations
- • Ayurveda: heavy metal risks and regulation
- • Aromatherapy and essential oils: safety profiles
- • Reiki and energy healing: evidence and patient expectations
- • Tea tree oil: topical applications and toxicity
- • Massage and manipulation: contraindications
- • Case studies: complex interaction scenarios
- • Ethical dilemmas: patient autonomy vs. safety
- • Breaking bad news about ineffective treatments
- • Collaborative care with CAM practitioners
Complete CAM Modality Reference
Detailed summaries of 15 key CAM approaches with evidence ratings and safety information
4.1 St John's Wort (Hypericum perforatum)
What it is:
Herbal antidepressant used mainly for mild–moderate depression and sometimes for menopausal symptoms.
Evidence:
Multiple RCTs suggest it is more effective than placebo and broadly similar to standard antidepressants for short-term treatment of mild–moderate depression. Evidence is inadequate or negative for severe depression and long-term outcomes.
Moderate evidence for mild–moderate depressionKey safety points:
Strong inducer of CYP3A4 and P-gp. Can reduce efficacy of many drugs (including hormonal contraception, warfarin, DOACs, antiepileptics, ciclosporin, some statins and antiretrovirals). Combining with SSRIs/SNRIs/MAOIs or triptans increases risk of serotonin syndrome. Can cause photosensitivity and insomnia.
St John's wort reduces SSRI, oral contraceptive, DOAC, warfarin, ciclosporin and antiretroviral levels by up to 30–50% This is due to CYP450 induction, comparable in scale to some prescription drug interactions.
👉 Paradigm shift: Some herbal remedies behave like unlicensed enzyme-inducing drugs.
5. Herb/Supplement–Drug Interaction Table
Key: ⚠️ = Major interaction (avoid/monitor closely) | ⚡ = Moderate interaction (caution advised) | ℹ️ = Minor/theoretical (awareness sufficient)
| CAM Product | Drug Class/Specific Drugs | Interaction Type | Clinical Significance | Management |
|---|---|---|---|---|
| St John's Wort | Hormonal contraception | ⚠️ CYP3A4 induction | Reduced contraceptive efficacy, breakthrough bleeding | Avoid combination or use additional contraception |
| St John's Wort | Warfarin, DOACs | ⚠️ CYP induction + P-gp | Reduced anticoagulant effect, thrombosis risk | Avoid combination; monitor INR/anti-Xa closely if used |
| St John's Wort | SSRIs, SNRIs, MAOIs | ⚠️ Serotonin syndrome | Agitation, hyperthermia, neuromuscular abnormalities | Avoid combination completely |
| St John's Wort | Antiretrovirals (HIV) | ⚠️ CYP3A4 induction | Reduced antiviral levels, treatment failure | Avoid combination |
| Ginkgo | Anticoagulants, antiplatelets | ⚡ Bleeding risk | Increased bleeding tendency | Caution; monitor for bleeding signs |
| Garlic (high dose) | Anticoagulants, antiplatelets | ⚡ Bleeding risk | Increased bleeding tendency | Stop 7 days before surgery; monitor bleeding |
| Turmeric/Curcumin | Anticoagulants, antiplatelets | ⚡ Bleeding risk | Increased bleeding tendency (high doses) | Caution with therapeutic doses; culinary use safe |
| Ginseng | Warfarin | ⚡ Anticoagulant effect | May reduce warfarin effectiveness | Monitor INR more frequently |
| Ginseng | Antidiabetic drugs | ⚡ Hypoglycaemia | Additive glucose-lowering effect | Monitor blood glucose; adjust doses if needed |
| Valerian | Sedatives, benzodiazepines | ⚡ Additive sedation | Excessive drowsiness, impaired coordination | Avoid combination or reduce doses |
| Chamomile | Anticoagulants | ℹ️ Theoretical bleeding risk | Possible increased bleeding (high intake) | Awareness sufficient; normal tea consumption safe |
| Echinacea | Immunosuppressants | ℹ️ Theoretical immune stimulation | May counteract immunosuppression | Discuss with specialist; probably avoid in transplant |
Scope & Rationale
This curriculum focuses on complementary and alternative medicine (CAM) that UK GPs are most likely to encounter in routine primary care. The approach is pragmatic rather than comprehensive, emphasizing safety, evidence assessment, and practical communication strategies.
Why CAM Matters in Primary Care:
- • 35% of UK adults use some form of CAM
- • 70% don't disclose CAM use to their GP
- • £4.5bn annual spend in the UK
- • Significant interaction potential with prescribed medicines
- • Patient safety and medicolegal considerations
Learning Approach:
- • Evidence-based assessment of common modalities
- • Focus on safety and drug interactions
- • Practical communication strategies
- • Regulatory and legal considerations
- • Respectful, non-judgmental patient care
You've Got This! 🌟
CAM conversations don't have to be awkward. With evidence-based knowledge and respectful communication, you can navigate these discussions confidently while keeping your patients safe.
Remember: Your role is to provide safe, evidence-based guidance while respecting patient autonomy and choice.