Background: The use of complementary medicines in addition to medical prescription by patients with hypertension, diabetes and other chronic diseases presents a challenge for healthcare providers in Nigeria and globally. There is very little data on the clinical outcomes in these patients.Objectives: To evaluate clinical outcomes in hypertensive or diabetic patients who use complimentary medicines in Lagos Nigeria .Design: Observational cross-sectional study.Setting: Lagos University Teaching Hospital Medical Outpatient Clinics.Subjects: Five hundred patients attending Lagos University Teaching Hospital Medical out-patient clinics with a diagnosis of diabetes mellitus or hypertension or diabetic hypertensive were studied.Main outcome measures: The effect of complementary medicines use on blood pressure and blood glucose control were evaluated.Results: The mean arterial blood pressure of non-users of complementary medicine was 115.329 mmHg and that of users was 105.138mmHg. Also the mean fasting blood sugar of non-users was 129.515mg/dl and that of users was 131.453mg/dl. (P&gt;0.05).Conclusion: Although not statistically significant, complimentary medicines were found to be of advantage to hypertensive patients but not diabetic patients

Aro, AO

Fasanmade, O

Ibrahim, A

Nwaiwu, O

Olayemi, SO

English

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20 East african MEdical Journal January 2015 East African Medical Journal Vol. 92 No. 1 January 2015CLINICAL OUTCOMES IN HYPERTENSIVE OR DIABETES PATIENTS WHO CONCOMITANTLY USE COMPLEMENTARY MEDICINES IN LAGOS, NIGERIAS. O. Olayemi, O. Nwaiwu, Department of Pharmacology, Therapeutics and Toxicology, O. Fasanmade, Department of Medicine, A. O. Aro, Department of Pharmacology, Therapeutics and Toxicology and A. Ibrahim, College of Medicine, University of Lagos, NigeriaRequest for reprints to: Dr S. O. Olayemi, Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, NigeriaCLINICAL OUTCOMES IN HYPERTENSIVE OR DIABETES PATIENTS WHO CONCOMITANTLY USE COMPLEMENTARY MEDICINES IN LAGOS, NIGERIAS. O. OLAYEMI, O. NWAIWU, O. FASANMADE, A. O. ARO and A. IBRAHIMABSTRACTBackground: The use of complementary medicines in addition to medical prescription by patients with hypertension, diabetes and other chronic diseases presents a challenge for healthcare providers in Nigeria and globally. There is very little data on the clinical outcomes in these patients.Objectives: To  evaluate  clinical outcomes in hypertensive or  diabetic patients  who use  complimentary  medicines  in  Lagos  Nigeria .Design: Observational cross-sectional study.Setting: Lagos University Teaching Hospital Medical Outpatient Clinics. Subjects: Five  hundred   patients attending Lagos University Teaching Hospital Medical out-patient clinics with a diagnosis of diabetes mellitus or hypertension or diabetic hypertensive  were studied. Main outcome  measures: The effect of complementary medicines use on blood pressure and blood glucose control were evaluated.Results: The mean arterial blood pressure of non-users of complementary medicine was 115.329 mmHg and that of users was 105.138mmHg. Also the mean fasting blood sugar of non-users was 129.515mg/dl and that of users was 131.453mg/dl. (P>0.05).Conclusion: Although not statistically significant, complimentary medicines were found to be of advantage to hypertensive patients but not diabetic patients.INTRODUCTIONNon-communicable chronic including hypertension and diabetes are becoming a major problem in low- and middle-income countries (1). Over 80% of deaths worldwide from cardiovascular diseases occur in low- and middle-income countries (2). Hypertension and diabetes are important risk factors for cardiovascular disease and persons with hypertension, are more likely to develop type 2 diabetes (3-5). Because these chronic diseases cannot be cured completely and cause life threatening acute and chronic complicationsindividuals with chronic diseases often seek help from sources other than conventional medicine (6,7).  There has been a great deal of interest recently in the role of complementary and alternative medicines for the treatment of various acute and chronic diseases (8).Complementary and alternative medicines (CAM) refer to practices that are not integral parts of conventional or orthodox medicine, and are consequently not taught as part of the medical education curriculum (9). A significant proportion of patients attending our tertiary facilities and receiving conventional treatment also use CAM therapies (10). Prevalence rates as high as 83.3% have been reported (11). The known determinants of CAM use include sociodemographic and patient characteristics such as age, gender, education level, illness, and illness duration (12). The safety and efficacy of complimentary medicines have not been established in the studies that have been done over the years. In Nigeria use of unprescribed drugs and herbal medicines were aetiologically responsible for acute kidney insult in 7%-9% of cases (13). Lack of efficacy, results in January 2015 East african MEdical Journal    21complications as compliance to conventional therapy may not be optimal. Clinical outcome studies of complementary medicine use in diabetes and hypertension are scarce. However there appears to be a growing utilisation of complementary medicine therapies. Therefore studies on clinical outcomes of treatment are required to determine the impact of complementary therapies on disease outcome. In the present study, we investigated the clinical outcomes of treatment among patients with diabetes and hypertension attending Lagos University Teaching Hospital Medical outpatient clinic.MATERIALS AND METHODSStudy Population: The study population consisted of 500 patients (250 diabetic and 250 hypertensive) who attended the medical outpatient clinic of the Lagos University Teaching Hospital over a period of three months.Data  Collection: Data from this crossectional observational study was collected using a structured questionnaire which had  questions on patients biodata including name weight, height, other information about the  nature  of disease , source of information on complimentary medicines  and use of complementary medicines, duration  and type of complementary medicine use,  clinical outcomes and perceived benefits of complementary medicine use.. Blood pressure  and  blood  sugar  values  at the  time of visit  were  obtained  from  case  notes. Those who  could  not  complete  the questionnaires were  interviewed  and assisted to complete the questionnaires .  All subjects gave informed consent before the questionnaires were administered. Statistical Analysis: Mean values (Mean ± SD) were compared by analysis of covariance. P values < 0.05 were considered significant. Data was presented as figures and tables.RESULTSA total of 500 subjects were studies. Figure 1 shows frequency distribution of the disease while table 1 shows age and weight of study subjects.Figure 1Frequency distribution of  type of  disease process Table 1Frequency distribution of ageAGE  frequency percent %10 years -29 years 22 430 years-49 years 280 5650 years  to  79 years 198 40Total 500 100%WEIGHT (KG) frequency percent %45-59 45 960-79 415 8380-110 40 8Total 500 100%22 East african MEdical Journal January 2015 Figure 2  shows knowledge and use  of  complementary medicines. Sixty four percent  of  the subjects  have heard  of  and also  used  complimentary  medicines and  thirty six percent  have  not  heard  of  or used complementary   medicines.  Majority of  the  subjects 53%  got  their information  from  other  patients. Figures 3 and 4 shows  sources  of  information about complementary  medicines and  duration of use  of complementary medicines respectively.  Fifty  percent of the  subjects  have  used  complementary  medicine for one to five years  while  less  than one  percent have  used  it  for  31-35  years. The commonly used complementary medicine by respondents is ginger (Table 2)Figure 2Knowledge  and use of complimentary medicinesFigure 3Sources of information about complementary medicines Figure 4Duration of use of complementary drugsJanuary 2015 East african MEdical Journal    23Table 2Frequency distribution of  type of complimentary medicinesComplementary medicines used Frequency % CumulativeCinnamon 1 0.3Cardiotonic pill 14 4.6Forever living products 30 9.8Garlic 17 5.5Ginger 52 16.9GNLD products 22 7.2Honey 21 6.8Morindacitrofolia (Noni juice) 48 15.6Mormodicacharantia 21 6.8Neem tree 32 10.4Onion 43 14Phyllanthusamarus 6 2Total 307 100%  Table 3 shows the percentage  of patients  who  perceived  some  benefit  from use of complementary  medicines.Table 3Perceived benefits  from complementary medicinesBenefit Frequency PercentageYes 261 85No 13 4.2Not sure 33 10.8Total 307 100%The mean arterial blood pressure of users was 105.138mmHg while the mean arterial blood pressure of non-users was 115.329 mmHg, giving us a difference of 10.191mmHg. hence the arterial blood in users of complimentary medicines is lowered. There   was  no difference  in the  mean fasting blood sugar of non-users   and   users  of complementary  medicines.Figure 5Mean arterial blood pressure and mean of fasting blood sugar in users and non users24 East african MEdical Journal January 2015 DISCUSSIONThe results of this study adds to existing data that shows that the use of complementary medicines is on the increase globallyand confirms like in other studiesa high usage of complimentary medicines by patients (14,15). This study found that about 64% of the patients know about and use complimentary medicines. This is similar other reports which reported that as many as 63.9% of their hypertensive subjects in a clinic in India took herbal medicines, while in Morocco 80% of patients with hypertension and diabetes used medicinal plants to treat their ailments (16,17). Although not statistically significant this study found better blood pressure control amongst complimentary medicines users and no difference in blood sugar control between users and non users of complimentary medicine. Similar and conflicting data has been reported previously in which thousands of plants are attributed with glucose-lowering effects (18) and some has not been shown to improve glucose control and may even be harmful in individuals with diabetes (19). The possible reasons for these differences include heterogeneity of CAM practices (20). The types of complimentary medicines used in this and other studies may differ  and may not be available in this locality. Some complimentary medicines  have been studied and evidence of efficacy  documented. Examples  include Gymnema sylvestre (gymenama) (21), Momordica charantia (bitter melo) (22,23), Opuntia streptacantha (pricky Pear cactus, nopal) (24), Panex ginseng, P. quiquefolius (ginseng) (25), Trigonella foenum graecum (fenugreek) (26). In this study Cinnamon, Cardiotonic pill, Forever living products, Garlic, Ginger, GNLD products, Honey, Morindacitrofolia (Noni juice), Mormodicacharantia, Neem tree, Onion, Phyllanthusamarus were more common. Momordica charantia (bitter melon) a tropical vegetable, grown in Africa, Asia, and South America, is known as bitter melon, or “vegetable insulin”. It is one of the complementary medicines used by the patients in this study. It may reduce blood glucose in patients with diabetes (22). Although  most clinical trials of bitter melon among patients with diabetes have lacked adequate design to determine clinical effectiveness, potential mechanisms of action for bitter melon are decreased hepatic glucose production, increased hepatic glycogen synthesis and insulin-mimetic activity (23). The use of different nutritional, lifestyle modifications and compliance with orthodox medicines by the patients in this and other studies could be responsible for differences in outcome between studies.In this study a large majority of patients (85%) claimed to have benefits from the use of complimentary medicines. Because of the Long-term management of hypertension and diabetes, diseases whose management may be lifelong , patients may choose to use complimentary medicines to achieve additional outcomes  and studies have shown that people use CAM to explore the potential benefits and feel that they would achieve a permanent cure of hypertension from complimentary medicine (27,28). The use of CAM is grounded on culture, knowledge, beliefs, experience and the advice of family and friends. Illness duration is a known determinants of CAM use along with sociodemographic, age, gender and education level (12). In this study very few patients got information on complimentary medicines from their doctors.  It is  important  that doctors and health care provides treating patients with hypertension and diabetes should identify patients who use complementary therapy. It is important they counsel these patients to adhere to and comply with conventional treatments. This will also help monitor, and identify adverse drug reactions and drug – complimentary medicine interactions. The World Health Organisation (WHO) encourages member states to integrate traditional and CAM therapy into national health care systems and ensure their rational use (29). This recommendation may be difficult to achieve because of absence of regulation and a comprehensive policy on use of complementary medicines in Nigeria. Establishment of independent regulatory, quality and standardization system would ensure integration into existing health systems. There were some limitations in this study. The study did not document and evaluate concomitant use, adherence and compliance to orthodox and conventional antidiabetic/antihypertensive drugs. This and use or non-use of other nutritional and lifestyle modification measures could affect the observed findings. Long term control of diabetes with evaluation of changes in HbA1c values were not done because of the short duration of the studies. In diabetes mellitus, higher amounts of glycated haemoglobin, indicating poorer control of blood glucose levels, have been associated with cardiovascular disease, nephropathy, and retinopathy. Monitoring HbA1c in type 2 diabetic patients may improve outcomes30 Future larger studies are recommended to assess efficacy, safety, clinical benefits and effect of these complimentary medicines on overall quality of life, morbidity and mortality in individuals with hypertension and diabetes.REFERENCES1. Alwan A & MacLean R. A review of non-communicable disease in low- and middle-income countries.  International Health. 2009; 1:3-9.2. WHO World Health Statistics 2008. WHO, Geneva. Available at:http://www.who.intJanuary 2015 East african MEdical Journal    253. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA,  Izzo JL et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003; 42:1206-1252.4. Kannel WB. Risk stratification in hypertension: new insights from the Framingham Study. Am J Hypertension 2000; 13:3S-10S.5. Gress TW, Nieto FJ, Shahar E, Wofford MR, Brancati FL. Hypertension and antihypertensive therapy as risk factors for type  II diabetes mellitus. N Engl J Med 2000; 342: 905-912.6. Eliot JA, Kealey CP, Olver IN. Using complementary and alternative medicine: the perceptions of palliative patients with cancer. J Palliat Med 2008; 11:58-67.7. Lee GBW, Charm TC, Chew ZH, Ng TP. Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs. Fam Pract 2004: 21:654-660.8. Seeff LB, Linsday  KL, Bacon BR, Kresina TF and Hoofnagle JH. Complementary and alternative medicines in chronic liver disease. Hepatology, 2001; 34:595-603.9. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler  RC: Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998, 280: 1569-1575.10. 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Clinical outcomes in hypertensive or diabetes patients who concomitantly use complementary medicines in Lagos, Nigeria

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Clinical outcomes in hypertensive or diabetes patients who concomitantly use complementary medicines in Lagos, Nigeria

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