Herbal Medicine Use in Germany

UPDATE It bears repeating that adverse reactions are possible with herbal medicine. I just translated an adverse event report on flushing syndrome caused by the administration of a Chinese herbal medicine containing Panax ginseng. Because so many herbal medicine users self-administer and do not inform their physicians of such behavior, it is important for health consumers and healthcare providers alike to be aware of the possibility of adverse reactions, including drug-herb interactions and herb-herb interactions. 

​GERMANY In contrast to other countries (Turkey, Kuwait, Malaysia, and Australia), herbal medicine use is very high in Germany with rates soaring from 50% in 1970 to 70% in 2010.
A 2019 online survey examining the role of herbal medicine in the German healthcare system reveals that herbal medicine use in the general German population is very high, and over 90% of regular herbal medicine users self-administer herbal remedies. Yet patients  lack awareness of the potential side effects and potential interactions of herbal medicine.

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SURVEY DESIGN Based in part on a survey instrument from the U.S. National Health Interview Survey, the questionnaire used quota sampling to provide a representative picture of the German population. A total of 2906 people participated in the survey.
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Survey topics:

• What is the purpose of your herbal medicine use? Treat illness? Prevent illness? Promote health?
• What sources of information do you access regarding herbal medicine?
• How much do you trust these information sources?
• Who prescribes/administers the herbal medicine to you?
• What is your current state of health?
• Do you have a chronic disease?
• Do you consume alcohol?
• Do you engage in preventive health activities?

 

​SURVEY FINDINGS

• Herbal medicine use is impressively high in the general German population (75.4% had used an herbal medicine in the past 12 months).
• The typical German user of herbal medicine is female, educated, employed, and engaged in a “healthy lifestyle.”
• Herbal medicine users tend to suffer from chronic diseases and demonstrate health-oriented lifestyles.
• Some 93% of regular herbal medicine users self-administer the herbal remedies, which can be interpreted as a form of proactive, health-oriented behavior. Users generally do not inform their physicians about this self-prescribing behavior. Only 38% of respondents in this survey informed their physician – results that were quantitatively similar to results from previous studies in Italy, the United States, and Turkey.
• Patients may overestimate the positive aspects of herbal medicine and may not be aware of potential side effects and potential interactions. Other researchers have found a clear lack of awareness. There is a bias toward using natural vs. synthetic drugs regardless of safety and efficacy.

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​HERBS In the survey, herbal medicine was defined as all plant-derived products in natural form and as pills. Here are the properties and general indications of the herbs used most frequently in Germany.
Peppermint (Mentha piperita) is used primarily to address digestive colic, cramps, and nausea. Of unknown origin, peppermint has been used by the Egyptians, Greeks, and Romans. Its potency is categorized as strong and it has slight emmenagogue effects.
Chamomile (Chamomile recutita) is another traditional remedy used for digestive problems from gastritis to irritable bowel syndrome, to treat tension and irritability, and to promote sleep. Chamomile inhibits the growth of Helicobacter pylori, one of the causes of peptic ulcers. Cautions include allergic hypersensitivity (chamomile is considered a ragweed) and reduced absorption of non-heme iron. Potency is medium and German chamomile contains a strong anti-inflammatory constituent.
Sage (Salvia officinalis) regulates menstruation and reduces sweating. It is indicated for hot flashes. Sage is also considered a digestive tonic. Native to Europe, sage possesses strong potency and is toxic in excess.
Ginger (Zingiber officinalis) is native to Asia and has anti-emetic, appetite-stimulant, and analgesic properties (eases generalized body ache). Its antiseptic properties are beneficial for intestinal infections. Ginger is contraindicated in combination with NSAIDs and should not be administered to patients with ulcers or bleeding disorders. Potency is strong.  
Valerian (Valeriana officinalis) is native to Europe and northern Asia. It is a sedative, nerve tonic, and cardiac depressant. Valerian induces relaxation in the smooth muscles of the uterus, colon, and bronchial passages. Overdose causes fainting and vomiting. Valerian may cause diuresis, thus it is not suitable as a sleep aid. Excess use causes depression of the central nervous system. Potency is strong.
Stinging nettle (Urtica dioica) grows in temperate regions of the northern hemisphere. It is diuretic, tonic, and anti-allergenic, and it cleanses the blood. Stinging nettle is contraindicated in pregnancy and possesses medium to strong potency.
St. John’s wort (Hypericum perforatum), native to Britain and Europe, is used to treat depression and anxiety and as a liver tonic. Do not take St. John’s wort during pregnancy and do not combine with birth control pills, statins, antidiabetics, and anticoagulants. Life-threatening serotonin toxicity is possible when used in combination with other antidepressants.  Potency is strong.
Arnica (Arnica montana) is found in the mountains of Europe, the United States, and Canada. It is used externally for bruises, sprains, muscle aches, and pains. Arnica is poisonous and should not be taken internally.
 
In conclusion, herbs were used most commonly to treat cold and flu, respiratory problems, and gastrointestinal disease. Perceived helpfulness of herbal medicine was greatest for insect bites, gastrointestinal issues, and respiratory problems. Herbal medicine was perceived as not very helpful for tinnitus and depression.

SOURCES OF INFORMATION As expected, the internet was the most popular source of information but, paradoxically, participants expressed low trust in internet information. Pharmacists and physicians were viewed as the most trustworthy sources. Does this reflect the lack of a centralized, trusted source of public information on herbal medicines?
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POTENTIAL FOR HARM

• Self-administered herbal medicines increase the risk of overdose and contraindicated use.
• Public knowledge is lacking with respect to interactions (drug-herb interactions and herb-herb interactions). More than one-third of participants (35.3%) rated their knowledge of the potential side effects of herbal medicine as poor or very poor and only 14.8% rated their knowledge as good or very good.
• There is a lack of communication with physicians regarding herbal medicine use. 

The survey demonstrates that use of herbal medicine plays an essential role in the German healthcare system. Healthcare providers need to be aware of patient behavior, and the general public needs a trusted source of information.
 
Caution: Use of herbal preparations is not recommended without the advice of a healthcare provider. Substances in herbal preparations may interact with prescription drugs to eliminate therapeutic efficacy or induce toxicity.
 
Citation: The importance of herbal medicine use in the German health-care system: prevalence,
usage pattern, and influencing factors (Welz et al., BMC Health Services Research, 2019 19:952)