Chronic Venous Insufficiency: Alternative Therapies

How strong is the evidence supporting the use of horse chestnut seed extract for chronic venous insufficiency?

Many Western physicians remain skeptical about the purported benefits of alternative therapies. Their reservations may stem from the paucity of double-blind, randomized, controlled trials (RCTs) that have evaluated alternative agents. In an era when practice is propelled by the mantra of "evidence," can skeptics ever be certain that these agents are safe and effective?

The answer is critical because patients are increasingly taking alternative remedies for diseases that run the gamut from back pain to cancer. These therapies are being used both with and without physician input. Some of them may interact with other medications, such as warfarin, which can lead to serious complications.

It would be reassuring to see published evidence that these agents have undergone rigorous study. Recently, a Cochrane review analyzed data from RCTs of an herbal remedy for chronic venous insufficiency.¹

SCIENCE AND ALTERNATIVE MEDICINE

As many as 15% of men and 25% of women are troubled by chronic venous insufficiency.² Traditional therapy consists of compression stockings; however, this treatment can cause discomfort, which leads to poor compliance.

In 1996, horse chestnut seed extract was suggested as beneficial for chronic venous insufficiency.³ This herbal remedy contains the extract of a seed called escin, a compound that inhibits the activity of elastase and hyaluronidase, two enzymes that degrade proteoglycans. Investigators have suspected that a leukocyte-mediated breakdown of proteoglycans by elastase and hyaluronidase in venous and surrounding soft tissue is responsible for the signs and symptoms of chronic venous insufficiency.

In the recent Cochrane study, all previously published RCTs (found by literature search) using horse chestnut seed extract were reviewed. The trials were chosen for analysis if they addressed the long-term treatment of chronic venous insufficiency and had measurable outcomes (pain, itching, edema, leg circumference, and adverse events). Scientific rigor was necessary for inclusion in the final tabulations. Twenty-nine RCTs that assessed horse chestnut seed extract monotherapy were selected.

The results of the trials demonstrated that when compared with placebo, horse chestnut seed extract is an effective therapy for chronic venous insufficiency. Fourteen of the studies reported adverse events in the active treatment arm; however, no serious events were reported, and most side effects were minor (eg, nausea, pruritus). The science was not perfect because some of the studies were small and hampered by significant dropout rates. Nonetheless, this is one example of science applied to alternative therapy to evaluate safety and benefit.

Why choose this Cochrane review as a "Top Paper of the Month"? It demonstrates that the benefits of certain alternative therapies for patients with common diseases can be proved scientifically. Am I completely convinced? The answer is yes and no. Although I may take horse chestnut seed extract for my chronic venous insufficiency, the thorny issues of standardization of alternative products, effective post-marketing surveillance, supplement-supplement and supplement-drug interactions (such as those resulting from cytochrome P-450 induction), and responsible adverse event reporting remain.

IMPLICATIONS FOR YOUR PRACTICE

A nonjudgmental review of all alternative therapies needs to be part of every patient visit. Information from Web sites like www.uiowa.edu/~idis/herbalinks, the Natural Medicine Comprehensive Database, and www.herbalsafety.utep.edu can then be applied to the list of therapies, followed by recommendations if warnings or interactions have not been addressed. In fact, the last Web site cautions that horse chestnut seed extract potentiates the anticoagulant effects of warfarin and may lead to bleeding.

References:

REFERENCES:

1.

Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency.

The Cochrane Library.

2006;Issue 1.

2.

Callam MJ. Epidemiology of varicose veins.

Br J Surg.

1994;81:167-173.

3.

Bombardelli E, Morazzoni P, Griffini A.

Aesculus hippocastanum L

.

Fitoterapia

. 1996;67:483-511.