CEDH Magazine - JANUARY 2018 - NUMBER 47 by Boiron USA

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6TH INTERNATIONAL CEDH CONFERENCE Barcelona 2017

How to communicate on homeopathy

Ankylosing spondylitis

Fatigue in Cancer Patients

Place of homeopathy

in order for people to listen to you (and want to learn more about it)

Fatigue in supportive care

Point of view of a community pharmacist

homeopathic approach and prescription method

Uncovering Platina!

Teaching Clinical Homeopathy

CEDH magazine C O N T I N U I N G M E D I C A L E D U C AT I O N C E D H M A G A Z I N E • J A N U A RY 2 0 1 8 • N U M B E R 4 7

6 International CEDH Conference in Barcelona th

6 & 7 october 2017

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Promoting the place of Homeopathy in today’s medicine but also the place it will hold in the future Yves Lévêque, MD Editor in Chief

See you very soon ! n

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ou have in your hands the first of two issues dedicated to the 6th International CEDH Conference placing homeopathy within integrative medicine in neuropsychology for adults/adolescents/children, geriatrics, autoimmune diseases, gynecology, rheumatology. The sharing of experiences and knowledge underlined the quality and relevance of these presentations, their diversity but also their complementarity. Our goal with this first issue is to discover or remember these important moments where experts, homeopathic physicians and pharmacists all contributed to promoting the place of Homeopathy in today’s medicine but also the place it will hold in the future. We made a choice to start with 5 articles: n The first from Dr Gualberto Diaz-Saez initiating us on “how to present homeopathy to neophytes, media representatives and other healthcare professionals” an exercise in “communication” facilitated by all the teachings and advices in integrative medicine from a physician’s daily clinical practice. n The second presentation by Martine Tassone, Maryvonne Nadaud and Jean-Marc Saillard, underlines the place of homeopathy in the treatment of Ankylosing Spondylitis (AS) and evidences through 12 clinical cases, the legitimacy of homeopathy as an integrative medicine in AS. n The third article by François Roux, PharmaD, opens the theme of fatigue in cancer patients, the experience of the patient and the role of the healthcare professional in this specific care pathway: the community pharmacist. n The fourth article, stemming from the experiences of Marie-Hélène Ribreau and Jean-Claude Karp, respectively primary care physician and homeopathic oncologist, continues to highlight the management of the “fatigue” symptom in cancer patients, from the diagnosis to the remission stage. n The 5th topic is focused on the constant and essential work on the Materia Medica, thanks to Sabine Chesneau with an analysis of Platina through authors and historical landmarks. The relevance enumerating situations where Platina is successfully prescribed, reminds physicians of the potential of this medicine that tends to be left “aside”! In the next issue of our CEDH Magazine (2nd part of our 6th International CEDH Conference: Homeopathy within integrative medicine) we will look at Dopamine and Serotonin, brain aging, anxiety, addictions, endometriosis and Actaea Racemosa.

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6TH INTERNATIONAL CEDH CONFERENCE

CEDH magazine

BARCELONA 2017

BARCELONA 6 & 7 OCTOBER 2017 (1/2)

47 N°

Published by CEDH, 60 boulevard Diderot, 75012 Paris - www.cedh.org Editor in Chief : Yves Lévêque, MD Editorial board : Yves Lévêque, MD Frédéric Voirin, MD Contributors for this issue : Gualberto Diaz-Saez, MD Sabine Chesneau, MD Jean-Claude Karp, MD Maryvonne Nadaud, MD Marie-Hélène Ribreau, MD François Roux, PharmaD

Production : Atelier Chalopin, Sérigraphie Translator : Bénédicte Clement Illustrations : Fotolia ISSN : 1950-8832 Legal mention : 0516 T 88691 Publication date : January 2018.

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3 EDITORIAL ,

Yves Lévêque, MD, 03

5 HOW TO COMMUNICATE ON HOMEOPATHY IN ORDER FOR PEOPLE TO LISTEN

TO YOU (AND WANT TO LEARN MORE ABOUT IT) Gualberto Diaz-Saez, MD, 05

13 PLACE OF HOMEOPATHY IN ANKYLOSING SPONDYLITIS

Maryvonne Nadaud-Lechner, MD, 13

21 FATIGUE IN CANCER PATIENTS POINT OF VIEW OF A COMMUNITY PHARMACIST

François Roux, PharmaD , 21

25 FATIGUE IN SUPPORTIVE CARE HOMEOPATHIC APPROACH AND PRESCRIPTION METHOD

Jean-Claude Karp, Marie-Hélène Ribreau, MD, 25

35 UNCOVERING PLATINA!

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Sabine Chesneau, MD, 35

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How to communicate on homeopathy in order for people to listen to you (and want to learn more about it) Gualberto Diaz-Saez, MD, Spain

Why?

The 6th International CEDH Conference held in Barcelona on October 6-7, 2017 had a session called “Communicating in Homeopathy”. This is a skill that is becoming essential to master, if one takes into account today’s context full of information (and misconceptions) regarding unconventional therapies and homeopathy specifically. We love homeopathy and it brings us joy every day in our practice. We love to talk about it, and we do it quite well because we have studied it at length and some of us even teach homeopathy to other physicians. We love homeopathy and we also like to set things straight when people criticize it for no reason and without any knowledge of it. However, this attitude is not the one that homeopathy needs to increase its credibility and widespread use. To be able to change one’s attitude and accept our views is not a question of winning, nor of having extensive knowledge (overdose) but rather to know how to share the important message in a quick and “physiological” manner, i.e. to disrupt as little as possible the person we are talking to. To sum up, let’s use this communication in homeopathic doses!

“

Please use words and not just ideas. If it took you more than 2 seconds to formulate a categorical answer or if you answer has the word “no” you already lost a great part of your credibility as a professional. No need to agree with me, but I would appreciate if you would give a chance to the opinions you will read here, because they are the result of several years of continuous experiences within scientific and communication fields, and even some publications in our Journals (Diaz-Saez G., Rev Med Homeopat 2010), these opinions grew among communication experts (such as Dr. Gonzalo Fernández and Guillermo Basauri) and were enriched by the students who attended training courses in how to communicate on homeopathy. n THE FIRST THING WE REALIZED, AND THAT WE ALSO

NOTICED IN OUR OWN PRESENTATIONS IS THAT: 1. Our explanations are too lengthy and too complex. 2. We react in a defensive manner when we perceive some doubt or hostility. And 3. We use obsolete words (there are some modern and equivalent ones) and abstract notions, rather than speaking about real-life situations, examples allowing others to identify to our explanations and be moved.

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Maybe this article is not essential for everyone, this is why I am proposing a game that includes 2 questions that a patient can ask us (or a journalist) and those who answer correctly do not need to keep on reading. The first one is “What is homeopathy?” Take two minutes to elaborate your answer. If you already mentioned similitude, infinitesimal dilutions or if it took you more than one minute, you decided to go for a complex and academic explanation when you could have said something more important or more moving for the patient (or any other person). The second one is “How does homeopathy work?”

Please use words and not just ideas”

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How to communicate on homeopathy in order for people to listen to you…

BARCELONA 2017

We must be aware that the way we explain homeopathy does not only affect our patient (or our brother-inlaw/sister-in-law) but it is also meant for others who will repeat what we explained to other persons and will ask questions to their physicians. Thus, if we were unclear and our audience is unable to repeat our messages, we lose a precious opportunity to spread the right message that will give a great impulse to homeopathy but that will also help trigger curiosity in people and patients. In cases of interviews with journalists (printed press, radio, TV) or articles in web pages or blogs, the impact of our message and how well we delivered it is even greater.

easier to follow than when one indicates what to do (which depends on common clinical practices and those are very heterogeneous). In a similar manner, let’s see a few rules on what to AVOID when talking about homeopathy, and if we can remember them we will already have taken an extraordinary step towards communicating correctly.

SHORT LIST OF COMMON MISTAKES TO AVOID

• ATTACKING THE CONVENTIONAL SYSTEM To go from the state “being convinced” to “knowing how to convince” some think it not necessary to be able to use scientific arguments with evidence-based medicine. However, very few among us are research experts or have dedicated enough time to reading publications that explain and enrich our practice day after day. It’s ok since we are so sure that scientific studies do not convince anyone (if you ask homeopathic physicians and patients what convinced them in homeopathy, almost none will say “research studies”!). So the key is somewhere else. Of course, it is obvious that it can be very useful to know some studies to propose them as illustrations and give more weight to some of our statements. .

We should not speak of errors and mistakes of conventional medicine. The essential thing is talk about us, our practice. Of course we do not use the term “conventional medicine” when we talk of “conventional pharmacology”, the latter term is more appropriate because medicine is unique and when one wants to put an adjective next to it we divide it, and thus we position ourselves outside of its rim. Furthermore, it is not healthy to speak of homeopathy in a superior manner, each therapeutic has its limits and virtues.

For example, regarding how the World Health Organization consider conventional and complimentary medicines to give some solutions to certain urgent issues that isolate third-world countries; as underlined in the study by K. Danno, 2014, on adding homeopathy to a malaria treatment in pregnant women in Africa to prevent its transmission to their unborn children evidenced that only 20% of them experienced adverse side effects (vs. 80% without homeopathy). I would add imagine the impact on more than 100 countries affected by this disease, with more than 200 million persons with malaria and over 600,000 deaths per year, knowing that most of them are young children and pregnant women! We can even drive the message home: You can see why homeopathy and conventional pharmacology can be great allies!

Someone who did not follow our training does not understand what we mean when speaking of miasma, infinitesimal dilution, homeopathic aggravation or terrain. The person we are talking to might barely understand the term “holistic”!

• USING STRANGE WORDS AND

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WEIRD EXPRESSIONS

Avoid mistakes In medicine, it is frequent to publish guidelines on what NOT TO DO (for example administering antibiotics for uncomplicated otitis) because these guidelines are

• LOOKING FOR EXPLANATIONS IN “ALTERNATIVE SCIENCES” It really isn’t about them being true or not, but rather that they are not recognized by the dominant model. They will not help in communicating (reaching the other person) in an effective manner.

• BEING NEGATIVE AND SPEAKING OF OUR PROBLEMS

The patient or journalist will not help us resolve our legal issues or challenges in being recognized, or give us the resources to conduct research. Conversely, sharing our problems will trigger insecurity or defiance. Problems stay between us and those who have the resources and power to solve them. Nobody likes to hear the complaints of others.

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SHORT LIST OF SENTENCES WE RECOMMEND TO NO LONGER USE • There is no active substance. The active substance is diluted, there are no molecules left, etc. • There is no mechanism of action. We cannot be sure about this. The necessary technology to explain it is not yet available, etc. • There are no side effects. Symptoms that appear are sometimes a good sign, etc. • There are no clinical studies like in conventional medicine. It is not possible to do research in the same manner. Homeopathic research is made through provings, etc. Truthfully, these sentences are to be avoided not only because they don’t sound right, or do not convince us. The fundamental problem is that if one day they seemed true, what we know now has changed our way of thinking (this is the basic principle of being scientific, by modifying the hypotheses in light of new evidence and data). n THUS, IT IS NOT THE ACTIVE SUBSTANCE THAT IS

DILUTED, BUT THE STRAIN. Not only is it diluted, it

is potentized (we must always use these two words together, never one without the other). Furthermore, we already OBSERVED the molecules, even in high dilutions (PS Chikramane, Langmuir 2012), and detected structural changes that are produced in the potentized dilution (JL Demangeat, Journal of Molecular Liquids 2009).

“

TWO EXAMPLES: • the increased allopregnanolone secretion in the neurons produced by Gelsemium; it is done via the glycine receptors, which we know because the effect is blocked by strychnine (Venard C., Neuroscience 2008 ; Olioso D., J Ethnopharmacol. 2014). • Aspirin 15CH triggers an increased platelet aggregation by acting via the COX2 enzyme in the endothelium (and not COX1 like allopathic Aspirin), which we can deduce because it does not work in COX2-inhibited rats (Doutremepuich C., Thrombosis Research 1998 ; Doutremepuich C., Cardiovasc Hematol Disord Drug Targets 2010).

SIDE EFFECTS EXIST, and it gives more credibility to homeopathy; something that has no adverse effects is not a primary thing, this is in fact a natural model of reasoning. In all cases, clinical studies show that there are more adverse effects in the treated group and systematic reviews also confirm this fact (F. Dantas, Br Hom J 2000). Furthermore, in the framework of pharmacovigilance, suspected side effects are reported and published every year in scientific journals (P. Posadzki, Int J Clin Pract 2012). Moreover, what we homeopaths call “aggravations” are also side effects, independently from the fact that they reflect the healing process! What represents a great advantage for homeopathy, is not the absence of side effects but rather the observation that they are rather rare, of mild intensity and transient by nature. n We have at our disposal a great number of scientific studies to answer the questions we might have both on scientific grounds and clinical results.

WE CAN ANSWER THE FIRST ONES with fundamental studies, there are today more than 2,300 of them (HOMBREX database). An analysis of the 1,500 ones that were published up to 2010 validated specific effects in 90% of the 830 studies conducted with high dilutions (Clausen J., Homeopathy 2011).

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The homeopathic active substance is the RESULT of the dilution and dynamisation of a strain in a hydro alcoholic solution.”

It is not possible to know the mechanism of action for an “antibiotic course”, but rather the mechanism of action of each antibiotic. We understand each day a little bit more the mechanism of action of certain homeopathic medicines, its effect on cells, the changes it induces.

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How to communicate on homeopathy in order for people to listen to you…

BARCELONA 2017

WE CAN REPLY TO THE SECOND ONES with different clinical studies: randomized study differentiating it from placebo, observation demonstrating its effectiveness in real-life situations and epidemiology showing an impact on public health (Project EPI3-LASER with 11 publications). Today there are more than 6,400 publication on Pubmed, among which 204 are randomized studies published in peer-reviewed journals (HRI). Among those, 68 report an individualized approach, evidencing that this manner of using homeopathy can also be tested with conventional methods with a positive result even if we filter them by the highest level of scientific evidence as proposed by the Cochrane Collaboration (Mathie RT., Systematic Reviews 2014).

Using research data Up to now we have seen strategies based on avoiding mistakes. Before getting on, and now that we have included references from the literature (simple illustrative examples of what is brought forward), let us not miss the opportunity to introduce a nuance: we talked about the relative importance of highlighting a scientific publication to defend our most interesting messages because it gives them credibility and using them shows our professionalism and our scientific competencies. It is rather important to remember that it is not about memorizing the studies and talking about the reported data, but rather understanding the deep significance that some of them might have, because of their impact or the methodology used, and explaining them by using data that emphasize our message.

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For example in a study on depression in menopausal women (Macías-Cortés E., PLoS One 2015), we can just say that homeopathy worked as well or better than fluoxetine: we limit ourselves to underlining its effectiveness, which is rather a good thing. Instead, we could opt for improving a most specific aspect of homeopathy, the one of the holistic approach: the same study gives us the opportunity to give another example.

By treating depression with an individualized homeopathic treatment, we are able to improve other systems and functions of the patient with the same medicine – in this case the different symptoms of menopause -, an effect of course not obtained with the fluoxetine.

What can we say? Once we are able to “clean-up” our message, we will have made a great step towards an effective communication. We now need to clean up the non-verbal language consisting of our own attitudes and emotions. At the beginning I was saying that we become a bit defensive when we perceive doubt or hostility, when in fact it is precisely in those moments that it is essential to maintain a serene attitude, project security and feed the link with positive emotions. After all, the goal is to share a precious treasure that improves the life of healthcare professionals and patients alike! There are techniques in the fields of psychology and communication fields, among those I would like to emphasize breathing and posture, they are not the focus of this article, but I invite those who wish to learn more about it to gather further information. SOME READERS WILL ASK THEMSELVES: “And if I cannot continue to answer questions the way I did before, how will I answer questions now?” We can divide this questioning into two main areas: 1. What are the key messages that should be shared with enthusiasm? 2. How to address the most frequent objections (you had a glimpse at some of them in the previous paragraph)? TO THE QUESTION “WHAT IS HOMEOPATHY, we will have to explain its characteristics (therapeutic method, similitude, potentized dilutions, individualization) but this doesn’t move the patient and it is too complex, because each term requires new explanations. Our team was involved in a national homeopathy conference with the following theme: “To explain homeopathy,

To explain homeopathy, do not tell people what it is, but rather what it BRINGS”

“

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do not tell people what it is, but rather what it BRINGS”. The theme in itself was rather explicit, let’s see how one can apply it in practice:

• THERAPEUTIC METHOD: this expression tells us that it helps to relieve or heal, things that the patient probably considers as normal. We could enrich it by commenting on its complementarity, with other techniques or interventions, i.e. it can be added to other therapeutics and not just replacing them. • DILUTIONS: What advantage do we get to use dilutions (potentized)? Why did Hahnemann start to dilute the strains? The goal was to obtain medicines that were better tolerated with less side effects and interactions. • SIMILITUDE: Why is it interesting to use substances that trigger symptoms? Our observation (practical and experimental) of what they trigger on the body without harming it, i.e. the onset of adaptation and reactions of reparation (homeostasis), in order to promote its ability to react and render it less vulnerable. • INDIVIDUALIZATION: A lot of the techniques can be personalized, it is the case in well-used conventional pharmacology (antacids added to anti-inflammatory agents in a patient with arthritis who also has a history of gastritis). In a distinctive manner, homeopathy offers the possibility (and not the obligation) of using medicines that simultaneously help the patient for his or her different problems, i.e. in a holistic manner when we choose them in accordance with the complete profile drawn by the patient in the specialist’s office. n However, homeopathy is an additional

• INTEGRATION AND SAFETY? We can talk about the role of homeopathy in a patient with breast cancer (improve the tolerance to chemotherapy since there is no interactions with it). • HEALING REACTION? We can describe the case of the child who stopped presenting with recurrent otitis episodes or the woman who stopped having migraines, it is not the acute episode that is solved, but it is about preparing the body to better fight the next one. • HOLISTIC? We already talked about the possibility of giving an example of depression during menopause and for which we can emphasize our communication with a clinical study of a high methodological quality. By answering on the different manners that homeopathic medicines and conventional medicines act, I am in the habit of giving the example of a pharyngitis with a fever, with an anti-inflammatory drug, the pain and fever are improved even though the child lacks appetite and doesn’t feel like playing. With Belladonna 9 CH for example, the fever might not completely go down because the body needs a little bit more heat to fight the germs, but we will see the child eat, play and laugh because we brought a global well-being and it will be easier for him to overcome the next pharyngitis episode, even maybe to avoid the episode all together.

Objections Some questions or comments are the result of misinformation and we must address them with patience and clarity. Others are malicious, or seem to be, because they aim for our weak spot. In that case, we are in the habit of shutting up or reacting excessively and we will start answering without having understood the question or the real concern behind this comment. Maybe the most meaningful example would be this one: “I don’t believe in homeopathy.” Maybe you will remember some answers that you gave, or read or

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tool that a healthcare professional can integrate in his or her practice to obtain better results, by using very reliable medicines that are compatible with other treatments to free or unlock the natural healing reactions of the body. Not only taking into account the disease but also the patient individual reaction, it allows us to propose a comprehensive or holistic treatment, to simultaneously solve the different problems of our patients.

OF COURSE, WE ARE THEN CONFRONTED WITH OTHER QUESTIONS: What are medicines made of? How are they chosen for each case? What diseases can be treated? And we must learn to answer them by keeping in mind to use an easy and accessible language, not proposing concepts that trigger more problems than opportunities and looking at generating interest rather than remaining too academic. Generally, from that point on, the best thing is to take any occasion to give examples.

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How to communicate on homeopathy in order for people to listen to you…

BARCELONA 2017

heard: This is not a religion. My patients come back because it works. There are numerous scientific studies, etc.

I PROPOSE THE ANSWER that I heard from a French trainer a few years back, i.e. being able to ask: n “Why do you say that?”

1. IF THE PERSON SAYS THAT SHE READ IT IN A NEWSPAPER, it will be sufficient to say that your professional practice is based on scientific data and clinical experience, and it is too bad that the media are not better informed. Afterwards, ask her what you can do to make her change her mind.

2. IF SHE ANSWERS THAT MEDICINES ARE SO DILUTED THAT THEY DON’T CONTAIN ANYTHING, answer her that the manufacturing is about the dilution and dynamisation and that this process, validated by the Health Authorities, produces active substances with specific physicochemical properties, but mostly they produce biological effects demonstrated in the experiments. It is simply impossible for them not to contain anything, because they are producing these effects.

3. IF THE PERSON ANSWERS THERE ARE NO STUDIES, ask again: “Why do you say that?” and when she has answered, add that when you search in PubMed you find more than 6,000 publications, some of them published in conventional journals (such as The Lancet or The British Medical Journal).

4. IF SHE BRINGS UP THE ARGUMENT THAT NO ONE HAS BEEN ABLE TO PROVE IN A SCIENTIFIC STUDY THAT HOMEOPATHY CAN CURE A DISEASE, give the example

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that you like to tell, find yours and study it until it becomes your own: allergic rhinitis and asthma, fibromyalgia, otitis… Personally and according to circumstances and the profile of the person in front of you, I like to give the example of patients intubated in an Intensive Care Unit in Vienna and the one from the London Observatory that manages chronic patients referred by their physician.

5. BUT ALWAYS END BY TALKING ABOUT YOUR CLINICAL EXPERIENCE and explain that for this famous evidence-

based medicine, experience associated with research is one of its pillars, the third one being the preference and values of patients. Talk about the fact that homeopathy is requested by more and more patients, because of the

We have very powerful messages that the public needs to hear: we must practice to deliver them while avoiding all things too abstract and complex, to better focus on the way homeopathy enriches physicians and patients alike”

“

positive results that they experienced themselves or heard from their closed ones and friends. If you don’t remember a specific study (I purposely did not list the references because there is nothing worse than talking about something that one doesn’t master), direct the person to a Web page where she can find this information (personally I recommend the FAQ web page of the HRI, available in several languages).

WHEN A SCIENTIFIC DEBATE EMERGES, we can be faced with several scenarios, from the gross ridicule (where one should remain patient and serene, using this time to share our messages rather than answering critics) going through the usual objections (previously seen in this article) to the academic-scientific debate based on negative popular reviews previously published (Lancet 2005, UK Science and Technology Committee 2010, NHMRC Australia 2015). One who loves research is already aware of the strong points and weak spots of these review studies and knows how to answer. There is no need to explain them to somebody who is not familiar with them and who would not be completely comfortable explaining them. However, it is easy for everyone to remind our

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audience that results depend on the criteria used when conducting the review and mention another report, much more comprehensive this time, requested by the Swiss government (the summary was published in a scientific review in 2006 and the complete report was published in a book in 2011), which was not only favorable to homeopathy but associated with a referendum that led the health services of the country to integrating homeopathy in practice. The fact that there is controversy is normal and the lack of awareness is precisely one of the characteristics of scientific knowledge, thus encouraging us to move forward. Consequently, I insist on the fact that you are trained homeopathic physicians with experience, and when comes the time to choose one type of treatment or another in certain patients (there can be many of them) you will find that homeopathy has its place, as a first-line treatment or in complement to other interventions.

the way homeopathy enriches physicians and patients alike. The best thing to do is to give examples that one must prepare ahead of time. • We need to learn how to better communicate about what we have done up to now with clear, interesting and accessible ideas. All this with a positive, constructive and conciliate (integrative) attitude. • We assume the responsibility to promote homeopathy. To colleagues, family and friends, patients and associations. Sooner or later, also on social networks (it only takes one “like” and a “retweet” or “share” of what is positive, whether it is once a day or seven times a week). Some might endorse this responsibility in conference and scientific journals, with accessible studies that infiltrate, little, by little, our scientific community. Others will have the pleasure to be involved in massive communication means: with practice, training and by paying attention to the strategy dictated by their Scientific Society, they will contribute to homeopathy in a distinctive manner thanks to their professional experience, as a communicator or scientific promoter.

Conclusion

We wish a lot of hope and enthusiasm to each and every one of you in this great communication adventure.

• We have very powerful messages that the public needs to hear: we must practice to deliver them while avoiding all things too abstract and complex, to better focus on

ACKNOWLEDGEMENT We would like to thank Dr. Guillermo Basauri and Dr. Gonzalo Fernandez Quiroga. My colleagues for the “Hablando de Homeopatía” blog, the communication

Table: Keys to talk about homeopathy MISTAKES TO AVOID

SENTENCES TO AVOID

CHARACTERISTIC ADVANTAGES

There no longer remains any active substance

Therapeutic method: complementary (in association with) other techniques or interventions

Using complicated words and expressions

We do not know the mechanism of action

Dilutions: better tolerated medicines

Looking for explanations in “alternative” medicines

There are no side effects

Similitude: it triggers in the body reactions of restoring the health (homeostasis)

Being negative and talking about our problems

There are no clinical studies and those cannot be conducted in the same manner

Individualization: possibility of helping the patient in a holistic manner

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Attacking the conventional system

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How to communicate on homeopathy in order for people to listen to you…

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team of the Homeopathy National Assembly and the support we received from Atrevia and the communication team at Boiron. To the participative learners and detractors (sceptics) who, in light of their high level of expectations, continue to motivate us to communicate better every day.

• https://gualbertodiaz.wordpress.com/ category/ investigacion/ (specifically look to the tab “destacados de investigación”)

RECOMMENDED READINGS AND VIDEOS

• https://www.hri-research.org/resources/ homeopathy - the-debate/

• Gualberto Díaz-Sáez. Communiquer sur l’homéopathie : savoir et “savoir faire” [To communicate about homeopathy : knowledge and "know-how"]. Rev Med Homeopat 2010 ; 3: 141-6 - DOI : 10.1016/S1888-8526(10)70075-8.

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• https://gualbertodiaz.wordpress.com/category/ entrevista/

• https://www.hri-research.org/es/homeopathy -faqs/

• http://www.hablandodehomeopatia.com/ que-es-la-homeopatia/ • http://www.hablandodehomeopatia.com/enlos-medios/ n

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Place of homeopathy in EVERY6TH INTERNATIONAL CEDH CONFERENCE DAY

Ankylosing spondylitis

BARCELONA 2017

Maryvonne Nadaud-Lechner, MD, France

fter a general overview, this work will have a dual objective:

• Giving a comprehensive array on what can be proposed as a homeopathic therapeutic in the care management of patients with ankylosing spondylitis, reasoning in the common homeopathic approach: etiology, pathophysiology,

symptoms, chronic reactional mode and sensitive type. • Demonstrating, as done during the Barcelona conference, that homeopathy is in ankylosing spondylitis a real integrative medicine, as defined by Dr Cloé Brami: “a medicine using unconventional medicines that have showed effectiveness, tolerance and safety, given in addition to treatments of reference, for a global care management of the patient”.

A link will be made with: “Ankylosing spondylitis around 12 clinical cases” presented at the Barcelona Conference on October 6-7, 2017 by Drs. Martine Tassone, Jean-Marc Saillard and myself.

Generalities

There is a hereditary factor, because, very often, we find in the patient’s family a similar rheumatoid affection.

Ankylosing spondylitis is an inflammatory condition, similarly to these other chronic inflammatory rheumatoid diseases:

ON A PATHOPHYSIOLOGICAL LEVEL

This is an autoimmune disease affecting young adults (before the age of 50) that is more frequent in men than women (three men for two women). The prevalence rate for this affection is 0.5 to 2% of the population.

It is interesting to note that contrarily to Rheumatoid arthritis (RA), in AS the synovial joint is not the one mostly affected. The initial essential lesion is an important inflammation of the enthesis – the junction area between the bone and attached structures: tendon, capsule, ligament -, the secondary lesion will be the synovial joint and thus will trigger peripheral joint affections.

JANUARY 2018 CEDH MAGAZINE

• Reactive arthritis (ReA), including Reiter’ syndrome; • Enthesitis-related arthritis (ERA); • Psoriatic arthritis; • Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome; • Juvenile rheumatoid arthritis.

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6TH INTERNATIONAL CEDH CONFERENCE

Place of homeopathy in Ankylosing spondylitis

BARCELONA 2017

The preferential and main localization are the entheses areas: • sacroiliacs; • spinal cord; • calcaneus; • enthesis of the phalangeal joint and capsule joint. Secondarily, the evolution of this entesopathy will progress towards ossification via the following steps: • bone erosions with fibrosis and scarring; • bone remodeling, progressing over several years; • ankylosis and stiffness, corresponding to the complicated and/or very severe forms.

 Ankylosing spondylitis is diagnosed if there is an association of a major and minor criterion of the ESSEG classification (European Seronegative Spondylarthropathy Group), however this classification is less used in routine practice. t MAJOR CRITERIA

MINOR CRITERIA

1. Inflammatory back pain

1. Family history of spondylarthropathy, psoriasis, uveitis, reactive arthritis or inflammatory bowel

2. Asymmetric synovitis or predominant to the lower limbs

2. Psoriasis (history or presence)

DIAGNOSTIC CRITERIA OF THE DISEASE

3. Chronic inflammatory bowel disease (IBD) or urethritis.

We will first look at the Amor criteria and ESSEG classification.

4. Alternating buttock pain

 The diagnosis of AS is validated if the total of all the points on the twelve criteria, listed in the Amor classification, is ≥ 6. t

Symptoms or history of the disease

5. Enthesopathy (Achilles heel or plantar) 6. Stage 2 Sacroiliitis if bilateral or stage 3 if unilateral as evidenced by plain radiography

Points

Clinical symptoms and imaging / genetic data + treatment response 1. Nighttime low-back pain or back pain and/or morning stiffness of the lower back or back

2. Asymmetric oligoarthritis

3. Undefined buttock pain

JANUARY 2018 CEDH MAGAZINE

Alternating buttock pain

4. Dactylitis “sausage-like” fingers and/or toes

5. Heel pain or any other entesopathy

6. Iritis

7. Non gonococcal urethritis or cervicitis less than one month before the onset of arthritis

8. Acute diarrhea less than a month before the onset of arthritis

9. Presence or history of psoriasis and/or balanitis

10. Sacroiliitis (stage >2 if bilateral or stage 3 if unilateral)

11. Presence of HLA-B27 + or FH of SpA and/or family history of pelvi-spondylitis, Reiter syndrome, psoriasis, uveitis, chronic inflammatory bowel disease (IBD)

12. Improvement of the pain in 48 hours with NSAIDs and/or quick aggravation (48 hours) of the pain when stopping NSAIDs

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Place of homeopathy in Ankylosing spondylitis

6TH INTERNATIONAL CEDH CONFERENCE BARCELONA 2017

Another criterion can be taken into account for the diagnosis. It is a biological criterion: studies have shown that in 90 % of ankylosing spondylitis cases, patients presented with the human leukocyte antigen B27 (HLA-B27). Finally, one should take into account another element: the existence of a bacterial infection: In AS there rarely is the notion of a specific CFU or direct action of infectious agents but a pathological reaction at the contact of certain bacteria (Klebsiella, Mycoplasma, Chlamydia…) mostly via the digestive tract or urogenital tract. Thus, we observed in a large percentage of patients (75%) intestinal lesions similar to those observed in intestinal pathologies. We can then underline the implication of the gut microbiota, promoting an increased intestinal permeability in these spondylarthropathies.

THERAPEUTIC ARRAY OF CONVENTIONAL MEDICINE IT IS EFFECTIVE ON AS AND ACTS ON DIFFERENT LEVELS: • First the treatment aims for pain relief via NSAIDs and steroids. • The long term treatment has for objective to stop or slow down the progression of AS with major medicines, mainly: - Sulfasalazine (Salazopyrin®); - Methotrexate, less used now with the arrival of TNF inhibitors; - Most recently TNFa inhibitors. • Functional rehabilitation is an important element of the treatment as well as the prescription of postural orthoses or splints. • Prosthetic surgery can also be a therapeutic option.

Homeopathy and AS

• Medicines that can take into account a possible etiology. In the study of 12 AS cases presented at the Barcelona conference, four patients spontaneously talked about a triggering factor in the onset of their disease: a divorce (two cases), death of a family member (one case), following childbirth (one case). For any homeopath, the evocation of these traumas can lead to an adapted prescription; • Symptomatic medicines taking into account the clinical expression of the disease and the patient’s experience (Individual Reaction of the Patient - IRP); • A long-term treatment taking into account the progression of the disease (its chronic reactional mode, CRM) as well as specificities of the patient (sensitive type, ST). We propose to proceed with the clinical study of AS on the joint affections and list the symptomatic homeopathic medicines but also define the CRM and/or ST. We will underline the results of the study presented in Barcelona.

CLINICAL STUDY OF AS AND FIRST REFLECTIONS ON HOMEOPATHY

1. AXIAL SPONDYLOARTHRITIS First, there are recurrent inflammatory episodes with buttock and low-back pain (followed by back pain) indicative of the disease: n BUTTOCK PAIN, most often alternating pain, often well localized that can be associated with limping when walking and/or radiating towards the outer thigh up xto the popliteal fossa, similar to a “pseudo-sciatica”.  Allium sativum  Kalium bichromicum  Ruta graveolens  Rhus toxicodendron  Bryonia  Kalmia latifolia  Hypericum perforatum Plain radiographs show a bilateral sacroiliitis, this symmetrical affection evidences the AS.

JANUARY 2018 CEDH MAGAZINE

Homeopathic therapeutic will be a firstline treatment, alongside and/or after conventional medicine by bringing in a new approach taking into account a possible etiology, of course the pathophysiological context (targets) but above all taking into account the patient in his/her globality.

IMPLEMENTING THE HOMEOPATHIC TREATMENT IS DONE THE USUAL WAY VIA THE PRESCRIPTION:

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6TH INTERNATIONAL CEDH CONFERENCE

Place of homeopathy in Ankylosing spondylitis

BARCELONA 2017

n INFLAMMATORY SPINAL ARTHRITIS affecting the thoracic and lower spine (knowing that the entire spine can be affected). Pain gets worse with rest, associated with morning stiffness improved by progressive movements.  Rhus toxicodendron  Radium bromatum Spine affection, often with an upward progression, that can worsen with loss of lumbar lordosis, onset of thoracic kyphosis and later lumbar and thoracic ankylosis. Plain radiographs of the spine will underline the characteristic symptoms of AS, especially: • Syndesmophytes (bony bridges leading to “bamboo spine”); • Erosion of the upper corner of the vertebra; • Vertebral squaring; • Posterior facet joint arthritis, ultimate stage progressing towards ankylosis; - Osteoporosis with sometimes vertebral collapse in in at least one third of the patients affected.  Calcarea fluorica  Aurum metallicum  Medorrhinum  Silicea / Calcarea fluorica

2. PERIPHERAL AFFECTION It is an asymmetric oligoarthritis predominant to the lower limbs with two preferential locations:

 Ruta graveolens / Ledum palustre  Hekla lava  Medorrhinum/ Calcarea fluorica

When listing the different progressing joint affections of AS, several homeopathic medicines were underlined, some more will be associated:

THE FIRST MEDICINES OF INFLAMMATION  Rhus toxicodendron,  Ruta graveolens,  Radium bromatum (its targets of action includes the lumbosacral spine, knees and toes),  Bryonia,  Prostaglandins E2 15 CH

MEDICINES FOR LOCAL ACTION:

TARGET FOR THE SACROILIACS: AESCULUS HIPPOCASTANUM lumbar and sacroiliac pain associated with pelvic congestion.

AMMONIUM MURIATICUM • Hip with a painful limitation when mobilizing the joint; • “Sausage-like” toes with metatarsal-phalangeal and proximal and distal interphalangeal affections.

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 Natrum sulfuricum  Causticum  Calcarea fluorica  Medorrhinum

3. SPECIFIC AFFECTION OF THE ENTHESIS OFTEN A PRELUDE TO AS Heel pain with pain when pressing on the enthesis (insertion of the plantar aponeurosis or insertion of the Achilles’ heel), edema in regards to the insertion of the Achilles’ heel and X-rays evidencing calcaneal spur with irregular facets.

sacroiliac pain and medicines for lumbar sciatica, aggravation when sitting down and presenting the sensation for “retracted or too short tendons”.

KALIUM CARBONICUM throbbing joint pain improved by sitting on a board or hard chair.

ELECTIVE ACTION ON SYMPHYSES IN GENERAL WITH POTENTIAL OSSIFICATION: CALCAREA PHOSPHORICA with painful sensitivity of the sacroiliacs unveiled with changes in climate conditions (snow melting).

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CALCAREA FLUORICA very important in calcifications, osteophytes and ossification of sacroiliac and intervertebral tendons and ligaments.

 Sulfur (and alternation or concomitance with digestive episodes)  Sulfur iodatum 2/ HOWEVER, it is obvious that the dominant chronic reactional mode in the evolution of the disease with slow, progressive and insidious development is the Sycotic Reactional Mode with mainly:

ELECTIVE ACTION ON THE PELVIC AREA (AND SCAPULAR BELT): DULCAMARA

MEDORRHINUM

muscle and tendon pain, with stiffness and ankylosis, triggered or aggravated in cold and damp weather. Possible alternation of rheumatoid joint pain and diarrhea episodes.

for its elective action on the tissues, histopathological similitude: affection of the large joints, spine with syndesmophytes, stiffness and ankylosis; calcaneal bone spurs, inflammation of the mucous membranes (digestive, genital and ocular).

MEDICINES FOR THE EVOLUTION TOWARDS ANKYLOSIS: CAUSTICUM is certainly at the forefront for spine pain and arthritic pain, mainly for hip pain, with joint stiffness, and all types of tendinitis with tendon retractions. Muscle spasms or cramps.

TUBERCULINUM RESIDUUM is relevant for its elective action on fibrousconjunctive and aponeurotic tissues, with retraction, fibrosis, ankylosis and stiffness improved by movement and pain unrelated to climate conditions.

THEN THUYA OCCIDENTALIS for intensive treatments and steroids, obsessional depressive tendency…

NATRUM SULFURICUM for its elective action on the articular or periarticular conjunctive tissue, its action on the lumbar spine, hips and also for its relevance in some enteropathies.

CAUSTICUM already listed previously.

We could discuss the Sensitive Types most often found in AS.

FOR A PROGRESSION TOWARDS PAINFUL THORACIC ANKYLOSIS, WE CAN PROPOSE: ASCLEPIAS TUBEROSA elective action on the periarticular tissues, especially on intercostal tendons and muscles with tearing, pounding or bruising pain.

The therapeutic strategy in homeopathy, and in this case in the context of AS, should have us look at the chronic reactional mode of this disease.

with weight loss, lumbosacral stiffness and the fluoric morphology. But also: Kalium carbonicum, Lycopodium clavatum aging into Causticum, Phosphorus aging into Causticum, Causticum itself…

In the study presented in Barcelona, there were 12 cases, seven of them treated only with homeopathy and five treated by the association allopathy and homeopathy. The efficacy criteria for the study were: pain, fatigue, sleep, emotional impact and impact on daily life activities.

JANUARY 2018 CEDH MAGAZINE

1/ The first inflammatory flare-ups can be separated by lengthy intervals without episodes, the Psoric reactional mode is at first a reference and if it the intervals between flare-ups are shorter and patients experience fatigue, the Psoric –Tuberculinic mode will be at the forefront.

NATRUM MURIATICUM

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6TH INTERNATIONAL CEDH CONFERENCE

Place of homeopathy in Ankylosing spondylitis

BARCELONA 2017

THREE STRONG ELEMENTS WERE EVIDENCED:

AS is an autoimmune disease with rheumatoid symptoms.

THE FIRST ONE concerns the dominant prescription: • Secondly, if we compare the Amor criteria and the Materia Medica of Medorrhinum, we can see a clinical similitude with affection of the lumbar spine, sacroiliacs, peripheral affections (“sausage-like” toes and heel pain) and even urethritis.

• For the medicines of the IRP, Rhus toxicodendron, followed by Radium bromatum, Bryonia, Causticum and Tuberculinum. (It is useful to underline that all medicines listed previously in the article have their importance when they correspond to the target and the Individual Reaction of the Patient)

Medorrhinum also fits the study criteria and its impact is quite important when there is fatigue, sleep disorders complicated by restless leg syndrome, as well as emotional disorders such depression and anxious agitation.

• For CRM and ST medicines, Medorrhinum followed by Natrum muriaticum, Calcarea fluorica, Natrum sulfuricum and Causticum.

It is also the medicine of the Sycotic CRM preceding the Luesis when these bony bridges appear transforming the spine into a “bamboo spine”.

THE SECOND ELEMENT concerns the results of the study showing a significant improvement for all study criteria. One should note that for these 5 cases, the allopathic treatment provided proper pain relief, criterion not impacted by the addition of the homeopathic treatment.

In the study, Medorrhinum was prescribed at all stages of the disease, as a medicine for the histopathological similitude, symptomatic medicine taking into account the individual reaction of the patient, but also as a terrain medicine taking into account the chronic reactional mode and specific elements of the sensitive type. If one looks at the existence of a bacterial infection in the onset of AS, should we not think about the possibility of prescribing Medorrhinum as an… etiology medicine?

THE THIRD POINT concerns the issue of the importance of Medorrhinum: prescribed in 10 out of the 12 cases of the study, it appears as an inescapable medicine for the homeopathic treatment of this pathology and this can be explained. • First, it is a deep-action biotherapeutic and its targets are the immune system and joints, and we know that

Study results on the pre-defined criteria for the 5 cases treated with associated treatments

5 Scale of 0 to 10

Scale of 0 to 10

JANUARY 2018 CEDH MAGAZINE

Study results on the pre-defined criteria for the 7 cases treated only with homeopathy

4 3

1 0

Pain

Fatigue

Before treatment *After a 3 to 6-month treatment period

Sleep

Emotional impact

After treatment*

Daily impact

Pain

Fatigue

Allopathy alone *After a 3 to 6-month treatment period

Sleep

Emotional impact

Daily impact

Associated to homeopathic treatment*

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B/ EXTRA-ARTICULAR AFFECTIONS OF AS AND PROPOSITION FOR HOMEOPATHIC MEDICINES (alongside “conventional” treatments)

They can be of different natures: • FIRST OCULAR AFFECTION manifesting as acute anterior uveitis with a painful red eye. In light of these symptoms you should refer your patient to a specialist and think of Cinnabaris. • THEN, THE BOWEL AFFECTION evidenced in almost two-thirds of cases during systematic endoscopies with a potential enteropathic arthritis syndrome bringing up Dulcamara and Natrum sulfuricum. • THEN THE PULMONARY AFFECTION, which can be secondary to the inflammatory affection of the chest and stiffness of the ribs. A restrictive lung disease is possible, bringing up the indication of  Carbo vegetabilis and/or  Prostaglandines F2 15 CH (for spastic types), with potential pulmonary fibrosis:  Calcarea fluorica – or bronchial dilatation:  Calcarea fluorica,  Silicea,  Stannum metallicum… • FINALLY, BUT MORE RARELY, A HEART AFFECTION can manifest itself with conduction disorders or, valvulopathy, and  Phosphorus can be proposed…

 Nux vomica,  Colocynthis,  Cocculus indicus,  even Phosphorus that could be regularly prescribed, especially at the beginning of the treatment to ensure the hepatic tolerance of the medicine but also renal, neurological and cardiac protection.

• METHOTREXATE less used in fact, however a homeopathic approach is still relevant. THE MOST COMMON ADVERSE EVENTS ARE: • inflammation of the oral mucosa with lesions in the mouth, • decreased red cells (anemia), • nausea, • abdominal pain, and loss of appetite, • malaise, • excessive fatigue, • dizziness, • chills and fever, • decreased resistance to infections, • increased transaminases. THE HOMEOPATHIC IMPACT COULD BE ESSENTIAL WITH MEDICINES SUCH AS:  Mercurius corrosivus and  Nitricum acidum,  China rubra,  Nux vomica,  Colocynthis,  Silicea,  Phosphorus….

• TNFA INHIBITORS Adverse side effects are dominated by the infectious risk and potential risk of aggravation of an eventual common infection. There were also some rare cases of aggravation of multiple sclerosis and exceptionally cardiac failure.

• SULFASALAZINE (SALAZOPYRIN®)

A SIGNIFICANT RELEVANCE WITH:

Sides effects are digestive and sensory (dizziness, vertigo) ones. We do have an answer for them in homeopathy with for example:

 Silicea,  Pyrogenium,  Phosphorus…

IN THIS CASE ALSO, A HOMEOPATHIC TREATMENT COULD HAVE

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C/ REFLECTION ON THE POSSIBILITIES OF HOMEOPATHY IN THE CARE MANAGEMENT OF THE SIDE EFFECTS OF CONVENTIONAL MEDICINE

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6TH INTERNATIONAL CEDH CONFERENCE

Place of homeopathy in Ankylosing spondylitis

BARCELONA 2017

It is important to say that the homeopathic care management of the patient, i.e. in his/her globality works effectively towards a better tolerance to the conventional recommended treatment and thus promote better treatment observance.

Conclusion Ankylosing spondylitis is a difficult pathology with a fearful progression. It is essential for the physician to implement an effective therapeutic adapted to his/her patient focusing on three objectives:

JANUARY 2018 CEDH MAGAZINE

• relieving physical and psychological pain; • space out the inflammatory flare-ups; • stabilize and slow down the progression by limiting to the maximum the onset of adverse side effects with conventional treatments.

“

The work presented shows once again the importance of homeopathic therapeutic which, far from being a comfort therapeutic, can be fully considered as an essential addition integrated within the multidisciplinary management of this chronic inflammatory pathology”.

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6TH INTERNATIONAL CEDH CONFERENCE

Fatigue in Cancer Patients Point of view of a community pharmacist

BARCELONA 2017

François Roux, PharmaD

oday, in France, the homeopathic therapeutic in oncology supportive care is becoming more predominant. At the forefront, oncologists recognize the benefits of a homeopathy complementary treatment for their patients. Furthermore, they became aware that their patients could use phytotherapy,

aromatherapy or nutritional supplements to improve their health and that it might lead to some major risks of medication interactions with the chemotherapy molecules. Homeopathy, besides its effectiveness, does not present this same risk of harmful interactions. This is why oncologists give it a place of choice, and this is becoming a growing trend.

Place of the community pharmacist in the care pathway of cancer patients

by community pharmacists: setrons (Ondansetron Zofran®), aprepitant Emend®;

Cancer patients are more present in the community pharmacy and the pharmacist is more and more solicited.

The community pharmacist has an important role to play in the cancer patient’s care pathway, at the forefront the delivery and explanation of prescriptions in order to facilitate the observance and increase treatment compliance. It is an undeniable and essential complementarity with the oncologist and oncology nurses.

THERE ARE SEVERAL REASONS FOR THIS: n The development of outpatient care management and oral cancer treatments, especially targeted oral therapies;

n Antiemetic agents of reference, which are no longer delivered by hospital pharmacies, and are now delivered

One should note that in France, since 2009 and the HPST (Hospital Patients Health Territories) law, the missions of the pharmacists were officially recognized or completed, positioning the community pharmacy at the heart of the healthcare system.

JANUARY 2018 CEDH MAGAZINE

n Oral chemotherapy treatments available in community pharmacies: vinorelbine Navelbine®, capecitabine Xeloda®, erlotinib Tarceva®, abiraterone Zytiga®…

• Drugs promoting red and white cells’ growth, hemopoietic growth factors (Aranesp®, Neorecormon®), lenograstim Granocyte®, pegfilgrastim Neulasta®…

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6TH INTERNATIONAL CEDH CONFERENCE

Fatigue in Cancer Patients: Point of view of a community pharmacist

BARCELONA 2017

Article 36 integrates pharmaceutical advice in first-line care management. Article 38 lists the new missions of the community pharmacists and specifically therapeutic education and cooperation between the different healthcare professionals. This cooperation, this complementarity between the physician and the pharmacist, are particularly important in the context of chronic patients and everyone knows that cancer is becoming much more of a chronic pathology.

THE COMMUNITY PHARMACIST IS ALSO ABLE TO PROPOSE SUPPORTIVE CARE SUCH AS HOMEOPATHIC MEDICINES, n either as first-line treatment to limit nausea for example in addition to the prescribed Setron, or by directing patients to an homeopath for a consultation, n or by collaborating, as I have been doing with pleasure, especially with my friend Dr Maryvonne Nadaud-Lechner.

HOWEVER, THERE ARE SEVERAL OBLIGATIONS FOR THE PHARMACIST AND HOMEOPATHIC PHYSICIAN: n Train on the cancer pathology (speaking the same language as the oncologist); n Knowing the different chemotherapy protocols and their major side effects, one of the most important ones being fatigue.

Focus on asthenia

JANUARY 2018 CEDH MAGAZINE

According to the AFSOS (French-Speaking Association for Oncology Supportive Care) guidelines dated December 3, 2010, asthenia can be defined by the subjective sensation of abnormal, chronic fatigue, without any immediate cause (absence of effort or minimal effort) not improved by rest and clinically significant.

We will differentiate physical asthenia generally predominant in the evening or at the end of the afternoon from psychological asthenia generally predominant in the morning often associated with psychopathological symptoms. In oncology, we can use both terms: fatigue or asthenia with the same meaning.

According to epidemiological data regarding frequency of fatigue, we estimate that globally 80% of cancer patients present with fatigue. 60 to 100 % of patients experiment fatigue during their care management, and for 50% of them they experience it right from the beginning of their care management. 80 % of patients report lingering fatigue at distance from the treatment. Severe fatigue after the end of the treatment is reported by 17 to 38% of patients.

“

In oncology, systematic screening for fatigue, even in the absence of complaint, is recommended”. We could even bring up the fatigue of the caregiver …

NON-PHARMACOLOGICAL APPROACH AND RECOMMENDATIONS As a first-line healthcare professional, the community pharmacist should act as a healthcare advisor and recommend to his/her cancer patients to practice a physical activity, ideally 45 to 60 minutes, 2 to 5 times a week. This activity should be adapted to the patient, ideally aerobic exercise. We can list walking, cycling, calisthenics, water exercise, yoga, but also like in Toulouse, France in patients after breast surgery, rugby or fencing in program initiated by Dr. Dominique Hornus.

PHARMACOLOGICAL APPROACH AND RECOMMENDATIONS Of course the first thing will be to treat a potential anemia. However, there are no reasons to give steroids, progestin or L-carnitine.

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In recommendations we can list the potential relevance of guarana (2010 ASCO conference), a potential relevance (yet not evidenced) for amphetamines and ginseng. Two studies conducted by the American team of Barton et al published in 2010 and 2013 showed the efficacy of panax quinquefolius or American ginseng and it has been used in certain supportive care departments in France for post-cancer fatigue. No other medicine has a sufficient level of evidence to be recommended and it is a vast and exciting project to propose a homeopathic database in the framework of AFSOS, project initiated by Jean-Lionel Bagot, MD and JeanClaude Karp, MD both at the origin of the creation of the SHISSO (International Homeopathic Society for Supportive Care in Oncology).

Etiological evaluation of fatigue and pharmacological answers First we would need to look at the main reasons for this fatigue, i.e. stress of course, but also malnutrition, weight loss, depression, loss of bodily fluids (vomiting, diarrhea), decreased white and blood cell counts and specifically anemia.

• THE COMMUNITY PHARMACIST CAN ALSO BRING ANSWERS ACCORDING TO EACH SITUATION: n STRESS: Gelsemium, Ignatia amara; n LOSS OF BODILY FLUIDS (VOMITING, DIARRHEA):

China rubra;

Phosphoricum acidum, concentrated phosphoric acid H3PO4, is an important medicine for physical and psychological fatigue with depression due to exhaustion, withdrawal, daytime sleepiness and nighttime insomnia with tiring diarrhea. In Phosphoricum acidum, psychasthenia consists of cognitive disorders preceding physical fatigue. n Phosphoricum acidum will be the easiest medicine for fatigue to prescribe in an almost systematic manner, either in 30 CH daily or weekly, or in increasing dilutions with the following doses in this order: 9-12-15-30 CH over 4 consecutive days after each chemotherapy course.

This prescription in increasing doses, after each chemotherapy cycle, after the effects of steroids and after nausea, i.e. generally from D4 seems in my experience very interesting and effective. It promotes an easy observance and avoid giving a too complicated homeopathic treatment, yet will manage an important number of adverse side effects by taking several takes per day.

EXAMPLE OF CAPECITABINE OR XELODA® Capecitabine is a prodrug that is enzymatically converted to fluorouracil (antimetabolite) in the tumor, where it inhibits DNA synthesis and slows growth of tumor tissue. Its main adverse events are fatigue and diarrhea that can lead to hospitalization. In my opinion it is relevant to implement right from the beginning of the cancer treatment a homeopathic supportive care therapeutic with sentinel medicines as detailed by Dr. Guy Villano in this same CEDH Magazine (n° 45, May 2017).

• TO THIS EFFECT WE CAN PROPOSE n China rubra 15 CH and n Phosphoricum acidum 30 CH, 5 pellets of each once a day right from the first take of Capecitabine.

JANUARY 2018 CEDH MAGAZINE

n AFTER SURGERY IF THERE IS HEMORRHAGING: Phosphorus, China rubra; n ACCORDING TO THE CBC: Phosphorus, Meduloss, Silicea; n LOSS OF APPETITE: Ignatia amara, Natrum muriaticum; n SLEEP DISORDERS: Gelsemium, Aconitum napellus, Arsenicum album, Phosphoricum acidum.

FOCUS ON PHOSPHORICUM ACIDUM

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6TH INTERNATIONAL CEDH CONFERENCE

Fatigue in Cancer Patients: Point of view of a community pharmacist

BARCELONA 2017

ON THE OTHER HAND WE CAN RECOMMEND SYMPTOMATIC MEDICINES FOR DIARRHEA SUCH AS

n n n n

Aloe, Podophyllum peltatum, Arsenicum album, Veratrum album… after each diarrhea episode. IN THIS CASE, n Arsenicum album prescribed in 15 CH can also be a good complement of n Phosphoricum acidum 30 CH in fatigue.

Fatigue in cancer patients is thus a major adverse effect of most chemotherapies, and the community pharmacist will be able to help manage it with homeopathic supportive care. It would be wise however to re-evaluate quickly and frequently the advice of the pharmacist and when possible refer the patient to a homeopath who will have a more comprehensive and astute vision of the situation.

JANUARY 2018 CEDH MAGAZINE

This is a great opportunity to implement a partnership between the different healthcare professionals. Homeopathy is really a chance for the community pharmacist, the cancer patient and oncologist. n

“

Homeopathy is really a chance for the community pharmacist, the cancer patient and oncologist”.

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EVERY6TH INTERNATIONAL CEDH CONFERENCE DAY

Fatigue in supportive care homeopathic approach and prescription

BARCELONA 2017

Jean-Claude Karp, MD, France Marie-Hélène Ribreau, MD, France

ur presentation follows the one given by Professor Père Gascon, Spanish oncologist, and François Roux, PharmD. We will get back to the different points covered to develop the possibilities of a consultation in supportive care, with a primary care physician, Marie-Hélène Ribreau, MD and an oncologist homeopath,

Jean-Claude Karp, MD. Our objective is to enlighten homeopathic physicians on a simple method for the care management of the “fatigue” symptom in cancer patients, throughout their care pathway: diagnostic screening, revelation of the diagnosis, up to remission.

SYNTHESIS OF PROFESSOR GASCON’S PRESENTATION In his presentation, he underlined the fact that fatigue is a pathological fatigue, clashing with the patients daily life habits. The patient and/or his closed ones observe a decreased energy, lassitude and can point out to everything the patient is no longer doing “like he used to”; even if it is just playing cards with friends twice a week, one should take it into account. Oncologists and patients tend to downplay fatigue considering it a normal consequence of the disease and treatments. In fact, 50% of patients do not speak about it to their oncologist.

THERE ARE MULTIPLE CAUSES FOR FATIGUE • DIRECT CAUSES related to the disease and chemotherapies; • INDIRECT CAUSES: anemia-related, radiotherapy-induced inflammation, especially in the treatment of brain and adrenal metastases, anxiety, depression and malnutrition. Then, Professor Gascon developed the importance of early screening for anemia, a known negative factor of fatigue progression. Based on several published studies, he demonstrated that the presence of anemia before cancer treatment was linked to a mean 65% increase in patient mortality, regardless of the cancer type.

JANUARY 2018 CEDH MAGAZINE

However, numbers are alarming: 75% of cancer patients experience this fatigue at one point or another in their care pathway, 57% say “they cannot enjoy life to the fullest”, and 91% report that “fatigue prevents them from leading a normal life”. Finally, 28% are on permanent sick leave because of their disease.

It is thus very important to replace fatigue at the core of our preoccupations and our patient’s interview during the consultation.

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6TH INTERNATIONAL CEDH CONFERENCE

Fatigue in supportive care: homeopathic approach and prescription method

BARCELONA 2017

Then he underlined the biological principles of anemia and the effectiveness of the different treatments studied. Oral iron supplementation is useless, because it is stocked in the macrophages. He insisted on using EPO (Erythropoietin) associated with iron in IV administration.

SPECIFIC APPROACH

Professor Gascon concluded by stating that fatigue should not be trivialized, it must be treated. Cancer treatments that are being studied right now must take into account two criteria: their effectiveness on patient survival but also on the patient’s quality of life.

• Systematically on the first-line of the prescription we start with: Phosphoricum acidum (see the presentation by François Roux, PharmD); • Second-line for symptomatic treatments of the factors generating or aggravating fatigue; • Third-line for prescribing a sensitive type medicine if possible.

Some advances must be made on other factors such as anxiety, depression and malnutrition. Fatigue is part of a comprehensive approach of the patient, which is difficult to implement in the short time dedicated to oncology consultations.

Before anything else, what do we list on our homeopathic prescription for the supportive care management of patient complaining about fatigue?

During chemotherapy courses an additional line will be useful.

REVIEW OF FATIGUE CAUSES IN CANCER PATIENTS

In light of this international observation and the presentation of François Roux, PharmD, here is what we want to share:

We can see on this table that we can group into three main themes the causes of fatigue: inflammation, deficiency and bone loss and psychological disorders.

n Homeopathy has an important role to play, in addition to the cancer treatment itself, to manage fatigue and its impact on quality of life. How can we do this in clinical practice?

As one can see on this graph, etiologies of fatigue in cancer patients can be grouped into

Anemia in cancer patients Cancer in itself Weight loss

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Depression

Medecine : anxiolytics, antidepressants opiates

Beguin. Leuk Lymphoma 1995; 18: 413-21 Ludwig & Fritz. Semin Oncol 1998; 25 (Suppl 7): 2-6 Ludwig et al. Hermatol J 2002; 3: 121-30 Wood & Hrushesky. J Clin Invest 1995; 95: 1650-9 Mercadente et al. Cancer Treat Rev 2000; 26: 303-11

Insomnia, stress

Anemia

Blood loss

Anemia due to inflammation Nutritional deficiency (iron/vitamin B12/ Folic acid)

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three main categories. Weight loss and direct consequences of the disease that will obviously impact all patients, but in our experience, patients from the Psoric Chronic Reactional mode will be the most affected. Patients from the Sycotic Reactional Mode will be disrupted by depression with rumination and repeated takes of medicines whereas patients from the PsoricTuberculinic mode will be weakened by stress, anemia by inflammation and loss of bodily fluids. n To be close to our daily practice, we will develop the homeopathic treatment possibilities, by following the chronology of the patient’s care pathway: • revelation of the diagnosis; • around surgery; • focus on anemia; • during chemotherapies; • during radiotherapy; • impact on quality of life.

The revelation of the diagnosis

FATIGUE SOMETIMES TAKES ROOT IN THE NEGATIVE EXPERIENCE OF THE REVELATION OF THE DIAGNOSIS. It is difficult to predict how the patient will react. Announcing a mortal disease is the equivalent of a “toxic shower” that will surpass the framework of the sensitive type of our patients, at least in the first days around this event, awaiting the results of the examinations, up to the “verdict”.

“ “ “

I felt like being hit on the head and I still have muscle pain”:  Arnica montana I felt stunned, unable to think, I could no longer hear anything, I was shaking”:  Gelsemium

I felt ashamed, dirty, as if I was affected with something disgusting” or “I feel betrayed, why me? What did I do to deserve this?” and “Since then I have been itching”:  Staphysagria

“

I panicked, I only had one thought: run away… my heart was going to explode”:  Aconitum

THESE MEDICINES WILL BE VALIDATED BY THE PATIENT’S CLINICAL SYMPTOMS It is possible to see, several years later, patients that bring up emotional suffering correlated to the announcement of the diagnosis. The diagnosis of the disease has been accepted, but not the way it was revealed. Their emotions stayed stuck, preventing the resilience process, and giving in to chronic fatigue, which becomes in itself a new pathology after the cancer. Patients become resentful, have a negative view on physicians, or they might be waiting for relief from symptoms that are hard to ascertain, and treat, like pain and chronic fatigue. It is always time to prescribe the adapted homeopathic treatment.

PAST THE MOST VIOLENT EMOTIONS RELATED TO THE REVELATION OF THE DIAGNOSIS, IT IS POSSIBLE TO PRESCRIBE MEDICINES FOR SENSITIVE TYPES THAT ARE MOST OFTEN IMPACTED, SUCH AS

 Nux vomica and Argentum nitricum in nervous, impatient patients. They are unsettled in the way they behave and by the slowness in the implementation of cancer treatments.  Lycopodium clavatum and Aurum metallicum in angry, anxious patients who lose their landmarks and the control on their health and life.  Natrum muriaticum and Ambra grisea in emotional,

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The French Cancer Plan greatly improved the diagnosis revelation protocol; however we still see many patients in our primary care consultations looking for further explanations and simpler terms. Some complain about sleep disorders and fatigue even before any treatment is implemented. The idea is to manage, without delay their complaint, with our homeopathic toolbox.

SOME EXAMPLES

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BARCELONA 2017

introvert patients who will try to protect themselves by putting up a brave front, with an emphasis on the unsaid.

WE CAN THEN LIST A PRESCRIPTION EXAMPLE: n Phosphoricum acidum 9 CH, 5 pellets twice a day during 1 month (fatigue) n Arnica montana 15 CH, 5 pellets, three times a day during 1 month (symptoms during the announcement of the diagnosis) n Nux vomica 15 CH, 5 pellets per day for 1 month then one dose per week during 3 months (Sensitive Type) TO BE REASSESSED ACCORDING TO THE EVOLUTION.

Around surgery The main idea is to avoid physical and psychological postoperative pain, which can also be at the core of the immediate or chronic fatigue. By avoiding the discomfort of surgery, the patient will better accept the rest of the treatment.

n Postoperative adynamic ileus:  Opium, Raphanus sativus niger n Thoracic surgery:  Asclepias tuberosa (costochondritis pain),  Ranunculus bulbosus (intercostal pain) n Pelvic surgery:  Bellis perennis n Retractile scar:  Causticum, Thiosinaminum

AND TO ANTICIPATE AND SUPPORT THE INBALANCE OF THEIR SENSITIVE TYPE,

TO AVOID THE DRAMA OF BODY IMAGE CHANGES AFTER SURGERY (mastectomy, colostomy, prostatectomy, facial palsy after neurosurgery, etc.)

SOME AT-RISK PROFILES:  Natrum muriaticum,  Platina,  Ignatia amara,  Staphysagria,  Aurum metallicum,  Lachesis mutus… all have a pre-existing sensitivity in relation to their body image for themselves, or their place in society, when facing the looks of others.

THE METHOD IS TO ANTICIPATE FATIGUE AND SENSITIVE TYPE

BEFORE SURGERY • AVOID ANXIETY:  Gelsemium, Aconitum, Arsenicum album (anxiety of death, fear of anesthesia, infections)… or any other medicine according to the patient’s symptoms. • AVOID BRUISING, HEMORRHAGING, MUSCLE PAIN:  Arnica montana.

OR TREAT

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AFTER SURGERY

According to the symptoms observed, or in prevention of those previously presented by the patient during a previous surgery: n Difficult wound healing:  Staphysagria n Postoperative edema:  Apis mellifica n Lymphocele:  Bovista gigantea, Rana bufo bufo

During cancer treatments, we are all subjected in the same manner to aggressions. According to our sensitive type and our specific sensitivity at the time, we will become more or less impacted. According to our potential for reaction, we will react more or less to the elements that affect us. Let’s take the example of the surgery illustrated above. A Natrum muriaticum sensitive type, affected by the morphological changes of adolescence will be more sensitive to psychological pain from the scar resulting from osteosarcoma treatment. This can be manifested by fatigue or depression. A Lycopodium clavatum sensitive type will most likely be very mildly sensitive to this aspect, but will develop fatigue with digestive disorders following anesthesia or analgesics treatment.

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Physical or psychological pain, stress

Operative and anesthetic shock

Tissue necrosis, scarring

Sensibility

ANEMIA

Sensitive type

Reactivity

Fatigue

PRESCRIPTION EXAMPLES

Around surgery

groups where pathophysiology is the direct toxicity, loss of bodily fluids and inflammation.

n FATIGUE AFTER BREAST CANCER SURGERY WITH

MASTECTOMY:

• Phosphoricum acidum 9 CH, 5 pellets twice a day during one month (fatigue) • Staphysagria 9 CH, 5 pellets twice a day during one month (wound healing) • Bovista gigantea 5 CH, 5 pellets twice a day during one month (lymphedema) • Natrum muriaticum 15 CH 5 pellets per day for 1 month, then in weekly dose (Sensitive Type)

Focus on anemia (related to the presentations by Professor Père Gascon and François Roux, PharmaD)

There are multiple etiologies for anemia in cancer patients. We can then categorize them into three

Direct toxicity impacts all sensitive types and all chronic reactional modes. It will be managemed by administering a great toxic, a symptomatic treatment and eventually a sensitive type medicine if the input of the latter is relevant. To illustrate this point, the FOLFIRINOX chemotherapy protocol tends to trigger skin dryness with flaking. Sensitive types such as a Natrum muriaticum, Arsenicum album or Graphites will be specifically sensitive to this type of reaction and the administration of corresponding medicines is indicated. Patients of the Psoric-Tuberculinic reactional mode are especially sensitive to loss of fluids. The administration of the sensitive type medicine is often indicated in this case. Inflammation is omnipresent in oncology, whether it is via the cancer disease itself or because of the treatments. Patients with a sensitive type promoting congestion and inflammations will be specifically exposed. Let’s list for example Sulfur, Aurum muriaticum, Lachesis mutus, Phosphorus…

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THE THREE ORIGINS OF ANEMIA: RELATED TO THE CHRONIC REACTIONAL MODE AND SENSITIVE TYPE FATIGUE AND ANEMIA

DIRECT TOXICITY OF THE CANCER OR ITS TREATMENTS

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BARCELONA 2017

Anemia in cancer patients Cancer in itself

Chemotherapy and/or radiotherapy-induced myelosuppression

Radiotherapy

Hemolysis Nutritional deficiency (iron/vitamin B12/Folic acid)

Anemia Abnormal iron metabolism

Blood loss Low EPO levels

Anemia of inflammation and chronic disease (AI/ACD)

TOXICITY-INDUCED ANEMIA: Materia Medica of two toxic products: Arsenic and Phosphorus We chose to develop these two specific medicines because their toxicology is close to the ones of most common chemotherapies.

ARSENIC TOXICOLOGY n ONCE ABSORBED, STRONGLY BINDS TO PLASMATIC PROTEINS AND HEMOGLOBIN

n IS FOUND IN ALL ORGANS, MAINLY

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• Liver • Kidneys • Lungs • Muscles • Skin, hair • Bones

n INORGANIC ARSENIC ACCUMULATES WITH AGE (IPCS, 2001) n ACUTE EFFECTS

• Gastrointestinal disorders - Nausea - Vomiting - Gastrointestinal hemorrhages

- Abdominal pain - “Rice water” diarrhea, “arsenic-like cholera”, which could lead to death • MATERIA MEDICA • Alteration of the general state, quick weight loss • Anemia: bleeding of the mucous membranes • Ulcerations then necrosis of the mucous membranes • Secretions with a cadaveric odor, nausea, vomiting • Burning digestive pain • Diarrhea with intense weakness • Diverse food intolerance: not very fresh foods, ice cream, frozen foods…

Arsenicum album is thus useful in preventing anemia related to mucosa hemorrhages.

PHOSPHORUS TOXICOLOGY n ABSORPTION OF WHITE PHOSPHORUS AFTER ORAL EXPOSURE

• after 15 minutes: blood and liver (5% of the dose)

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ANEMIA DUE TO LOSS OF FLUIDS AND NUTRITIONAL DEFICIENCY

• after 2-3 hours: - liver (65-70 %) - blood (12 %) - kidneys (4 %) - spleen (0.4 %) - pancreas (0.4 %) - brain (0.4 %)

CURATIVE: China rubra: Paleness, weakness, palpitations

EVOLUTION: Natrum muriaticum: aggravation of fatigue, dryness of the mucous membranes (mouth, constipation), cold-sensitivity then Silicea: cold sweats, cold sensitivity, intense fatigue, malaise, dizziness when lifting their head from the bed.

• The total absorption corresponds to 82-87% of the dose. n MATERIA MEDICA

The difference between Ferrum metallicum and China rubra will be based on the notion of “recurrent” congestive aspect of Ferrum metallicum with hot flushes and palpitations contrasting with the emaciated, dehydrated aspect of China rubra.

• Nausea • Reflex vomiting related to gastritis • Vomits when drinking • Hematemesis, vomiting streaked with blood • Stomatitis, esophagitis, gastric pain improved when drinking cold water • Sensation of gastric emptiness • Hypersensitivity to odors • Perception of imaginary odors • Salty or bloody taste in mouth • Jaundice, hepatitis, toxic hepatitis • Anemia: spinal cord toxicity

Phosphorus is thus relevant for the prevention of inflammatory anemia following chemotherapy toxicity, liver or bone marrow in particular. It can also prevent bleeding due to blood coagulation disorders.

ANEMIA DUE TO INFLAMMATION

CURATIVE ACTION: Ferrum metallicum: Paleness, weakness, palpitations, skin flushing, hot flashes and pounding headaches The congestive and inflammatory expression of anemia can be associated to the prescription of medicines of the sensitive type like Phosphorus, Sulfur, Lachesis mutus, Aurum metallicum.

if aggravation of fatigue with hypotension and muscle weakness, then Silicea: aggravation of fatigue with cold sweats, cold-sensitive, weight loss and finally staying in bed for long periods of time.

WE MUST BE VIGILANT OF • FOR THE “SMALL APPETITES” of Materia Medica such as Lycopodium clavatum, Arsenicum album and Sepia officinalis ; • FOR TUBERCULINICS: Calcarea phosphorica, Silicea, Phosphorus, Natrum muriaticum, Tuberculinum;

• FOCUSING ON THE PREVENTION ON THE DIGESTIVE DISORDERS (nausea, vomiting, mucositis, diarrhea…)

During chemotherapies We will look at the major relevance of using four polychrests, whose toxicity is similar to the chemotherapies’ toxicity. On top of the two ones previously listed (Arsenicum album and Phosphorus), one should add Causticum and Mercurius solubilis. n THIS IS WHERE THE PRESCRIPTION OF THE HOMEOPATHIC PHYSICIAN CAN BE PRESENTED IN FOUR LINES: • Phosphoricum acidum; • Symptomatic treatments of factors that generate or aggravate fatigue; • Sensitive type medicine if needed;

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EVOLUTION: Calcarea phosphorica:

Proper nutrition is essential for each step of the cancer treatment and even afterwards.

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BARCELONA 2017

MERCURIUS CORROSIVUS • One or several polychrests called the “great toxics” n They can be prescribed at any time during the patient care pathway: for a preventive action before chemotherapy, or curative action for side effects of chemotherapy. n The choice between the four will be based on the common principle of similitude.

Let us study the similitude of each of them:

PHOSPHORUS

preventive medicine for mucositis and good complementary medicine of Arsenicum album and Natrum muriaticum in case of lesions of the mucous membranes. In all cases, a prescription for a patient who will start a 5-Fluorouracil, epirubicin and cyclophosphamide (FEC combination) protocol. EXPECTED TOXICITY: skin, heart, digestive, urinary mucous membranes and fatigue. SEE BOOK: Homeopathic treatments in oncology supportive care, Dr Karp and M. Roux, published by the CEDH.

• targeted organs: liver, lungs, kidney, and heart. • Hematologic and coagulation system: hemorrhages, anemia… • Nervous system: chemo-induced neuropathies, affection of the central nervous system.

• PRESCRIPTION n Phosphoricum acidum in increasing doses 9 CH then 12 CH then 15 CH and finally 30 CH over a 4-day period after the chemotherapy IV (see article by François Roux, PharmD).

ARSENICUM ALBUM • digestive, respiratory and urogenital mucous membranes. • Then kidneys, liver, adrenal glands, heart. • Central nervous system. • Skin

n Arsenicum album 15 CH, 5 pellets per day or 1 dose weekly during the entire chemotherapy at least (great toxic in similitude with the expected toxicity).

CAUSTICUM

n Natrum muriaticum 15 CH, 5 pellets per day then 1 dose weekly (CEDH consensus, according to the sensitive type)

• digestive, respiratory and urogenital mucous membranes. • Nervous system with paresis. • Osteoarticular tissue with tendon retractions. • Skin

n Nux vomica 9 CH before and after the IV perfusions to avoid nausea and vomiting. The treatment should be continued the following days according to the symptoms. From 5 pellets every hour to 5 pellets three times a day.

MERCURIUS SOLUBILIS

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• ENT, respiratory, ophthalmologic and urogenital mucous membranes. • Bone suppurations. • Nervous system with shaking, paresis and paralysis.

n In addition to these four toxics administered in preventive and curative treatments, related to the direct toxicity of chemotherapies, we can use more symptomatic medicines for prevention and treatment:

EXAMPLE FOR MUCOSITIS:  Kalium bichromicum,  Mercurius corrosivus,  Arsenicum album

During radiotherapy We propose the systematic prescription of Radium bromatum, in prevention of local side effects of radiotherapy and associated fatigue. Here also, just like for surgery, we try to avoid factors that aggravate fatigue (pain, inflammation, etc.)

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EXAMPLES

SYSTEMATICALLY:

 Apis mellifica and Belladonna: prevent or treat edema and inflammation.

ACCORDING TO THE LOCALIZATIONS: FOR BRAIN RADIATION:  Apis mellifica, Natrum sulfuricum and Helleborus niger (if there is an intellectual slowing down and “viscosity” related to the brain tumors or metastases) FOR THE THORAX:  Apis mellifica and Phosphorus (to protect the lungs and heart) FOR THE ABDOMEN:  Apis mellifica and Causticum (to protect the digestive mucosa) FOR THE PELVIS:  Apis mellifica, Causticum and Mercurius corrosivus (to prevent post-radiotherapy proctitis)

• THUS A PRESCRIPTION BEFORE RADIOTHERAPY MIGHT BE SIMILAR TO THIS:

n Phosphoricum acidum 9 CH, 5 pellets twice a day (fatigue) n Radium bromatum 9 CH, 5 pellets per day right from the start of the radiotherapy, during and 2 weeks after the end of the radiation treatments. n Apis mellifica 9 CH, 5 pellets right before and after the sessions (systematic) n Belladonna 9 CH, 5 pellets right before and after the sessions (systematic) n Phosphorus 15 CH, 5 pellets per day during the entire treatment duration and two weeks after (for chest radiation)

During hormone therapy

In both cases, the woman experiences a “forced estrogen privation” with symptoms including fatigue, hot flushes, dryness of the mucous membranes and hepatic digestive disorders… For women underg aromatase inhibitors, joint pain is common and alter the quality of sleep. Following the same logic – “avoiding pain and functional discomfort helps prevent the onset or aggravation of fatigue” –, it is interesting to use the homeopathic therapeutic tools for prevention and treatment of joint pain. A study was conducted with a protocol associating Rhux toxicodendron 9 CH, 5 pellets twice per day showing a clear decrease of pain and stiffness induced by the treatment. n EXAMPLE OF PRESCRIPTION FOR A WOMAN PRESENTING with dryness of the mucous membranes, hot flashes, withdrawal and joint pain inducing fatigue: n Phosphoricum acidum 9 CH, 5 pellets twice a day (fatigue) n Sepia officinalis 15 CH, 5 pellets per day then 1 dose weekly (symptom and sensitive type) n Rhus toxicodendron 9 CH, 5 pellets twice a day (joint pain) n Ruta graveolens 5 CH, 5 pellets twice a day until the joint pain disappears (tendon pain)

Please note that Rhus toxicodendron and Ruta graveolens can be prescribed in a systematic manner right from the beginning of the aromatase inhibitors treatment, for pain prevention during 6 months. • If after that time there is no pain: stop the treatment after 6 months and observe AFTERWARDS • If there is no pain: no new prescription.

Hormone therapy is prescribed for hormonedependent cancers in menopausal or non-menopausal women.

• If pain comes back: prescribe again and add other medicines according to the clinical similitude

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Here we cover more specifically breast cancer treatment after surgery and/or chemotherapy.

This treatment inhibits the estrogen receptors in the mammary gland before menopause (tamoxifen) or inhibits the aromatases that transform androstenedione to estrone and testosterone to estradiol in menopausal women (anti-aromatase).

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BARCELONA 2017

Impact on quality of life Professor Gascon insisted on this notion as a real objective of future treatments, in addition to their relevance in patients’ survival. Several studies have showed the effectiveness of homeopathy in preserving the quality of life of cancer patients however fatigue is the core of the problem. It impacts the quality of life, decreasing social, emotional, physical and functional well-being. Moreover, it has been evidenced that in order to have a good quality of life, it is important to eat well, exercise regularly, have a social life, get back to work, etc. Is that even possible when the patient complains about fatigue? Fatigue is thus the consequence and the cause; if you let it settle in, it starts a vicious circle that will be difficult to stop.

CONCLUSION Homeopathy, via its comprehensive approach (symptomatic, chronic reactional mode, sensitive type and great toxics), is a real opportunity for the patients. The earlier the homeopathic treatment is implemented in the patient’s care pathway, the better we will avoid the negative progression towards chronic fatigue. n

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REFERENCES

• KARP JC et al., Homéopathie, cancers et troubles psychologiques, Cancers et psy n° 2, édition 2016, p. 4. • KARP JC, Les mucites chimio-induites. Approche homéopathique privilégiant l’abord toxicologique, La Revue du CEDH n° 42 p23-29, p. 13. • KARP JC et al., Treatment with Ruta graveolens 5 CH and Rhus toxicodendron 9 CH may reduce joint pain and stiffness linked to aromatase inhibitors in women with early breast cancer: results of a pilot observational study, Homeopathy 2016 1-10, p. 15. • TAIN MICHAËL, Évaluation de la qualité de vie au cours de la chimiothérapie adjuvante du cancer du sein et suivi homéopathique personnalisé, Thèse doctorat en medecine, 2 novembre 2015. • FRASS M, FRIEHS H, THALLINGER C, et al. Influence of adjunctive classical homeopathy on global health status and subjective well-being in cancer patients —

a pragmatic randomized controlled trial. Complement Ther Med. 2015; 23(3): 309–17. • ROSTOCK M, NAUMANN J, GUETHLIN C, GUENTHER L, BARTSCH HH, WALACH H, Classical homeopathy in the treatment of cancer patients—a prospective observational study of two independent cohorts. BMC Cancer. 2011; 11: 19, p. 15. • Book: Traitements en soins de support homéopathiques en cancérologie DR KARP, M. ROUX, éditions CEDH, p13 • Articles: - CAIRN l’expérience de la fatigue chez les patients atteints de cancer S. ROSMAN 2004, - Saint Louis Réseau Sein, Fatigue et cancer du sein MARJORIE LALLOUM gynécologue CMS, • Fatigue questionnaire: FACT-G the Functional Assessment of Cancer Therapy General Scale, version 4*,

The earlier the homeopathic treatment is implemented in the patient’s care pathway, the better we will avoid the negative progression towards chronic fatigue.

“

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Uncovering Platina!

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Dr Sabine Chesneau, MD, France

et’s (re) discover this “unloved” medicine Platina, which often has an

emotional, hysterical image stuck to it. However, when used in IRP or as an etiology medicine, Platina is an excellent medicine to prescribe daily in your clinical practice.

Platina: an old medicine? In order to better understand this medicine, let’s take some pleasure in browsing through the Materia Medica we use every day. n

THE BEST INTRODUCTION IS OFFERED TO US BY JOHN-TAYLOR KENT. WE ARE IN 1932 “The Platinum proving represents the woman's mind perverted”. “It is especially suited to hysterical women who have undergone a fright, prolonged excitement, or from disappointment, shock, or prolonged hemorrhages. She becomes arrogant and haughty. One of the most striking characteristics of this drug is pride and over-estimate of one’s self. (1). ” n

A LITTLE EARLIER IN 1927, WILLIAM BOERICKE WROTE

n IN 1929, LÉON VANNIER AND JEAN POIRIER WROTE ABOUT PLATINA

• “See each object smaller than what it actually is” •“Arrogant, proud and condescending, looking down with disdain on persons who are usually the most respected. He cannot stand the slightest contradiction, impatient, destructive impulses” (Let’s note that “he” is used.) •“Tired of leaving. Anxiety with fear of death, imminent death” • “Alternation of sadness and joy, laughs about serious subjects and laughs out loud when one speaks about sad things (3).” n

NOW WE ARE IN 1973. ROLAND ZISSU AND MICHEL GUILLAUME PUT FORWARD IN A VERY INTERESTING

MANNER THE NOTION OF EVOLUTION OVER TIME

They list in the “general action” chapter: “1- Action on sexuality, according to a marked biphasic evolution:

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“Is pre-eminently a woman's remedy. Strong tendency to paralysis, anesthesia, localized numbness and coldness are shown. • Hysterical spasms; pains increase and decrease gradually. Shaking. • Mind: Irresistible impulse to kill. Self-exaltation; contempt for others. She is arrogant and proud. Disgusted by everything. Seems indifferent. Mental disorders related to the end of menstruation (2).”

He also added an important notion of alternation, also underlined by Léon Vannier and Jean Poirier: “The physical symptoms disappear when mental symptoms appear. And vice-versa. (2) (3).”

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• EXCITEMENT: hemorrhagic congestion of the female genital organs, physical but above all psychological sexual arousal: the beginning point is genital but the manifestation is essentially mental and emotional, leading to perversions, or hysterical manifestations, or cramps or spasms. • DEPRESSION: frigidity or impotence leading to mental depression, paresis with spasms. 2- One should note the appearance of the disorders over time: either chronic depression with paroxysmal phases of excitement, or chronic excitement with transient phases of depression (4).” They add a characteristic morphology: “Type: nervo-bilious, classically thin with black hair, prone to spasmodic, even hysterical, symptoms; hypersexual, proud, mood swings. Women who are concerned about their appearance. “Femmes fatales (4).” n HENRI VOISIN, IN HIS SECOND EDITION OF THE 1976 Materia Medica of the homeopathic practitioner, brings a very interesting approach also because it categorizes the symptoms of Platina into five great chapters by spacing out the disorders in the homeopathic areas from “5 to 30 CH”, from the more “local” to the more “psychological”: “• Genital hyperesthesia (5 CH) • Neuralgia and spasms • Exaltation by dissatisfied and hypertrophied needs or sexuality • “Full of himself/herself” exhilarated patient • Depressed and melancholic withdrawn patient (30 CH) (5).” n

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MORE RECENTLY, IN 1985, MICHEL GUERMONPREZ WROTE

“• Medicine with a limited action: Pride, Ovaralgia, Constipation • Overestimation of the self: pride, disdain for the other person seen as small and who is despised. • Refined language and presentation. Ornaments, jewelry, flashy and sexy clothes. • Genital hyperesthesia; metrorrhagia; pain; ovarian tumor • Spasms, cramps, compressions, paresthesia, spasmodic constipation when traveling. • Aggravation by touch, pressure, fear, sexual inhibition.” He also added: “The female biotype of Platina: darkhaired, with a dominating look, high heels, always

describing people with disdain, hides a sexual and social maladaptation; almost paranoid, most often a simple “panic attack”. This picture can also be seen in men (6).” n

MRS. LEA DE MATTOS, AUTHOR OF THE FIRST WORKS ON FOLLICULINUM, is not very tender-hearted with Platina and wrote: “Because of its sexual modalities, Platina is the medicine of perversions. Let’s not forget that while desiring intercourse, the woman fears it. This is why the absorption of Platina doses will benefit nymphomaniacs, onanists and erotomaniacs (7)”. n

GOING BACK TO BASICS, WITH HAHNNEMAN AND HERING, PURE CLINICAL APPROACH Samuel Hahnemann described Platina in his book The Chronic Diseases, their Peculiar Nature and their Homoeopathic Cure (Second edition of 1846). In the introduction of the medicine, he lists the most striking symptoms: “Platina can fit in all cases where we see the following symptoms: Lack of appetite; eructation after eating; constipation while traveling; emission of prostatic juice; induration of the uterus; weariness of the lower limbs; cold feet; stuffed coryza.” In the next twenty-one pages where all pathogenic symptoms of Platina are listed, he differentiates the female and male symptoms with the following pronoun He and She: “Dejected, taciturn, sad. She imagines herself deserted and standing alone in the world. Anxiety, with trembling of the hands and ebullition of heat. Anxiety and palpitation, especially during a walk.” There are some examples of male symptoms of the medicine that were later attributed by his successors in their Materia Medica to the female genital system. Example: “In the morning upon awaking he lies with out-stretched lower limbs (…) and always upon his back, with a great tendency to bare his thighs and constant erections (8).”

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Uncovering Platina!

6TH INTERNATIONAL CEDH CONFERENCE BARCELONA 2017

CONSTANTIN HERING, IN 1891, WROTE FOR THE GENERAL PUBLIC:

Homoeopathic Domestic Kit, a collection of the most used homeopathic medicines at the time with their clinical indications. For Platina, he listed: • “Fright with sadness, sorrow with intellectual disorders, homesickness, anger with indignation, excesses (lead); • Eruptive fever: small pox; • Migraine, earaches; • Dysentery, constipation; • Heavy periods, blood loss during pregnancy or after delivery; • Headache, seizures, miscarriage, screams, stuttering (9).”

parasympathetic nervous system): • general, chills, tremors, (over the entire body); • sighing; • eyelids, uvula, upper lip; • false angina; • digestive, esophagus (reflux, eructation), colic, constipation (with tenesmus); • genital tract (vaginism, urethral spasms); • Hyperesthesia with anxiety, headaches, ear ringing (tinnitus). • CRAMPS • FACIAL NEURALGIA, LOW BACK SPINE PAIN Numbness in the coccyx, when sitting down or sensation of weakness in the limbs after walking. Weakness in the nape of the neck. FOUR EXAMPLES OF CLINICAL CASES RELATED WITH THESE SPASTIC SYMPTOMS

We can see throughout the years that the use of Platina was limited to a very specific “genital-psychological” behavior. However, times have changed. Like Sepia or Pulsatilla that are more largely prescribed today, what about reconsidering the status of Platina?

Platina: A relevant medicine today! The homeopathic strain used to manufacture Platina is platinum sponge.

THE TARGETS OF PLATINA • The peripheral neuromuscular system and parasympathetic nervous system; • Genital tracts (in women, but not just…); • Digestive tract.

• Samira, 44 years old, polyuria with urgent needs without bladder incontinence. Cystoscopy showed a bladder too small and very spastic. • Leo, 8 years old, constipation for the past two years, was holding back because he did not want to go to the restrooms at school. • Martine, 63 years old, pays attention to the way she looks (without excesses). Spasms on all floors ++ (throat, stomach, asthma, palpitations, UTIs, vaginitis), dissatisfied with her husband, she can no longer stand him. • Sylvie, 51 years, lung cancer with bone metastases, palliative stage. Hyperesthesia to everything: “everything is going wrong”, muscle spasms with involuntary twitches, very anxious. 2/ HYPERESTROGENIA • Premenstrual and intermenstrual syndromes related to the hyperestrogenia • Dysmenorrhea, menorrhagia with black blood and clots • Various type of ovarian pain (often on the left side) (no laterality noted in Hahnemann’s work) • Endometriosis

TWO GREAT POLES OF SYMPTOMS: 1/ SPASMS ON EVERY FLOORS! (Peripheral neuromuscular system and

• Aurélie, 31 years old, cumulates polycystic ovary syndrome (PCOS) and endometriosis for which she had two laparoscopic interventions. She is undergoing medically assisted procreation with ovulation stimulation aggravating ovarian pain.

JANUARY 2018 CEDH MAGAZINE

CLINICAL CASES REPRESENT A GREAT NUMBER OF WOMEN

CHARACTERISTIC SIGNS

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6TH INTERNATIONAL CEDH CONFERENCE

Uncovering Platina!

BARCELONA 2017

THE INDIVIDUAL REACTION OF THE PATIENT (IRP)

SENSATIONS • Compression, constriction (clamp, tight bandage) • Throbbing, gnawing, dull pain (described by Hahnemann); • Cramps (hands, fingers, legs); • Numbness, tingling (temples, vertex, coccyx…); • Sensations that some parts of the body are swollen; • Pain increase and decrease progressively.

MODALITIES • AGGRAVATION: by touch, in the evening, during her periods. • IMPROVEMENT: by walking, fresh air.

CONCOMITANT SYMPTOMS • Panic attacks taking on various aspects. • Genital hyperesthesia (often dissimulated).

THREE EXAMPLES OF CLINICAL CASES WHERE PLATINA WAS PRESCRIBED ACCORDING TO THE IRP • Féthia, 59 years old: complains of hip pain (right side): “sensation that the hip is going to burst, this feeling can last from 20 minutes to 2 hours, not related to effort, with sensation of hardened muscle and sensation that the hip got bigger”, no biological inflammatory syndrome or fever. • Charles, 65 years old, myocardial infarction 5 years ago. Chest pain, not related to his cardiac issues and coming from multiple factors (anxiety of death, intercostal neuralgia, esophageal spasm) the pain appears and disappears progressively ++ Platina.

JANUARY 2018 CEDH MAGAZINE

• Keltoum, 82 years old, from Berber origin. Had surgery for ovarian cancer followed by palliative chemotherapy with Carboplatin. Abdominal torsion pain, with chills, erratic pain, as if beaten up. Platina was most effective on the post-chemotherapy headaches with compression of the temples, the pain started and ended progressively.

CORRESPONDING ETIOLOGIES “This is the moment when the dialog with the physician helps to know and understand the psychogenesis of their disorders, the starting point is called “deception” (10).”

The etiology is very important in Platina should always be looked for: • Emotional shocks, frights (often a context of violence can be found); • betrayals (truly experienced or felt), angers; • solitude (experienced or felt), dissatisfied.

SIX EXAMPLES OF CLINICAL CASES WHERE PLATINA WAS AN EXCELLENT ETIOLOGY MEDICINE. • Myriam, 5 years old, vulvar eczema treated during two years with topical steroid cream… it happened after a car accident, Staphysagria and Platina were prescribed to manage these episodes of vulvar itching but the mother noted a preference for Platina. • Latifa, 35 years old, first marriage was complicated, the second one was very happy, then multiple panic attacks and slow descent into anorexia, this was triggered because she was terribly deceived by her second husband. • Suren, 62 years old, from Armenia originally, political refugee after having been tortured in his country. Developed Parkinson’s disease as a consequence. Depression. Platina improved the throat spasms with sensation of choking when he is stressed. • Chinar, 28 years old, his daughter, is also a political refugee. Post-traumatic stress disorders (PTSD) from having seen her family members killed. Hemicrania continua, muscular twitches, hemiparesis on the right side of the body (evidenced at the electromyogram) (Platina and Causticum).

THE LAST TWO CASES ARE A TRIBUTE TO ALL THESE PERSONS LIVING WITH THOSE SILENT EMOTIONAL SHOCKS…

• Bernadette, 78 years old, chronic constipation. Very complicated Ob/Gyn history with spontaneous miscarriages, C-section with complications, late-onset menopause at 56, “she was fed up with it”, she said. We learn that she was raped at the age of 8. Her femininity was traumatized but she showed great resilience.

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6TH INTERNATIONAL CEDH CONFERENCE BARCELONA 2017

• Josette, 81 years old, cares for her appearance but without excesses. Hyperesthesia to everything, extreme anxiety, always comes to the consultation in a hurry because she is afraid to die. Initial prescription of Aconit, without much effect, then we changed for Platina when we learned that she was repeatedly raped by her father at the age of 14. Really does not want to stop “her Platina” because it calms her anxiety.

Conclusion Let us not wait for Cleopatra or Kanye West to walk into our waiting room! There are so many patients who are waiting for us to prescribe Platina to relieve them. Let’s keep in mind that the sensitive type of a homeopathic medicine is made of three inseparable elements: • Pathological tendencies; • Behavioral tendencies; • Morphological tendencies.

REFERENCES J.T. KENt, Matière médicale homéopathique, 1932, p1 W. BOERICKE, Matière médicale, 1927, p1 3 L. VANNIER, J. POIRIER, Précis de matière médicale homéopathique, 1929, p1 et 2 4 R. ZISSU, M. GUILLAUME, Fiches de Matière médicale homéopathique, 1973, p2 5 H. VOISIN, Matière médicale du praticien homéopathe, 2e édition, 1976, p2 6 GUERMONPREZ, PINKAS, TORCK, Matière médicale homéopathique, Boiron, 1985, p2 7 L. DE MATTOS, Homéopathie et gynécologie, Similia, 1987, p3 8 S. HAHNEMANN, Doctrine et traitement homoeopathique des maladies chroniques, traduit par A.J.L. JOURDAN, 2e édition, 1846, p3 9 C. HERING, Médecine homoeopathique domestique, traduit par L. SIMON, 7e édition, 1891, p3 10 J. BARBANCEY, Pratique homeopathique en psychopathologie, 1977, p6 11 D. DEMARQUE, J. JOUANNY, B. POITEVIN, Y. SAINT-JEAN, Pharmacologie et matière médicale homéopathique, 3e édition, 2003. 1 2

“

Here pathological tendencies are at the forefront for the choice of medicines.

Also important: the description of the behavioral tendencies of our medicines, often quite entertaining for our great learning pleasure, are only the decompensated states of our patients.

JANUARY 2018 CEDH MAGAZINE

A medicine cannot be summed up by a behavior. Let us always look behind the mask worn by Platina. That is what will get it back in our hearts and homeopathic prescriptions. n

Raw platinum where were extract the moss to manufacture Platina

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