MoonDragon's Health & Wellness
ADDISON'S DISEASE
by NIH

ADDISON'S DISEASE INFORMATION

Causes Symptoms Diagnosis ACTH Stimulation Test Insulin-Induced Hypoglycemia Test Other Tests Treatment Special Problems Patient Education Suggested Reading Other Resources

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Addison's disease is a rare endocrine or hormonal disorder that affects about 1 in 100,000 people. It occurs in all age groups and afflicts men and women equally. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and sometimes darkening of the skin in both exposed and non-exposed parts of the body.

Addison's disease occurs when the adrenal glands do not produce enough of the hormone cortisol and in some cases, the hormone aldosterone. For this reason, the disease is sometimes called chronic adrenal insufficiency, or hypocortisolism.

Cortisol is normally produced by the adrenal glands, located just above the kidneys. It belongs to a class of hormones called glucocorticoids, which affect almost every organ and tissue in the body. Scientists think that cortisol has possibly hundreds of effects in the body. Cortisol's most important job is to help the body respond to stress. Among its other vital tasks, cortisol:

• helps maintain blood pressure and cardiovascular function;
• helps slow the immune system's inflammatory response;
• helps balance the effects of insulin in breaking down sugar for energy; and
• helps regulate the metabolism of proteins, carbohydrates, and fats.

Because cortisol is so vital to health, the amount of cortisol produced by the adrenals is precisely balanced. Like many other hormones, cortisol is regulated by the brain's hypothalamus and the pituitary gland, a bean-sized organ at the base of the brain. First, the hypothalamus sends "releasing hormones" to the pituitary gland. The pituitary responds by secreting other hormones that regulate growth, thyroid and adrenal function, and sex hormones such as estrogen and testosterone. One of the pituitary's main functions is to secrete ACTH (adrenocorticotropin), a hormone that stimulates the adrenal glands. When the adrenals receive the pituitary's signal in the form of ACTH, they respond by producing cortisol. Completing the cycle, cortisol then signals the pituitary to lower secretion of ACTH.

Aldosterone belongs to a class of hormones called mineralocorticoids, also produced by the adrenal glands. It helps maintain blood pressure and water and salt balance in the body by helping the kidney retain sodium and excrete potassium. When aldosterone production falls too low, the kidneys are not able to regulate salt and water balance, causing blood volume and blood pressure to drop.

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CAUSES

Failure to produce adequate levels of cortisol, or adrenal insufficiency, can occur for different reasons. The problem may be due to a disorder of the adrenal glands themselves (primary adrenal insufficiency) or to inadequate secretion of ACTH by the pituitary gland (secondary adrenal insufficiency).

PRIMARY ADRENAL INSUFFICIENCY

Most cases of Addison's disease are caused by the gradual destruction of the adrenal cortex, the outer layer of the adrenal glands, by the body's own immune system. About 70 percent of reported cases of Addison's disease are due to autoimmune disorders, in which the immune system makes antibodies that attack the body's own tissues or organs and slowly destroy them. Adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid and mineralocorticoid hormones are lacking. Sometimes only the adrenal gland is affected, as in idiopathic adrenal insufficiency; sometimes other glands also are affected, as in the polyendocrine deficiency syndrome.

The polyendocrine deficiency syndrome is classified into two separate forms, referred to as type I and type II. Type I occurs in children, and adrenal insufficiency may be accompanied by under active parathyroid glands, slow sexual development, pernicious anemia, chronic candida infections, chronic active hepatitis, and, in very rare cases, hair loss. Type II, often called Schmidt's syndrome, usually afflicts young adults. Features of type II may include an under active thyroid gland, slow sexual development, and diabetes mellitus. About 10 percent of patients with type II have vitiligo, or loss of pigment, on areas of the skin. Scientists think that the polyendocrine deficiency syndrome is inherited because frequently more than one family member tends to have one or more endocrine deficiencies.

Tuberculosis (TB) accounts for about 20 percent of cases of primary adrenal insufficiency in developed countries. When adrenal insufficiency was first identified by Dr. Thomas Addison in 1849, TB was found at autopsy in 70 to 90 percent of cases. As the treatment for TB improved, however, the incidence of adrenal insufficiency due to TB of the adrenal glands has greatly decreased.

Less common causes of primary adrenal insufficiency are chronic infections, mainly fungal infections; cancer cells spreading from other parts of the body to the adrenal glands; amyloidosis; and surgical removal of the adrenal glands. Each of these causes is discussed in more detail below.

SECONDARY ADRENAL INSUFFICIENCY

This form of Addison's disease can be traced to a lack of ACTH, which causes a drop in the adrenal glands' production of cortisol but not aldosterone. A temporary form of secondary adrenal insufficiency may occur when a person who has been receiving a glucocorticoid hormone such as prednisone for a long time abruptly stops or interrupts taking the medication. Glucocorticoid hormones, which are often used to treat inflammatory illnesses like rheumatoid arthritis, asthma, or ulcerative colitis, block the release of both corticotropin-releasing hormone (CRH) and ACTH. Normally, CRH instructs the pituitary gland to release ACTH. If CRH levels drop, the pituitary is not stimulated to release ACTH, and the adrenals then fail to secrete sufficient levels of cortisol.

Another cause of secondary adrenal insufficiency is the surgical removal of benign, or non-cancerous, ACTH-producing tumors of the pituitary gland (Cushing's disease). In this case, the source of ACTH is suddenly removed, and replacement hormone must be taken until normal ACTH and cortisol production resumes. Less commonly, adrenal insufficiency occurs when the pituitary gland either decreases in size or stops producing ACTH. This can result from tumors or infections of the area, loss of blood flow to the pituitary, radiation for the treatment of pituitary tumors, or surgical removal of parts of the hypothalamus or the pituitary gland during neurosurgery of these areas.

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ADRENAL INSUFFICIENCY SYMPTOMS

The symptoms of adrenal insufficiency usually begin gradually. Chronic, worsening fatigue and muscle weakness, loss of appetite, and weight loss are characteristic of the disease. Nausea, vomiting, and diarrhea occur in about 50 percent of cases. Blood pressure is low and falls further when standing, causing dizziness or fainting. Skin changes also are common in Addison's disease, with areas of hyperpigmentation, or dark tanning, covering exposed and non exposed parts of the body. This darkening of the skin is most visible on scars; skin folds; pressure points such as the elbows, knees, knuckles, and toes; lips; and mucous membranes.

Addison's disease can cause irritability and depression. Because of salt loss, craving of salty foods also is common. Hypoglycemia, or low blood sugar, is more severe in children than in adults. In women, menstrual periods may become irregular or stop.

Because the symptoms progress slowly, they are usually ignored until a stressful event like an illness or an accident causes them to become worse. This is called an addisonian crisis, or acute adrenal insufficiency. In most patients, symptoms are severe enough to seek medical treatment before a crisis occurs. However, in about 25 percent of patients, symptoms first appear during an addisonian crisis.

Symptoms of an addisonian crisis include sudden penetrating pain in the lower back, abdomen, or legs; severe vomiting and diarrhea, followed by dehydration; low blood pressure; and loss of consciousness. Left untreated, an addisonian crisis can be fatal.

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DIAGNOSIS

In its early stages, adrenal insufficiency can be difficult to diagnose. A review of a patient's medical history based on the symptoms, especially the dark tanning of the skin, will lead a doctor to suspect Addison's disease.

A diagnosis of Addison's disease is made by biochemical laboratory tests. The aim of these tests is first to determine whether there are insufficient levels of cortisol and then to establish the cause. X-ray exams of the adrenal and pituitary glands also are useful in helping to establish the cause.

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ACTH STIMULATION TEST

This is the most specific test for diagnosing Addison's disease. In this test, blood and/or urine cortisol levels are measured before and after a synthetic form of ACTH is given by injection. In the so called short, or rapid, ACTH test, cortisol measurement in blood is repeated 30 to 60 minutes after an intravenous ACTH injection. The normal response after an injection of ACTH is a rise in blood and urine cortisol levels. Patients with either form of adrenal insufficiency respond poorly or do not respond at all.

When the response to the short ACTH test is abnormal, a "long" ACTH stimulation test is required to determine the cause of adrenal insufficiency. In this test, synthetic ACTH is injected either intravenously or intramuscular over a 48- to 72-hour period, and blood and/or urine cortisol are measured the day before and during the 2 to 3 days of the injection. Patients with primary adrenal insufficiency do not produce cortisol during the 48- to 72-hour period; however, patients with secondary adrenal insufficiency have adequate responses to the test on the second or third day.

In patients suspected of having an addisonian crisis, the doctor must begin treatment with injections of salt, fluids, and glucocorticoid hormones immediately. Although a reliable diagnosis is not possible while the patient is being treated, measurement of blood ACTH and cortisol during the crisis and before glucocorticoids are given is sufficient to make the diagnosis. Once the crisis is controlled and medication has been stopped, the doctor will delay further testing for up to 1 month to obtain an accurate diagnosis.

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INSULIN-INDUCED HYPOGLYCEMIA TEST

A reliable test to determine how the hypothalamus and pituitary and adrenal glands respond to stress is the insulin-induced hypoglycemia test. In this test, blood is drawn to measure the blood glucose and cortisol levels, followed by an injection of fast-acting insulin. Blood glucose and cortisol levels are measured again at 30, 45, and 90 minutes after the insulin injection. The normal response is for blood glucose levels to fall and cortisol levels to rise.

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OTHER TESTS

Once a diagnosis of primary adrenal insufficiency has been made, x-ray exams of the abdomen may be taken to see if the adrenals have any signs of calcium deposits. Calcium deposits may indicate TB. A tuberculin skin test also may be used.

If secondary adrenal insufficiency is the cause, doctors may use different imaging tools to reveal the size and shape of the pituitary gland. The most common is the CT scan, which produces a series of x-ray pictures giving a cross-sectional image of a body part. The function of the pituitary and its ability to produce other hormones also are tested.

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TREATMENT

Treatment of Addison's disease involves replacing, or substituting, the hormones that the adrenal glands are not making. Cortisol is replaced orally with hydrocortisone tablets, a synthetic glucocorticoid, taken once or twice a day. If aldosterone is also deficient, it is replaced with oral doses of a mineralocorticoid, called fludrocortisone acetate (Florinef)), which is taken once a day. Patients receiving aldosterone replacement therapy are usually advised by a doctor to increase their salt intake. Because patients with secondary adrenal insufficiency normally maintain aldosterone production, they do not require aldosterone replacement therapy. The doses of each of these medications are adjusted to meet the needs of individual patients.

During an addisonian crisis, low blood pressure, low blood sugar, and high levels of potassium can be life threatening. Standard therapy involves intravenous injections of hydrocortisone, saline (salt water), and dextrose (sugar). This treatment usually brings rapid improvement. When the patient can take fluids and medications by mouth, the amount of hydrocortisone is decreased until a maintenance dose is achieved. If aldosterone is deficient, maintenance therapy also includes oral doses of fludrocortisone acetate.

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SPECIAL PROBLEMS

SURGERY

Patients with chronic adrenal insufficiency who need surgery with general anesthesia are treated with injections of hydrocortisone and saline. Injections begin on the evening before surgery and continue until the patient is fully awake and able to take medication by mouth. The dosage is adjusted until the maintenance dosage given before surgery is reached.

PREGNANCY

Women with primary adrenal insufficiency who become pregnant are treated with standard replacement therapy. If nausea and vomiting in early pregnancy interfere with oral medication, injections of the hormone may be necessary. During delivery, treatment is similar to that of patients needing surgery; following delivery, the dose is gradually tapered and the usual maintenance doses of hydrocortisone and fludrocortisone acetate by mouth are not reached until about 10 days after childbirth.

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PATIENT EDUCATION

A person who has adrenal insufficiency should always carry identification stating his or her condition in case of an emergency. The card should alert emergency personnel about the need to inject 100 mg of cortisol if its bearer is found severely injured or unable to answer questions. The card should also include the doctor's name and telephone number and the name and telephone number of the nearest relative to be notified. When traveling, it is important to have a needle, syringe, and an injectable form of cortisol for emergencies. A person with Addison's disease also should know how to increase medication during periods of stress or mild upper respiratory infections. Immediate medical attention is needed when severe infections or vomiting or diarrhea occur. These conditions can precipitate an addisonian crisis. A patient who is vomiting may require injections of hydrocortisone.

It is very helpful for persons with medical problems to wear a descriptive warning bracelet or neck chain to alert emergency personnel. Bracelets and neck chains can be obtained from:

Medic Alert Foundation International
2323 Colorado
Turlock, California 95381
(209) 668-3333

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SUGGESTED READING

The following materials can be found in medical libraries, many college and university libraries, and through interlibrary loan in most public libraries.

Wingert, Terence D. and Mulrow, Patrick J., "Chronic Adrenal Insufficiency," in Current Diagnosis, edited by Rex B. Conn. Philadelphia, MI.B. Saunders Company, 1985, pp 860-863.

Bravo, Emmanuel L., "Adrenocortical Insufficiency," in Conn's Current Therapy, edited by Robert E. Rakel. Philadelphia, W.B. Saunders Company, 1987, pp 493-495.

Bondy, Philip K., "Disorders of the Adrenal Cortex," in Williams Textbook of Endocrinology, seventh edition, edited by Jean D. Wilson and Daniel W. Foster. Philadelphia, R.B. Saunders Company, 1985, pp 844-858.

Loriaux, D. Lynn and Cutler, Gordon B., "Diseases of the Adrenal Glands," in Clinical Endocrinology, edited by Peter O. Kohler. New York, lohn Wiley & Sons, 1986, pp 208-215.

Williams, Gordon H. and Dluhy, Robert G., "Diseases of the Adrenal Cortex," in Harnson's Principles of Internal Medicine, 11th edition, edited by Eugene Braunwald, Kurt J. Isselbacher, Robert G. Petersdorf, Jean D. Wilson, Joseph B. Martin, and Anthony S. Fauci. New York, McGraw-Hill Book Company, 1987, pp 1769-1772.

Baxter, John D. and Tyrrell, 1. Blake, "The Adrenal Cortex," in Endocrinology and Metabolism, second edition, edited by Philip Felig,, John D. Baxter, Arthur E. Broadus, and Lawrence A. Frohman. New York, McGraw-Hill Book Company, 1987, pp 581-599.

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OTHER RESOURCES

National Adrenal Disease Foundation
505 Northern Boulevard, Suite 200
Great Neck, New York 11021
(516) 487-4992

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This e-pub was written by Eileen K. Corrigan of NIDDK's Office of Health Research Reports. The draft was reviewed by Dr. George P Chrousos, National Institute of Child Health and Human Development, Dr. Judith Fradkin, National Institute of Diabetes and Digestive and Kidney Diseases, and by Dr. Richard Horton, University of Southern California Medical Center.

This e-text is not copyrighted. NIDDK encourages users to duplicate and distribute as many copies as needed. Printed single copies may be obtained from the Office of Communications and Public Liaison, NIDDK, 31 CENTER DRIVE, MSC 2560, Bethesda, Maryland 20892-2560.

NIH Publication No. 90-3054
November 1989

E-text posted: 12 February 1998

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ADDISON'S DISEASE SUPPLEMENTS

Addison's Disease Supplements: Information for help with Addison's disease, a rare disorder that occurs when the adrenal glands are not able to produce enough of the hormones cortisol and aldosterone.

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Echinacea is effective both internally, against such as colds, flu and tonsilitis, and externally against many kinds of stubborn skin problems. The decoction can be used as a mouthwash for pyorrhoea and gingivitis, and as a douche for vaginal infections. Echinacea is the subject of much contemporary research. Its complex chemistry seems to support the immune system by activating white blood cells. Echinacea also increases the production of interferon, an important part of the body’s response to viral infections. Many double-blind studies have confirmed that echinacea is effective for treating colds and flu. Other modern clincial studies confirm that echinacea, taken both internally and used as a douche, is extremely effective against vaginal yeast infections. Echinacea is usually taken at the onset of a cold or flu and continued for 7 to 14 days. When using a powdered extract, take 300 mg 3 times a day. The standard dosage of an alcohol tincture (1:5) is 3 to 4 ml 3 times daily. For Echinacea juice, take 2 to 3 ml 3 times a day, and the whole root, 1 to 2 g, 3 times a day. Echinacea comes in many forms: Capsules, Tablets, Powder and Tincture, the best result is to follow the instructions on the package. Mountain Rose Herbs: Echinacea Root, Herb & Powder, Certified Organic Bulk Herbs Mountain Rose Herbs: Echinacea Extract, Certified Organic Herbal Extracts Starwest Botanicals: Echinacea Angustifolia & Purpurea Extract, Organic, 4 fl. oz. Starwest Botanicals: Echinacea Angustifolia Root Extract, Organic, 4 fl. oz. Starwest Botanicals: Echinacea Purpurea Root Extract, Organic, 4 fl. oz. Starwest Botanicals: Echinacea Purpurea Root Capsules, 450 mg, 100 Caps Starwest Botanicals: Echinacea Purpurea Root Capsules, 450 mg, 500 Caps Starwest Botanicals: Echinacea Angustifolia Root Capsules, 500 mg, 500 Caps Starwest Botanicals: Echinacea Angustifolia Herb, Cut & Sifted, Organic, 1 lb. Starwest Botanicals: Echinacea Angustifolia Root, Cut & Sifted, Wildcrafted, 1 lb. Starwest Botanicals: Echinacea Angustifolia Herb Powder, Organic, 1 lb. Starwest Botanicals: Echinacea Angustifolia Root Powder, Wildcrafted, 1 lb. Starwest Botanicals: Echinacea Purpurea Herb, Cut & Sifted, Organic, 1 lb. Starwest Botanicals: Echinacea Purpurea Root, Cut & Sifted, Organic, 1 lb. Starwest Botanicals: Echinacea Purpurea Root Powder, Organic, 1 lb. Kalyx: Echinacea, Natrol, 410 mg, 90 Caps Kalyx: Echinacea Angustifolia Extract, Health & Herbs, 2 fl. oz. Kalyx: Echinacea Angustifolia Extract, Health & Herbs, 8 fl. oz. Kalyx: Echinacea Angustifolia Extract, Health & Herbs, 16 fl. oz. Kalyx: Echinacea Angustifolia-Purpurea Extract, Starwest Botanicals, 1 fl. oz. Kalyx: Echinacea Angustifolia-Purpurea Extract, Starwest Botanicals, 4 fl. oz. Kalyx: Echinacea Purpurea Extract, Health & Herbs, 2 fl. oz. Kalyx: Echinacea Purpurea Extract, Health & Herbs, 8 fl. oz. Kalyx: Echinacea Purpurea Extract, Health & Herbs, 16 fl. oz. Kalyx: Echinacea Immune Support Tea, Yogi Tea, 16 Tea Bags Kalyx: Echinacea Plus Tea, Traditional Medicinals, 16 Tea Bags. HerbsPro: Echinacea Purpurea, Alcohol Free, Glycerite With Vitamin C, Tangerine Flavor, Eclectic Institute, 2 oz. HerbsPro: Echinacea Purpurea, Alcohol Free, Glycerite With Vitamin C, Tangerine Flavor, Eclectic Institute, 1 oz. HerbsPro: Echinacea Angustifolia, Alcohol Free, Glycerite, Eclectic Institute, 1 oz. TakeHerb: Echinacea Extract, Boosts Immune System, Health Herbs, 2 fl. oz. TakeHerb: Echinacea With Grape Flavor, Alcohol Free, Promotes Healthy Immune System, Natures Answer, 1 fl. oz. TakeHerb: Echinacea With Mandarin Orange Flavor, Alcohol Free, Promotes Healthy Immune System, Natures Answer, 1 fl. oz. TakeHerb: Echinacea Glycerite, Peppermint Flavor, Alcohol Free, Planetary Herbals, 4 fl. oz. TakeHerb: Echinacea Glycerite, Lemongrass Flavor, Alcohol Free, Planetary Herbals, 4 fl. oz. TakeHerb: Echinacea With Grape Flavor, Alcohol Free, Promotes Healthy Immune System, Natures Answer, 1 fl. oz. TakeHerb: Echinacea Golden Root, Orange Flavor, Alcohol Free, Herbs For Kids, 1 fl. oz. TakeHerb: Echinacea Plus Tea, Organic, Traditional Medicinals, 16 Bags

TYROSINE PRODUCTS L-Tyrosine is used to treat insomnia, improve muscle tone, improve skin and hair pigment and depression and anxiety. L-Tyrosine should not to be used while taking prescription antidepressants or MAO inhibitors. Kalyx: L-Tyrosine, TwinLab, 500 mg, 100 Caps Kalyx: L-Tyrosine, FoodScience Labs, 500 mg, 60 VCaps HerbsPro: L-Tyrosine Powder, Amino Acid Free-Form Supplement, 100 gm, 3.53 oz. HerbsPro: Tyrosine Powder, Now Foods, 4 oz. HerbsPro: L-Tyrosine, Now Foods, 500 mg, 120 Caps HerbsPro: L-Tyrosine, Nutricology, 500 mg, 100 Caps House of Nutrition: L-Tyrosine, Douglas Lab, 800 mg, 100 Caps House of Nutrition: L-Tyrosine, Ecological Formula, 800 mg, 100 Caps TakeHerb: L-Tyrosine With Vitamin B-6, Aids Melanin Production & Helps Moon, Health Herbs, 500 mg, 60 Caps

MILK THISTLE / SILYMARIN PRODUCTS Milk Thistle (Silymarin) may be taken in capsule form and prevents and treats cirrhosis and other liver disorders. Milk thistle extract is a potent antioxidant which prevents harm from free radicals and lends nutritional support to the liver. Milk thistle seed extract contains silymarin, a unique type of flavonoid-like compound considered the active ingredient of milk thistle. Take 600 mg (about 5 tablets) daily. Note: Milk thistle may cause mild diarrhea. If this occurs, reduce the dosage or discontinue use. Milk Thistle (standardized to 80 mg silymarin) is taken consistently before pregnancy and during the first trimester will help the liver to gently detox and help hyperemesis to be avoided. Clinical studies using standardized milk thistle extract show that it supports and promotes normal liver function. The active bioflavonoid complex, silymarin, is a powerful antioxidant that exerts a protective effect against substances harmful to the liver. Thisilyn is especially recommended for those who use alcohol, smoke or are exposed to environmental pollutants. Thisily, the unique standardized milk thistle extract, is the world's standard for quality. The milk thistle used to manufacture Thisilyn is carefully extracted and tested for purity, ensuring all the plant's desirable benefits remain bioavailable. Mountain Rose Herbs: Milk Thistle, Organic Bulk Herbs Starwest Botanicals: Milk Thistle, Whole Seed, Organic, 1 lb. Starwest Botanicals: Milk Thistle, Whole Seed, 1 lb. Starwest Botanicals: Milk Thistle Leaf, Cut & Sifted, Organic, 1 lb. Starwest Botanicals: Milk Thistle Seed Powder, 1 lb. Starwest Botanicals: Milk Thistle Seed Powder, Organic, 1 lb. Starwest Botanicals: Milk Thistle Standardized Extract (Silybum marianum). 80% Silymarin, 1 lb. Starwest Botanicals: Milk Thistle Extract, Organic, 1 fl. oz. Starwest Botanicals: Milk Thistle Extract, Organic, 4 fl. oz. Starwest Botanicals: Milk Thistle Herb, Standardized Extract Capsules, 80% Silymarin, 150 mg, 100 Caps Starwest Botanicals: Milk Thistle Herb, Standardized Extract Caps, 80% Silymarin, 150 mg, 500 Caps Kalyx: Milk Thistle Advantage, Liver Support Formula, Natrol, 525 mg, 60 VCaps Kalyx: Milk Thistle, Standardized 80% Silymarin, Natures Way, 175 mg, 60 Caps Kalyx: Milk Thistle 4:1, Herbal Extracts Plus, 600 mg, 90 VCaps Kalyx: Milk Thistle, Standardized 80% Silymarin, Starwest Botanicals, 150 mg, 60 VCaps Kalyx: Milk Thistle Extract, Herb Pharm, 4 fl. oz. HerbsPro: Milk Thistle, Eclectic Institute, 600 mg, 120 Caps HerbsPro: Milk Thistle Tea, Alvita Teas, 24 Bags HerbsPro: Thisilyn Milk Thistle Extract, Natures Way, 175 mg, 100 Caps HerbsPro: Milk Thistle, Organic, Genceutic Naturals, 350 mg, 60 Caps HerbsPro: Milk Thistle Complex, Liver Gallbladder Drops, Bioforce USA, 1.7 fl. oz. HerbsPro: Milk Thistle, Alcohol Free, Natures Answer, 1 fl. oz. HerbsPro: Milk Thistle Extract, Eclectic Institute, 1 fl. oz. HerbsPro: Milk Thistle-Dandelion Extract, Eclectic Institute, 2 fl. oz. HerbsPro: Milk Thistle Extract, Eclectic Institute, 2 fl. oz. HerbsPro: Milk Thistle Extract, Herb Pharm, 4 fl. oz. House of Nutrition: Super Milk Thistle, Enzymatic, 120 Softgels TakeHerb: Milk Thistle Seed Powder, Starwest Botanicals, 1 lb. TakeHerb: Milk Thistle Seed, Protect & Regenerate Liver Cells, Health Herbs, 2 fl. oz. TakeHerb: Milk Thistle, Standardized, Promotes Healthy Liver Function, Good'n Natural, 175 mg, 100 Caps

VITAMIN B-5 - PANTOTHINE - PANTOTHENIC ACID PRODUCTS Pantothenic Acid (Vitamin B-5; Pantethine) is converted to coenzyme A, which is involved in the biochemical cycles responsible for conversion of fats, proteins and carbohydrates into energy. Needed to counteract stress. the most potent anti-stress vitamin. Kalyx: Pantethine, Nutricology, 330 mg, 60 Caps HerbsPro: Pantethine, Now Foods, 300 mg, 60 Softgels HerbsPro: Pantethine (Pantothenic Acid; Vitamin B-5), Source Naturals, 300 mg, 90 Tabs HerbsPro: Pantethine, Jarrow Formulas, 450 mg, 60 Softgels HerbsPro: Pantethine (Pantesin), Nutricology, 330 mg (600 mg), 60 VCaps HerbsPro: Pantethine, Now Foods, 600 mg, 60 Softgels HerbsPro: Pantethine Co-B-5 Sublingual, Coenzyme B-5 Precursor, Source Naturals, 25 mg, 60 Tabs House of Nutrition: Pantethine, Pure Encap, 250 mg, 60 VCaps House of Nutrition: Pantethine (Vitamin B-5; Pantothenic Acid), Cardiovasular, 165 mg (300 mg; 135 mg), 60 Tabs House of Nutrition: Pantethine, Douglas Labs, 500 mg, 50 Tabs TakeHerb: Pantethine Sublingual, Source Naturals, 25 mg, 60 Tabs TakeHerb: Pantothenic Acid (Vitamin B-5), Source Naturals, 100 mg, 250 Tabs TakeHerb: Pantothenic Acid (Vitamin B-5), Source Naturals, 250 mg, 250 Tabs TakeHerb: Pantethine (Vitamin B-5), Now Foods, 300 mg, 60 Softgels TakeHerb: Pantothenic Acid (Vitamin B-5), Source Naturals, 500 mg, 200 Tabs TakeHerb: Pantothenic Acid (Vitamin B-5), Solgar, 550 mg, 100 VCaps

SIBERIAN ELEUTHERO GINSENG PRODUCTS Siberian Ginseng, also known s Eleuthero helps bronchial disorders and boosts energy. It improves physical and mental vitality. It is an adaptogenic herb, which helps t he body to adapt to daily stress and is an ideal herb supplement for those leading a demanding and hectic lifestyle. Siberian Ginseng strengthens the adrenal and reproductive glands. It enhances immune function, helps support the immune system, prevent infection, promotes lung functioning, improve memory, endurance vitality and to balance the hormone levels in male and female, and stimulates the appetite. It useful for bronchitis, circulatory problems, diabetes, infertility, lack of energy, and stress. There is some evidence that it can help ease withdrawal from cocaine, and help improve drug or alcohol induced liver dysfunction in older adults. Siberian Ginseng protects the body against the effects of radiation exposure. It is used by athletes for overall body strengthening. Siberian Ginseng is most effective in the treatment of prolonged exhaustion and debility, resulting from overwork and long-term stress. As a decoction take 35 ml of Siberian Ginseng 2 times a day for use as a general tonic. To take in tincture form, use 1/2 teaspoon with water 3 times a day. For other forms, read follow product label directions. Caution: Do not use this herb if you have hypoglycemia, high blood pressure, or a heart disorder. Mountain Rose Herbs: Eleuthero Root, Organic Bulk Herbs Kalyx: Eleuthero Root Powder (Eleutherococcus senticosus; Siberian Ginseng), Certified Organic, Frontier Chinese Herbs, 1 lb Kalyx: Eleuthero Root (Eleutherococcus senticosus; Siberian Ginseng), Cut & Sifted, Certified Organic, Frontier Chinese Herbs, 1 lb Kalyx: Eleuthero Root Extract, Starwest Botanicals, Certified Organic, 1 fl. oz. Kalyx: Eleuthero Root Extract, Health & Herbs, 2 fl. oz. Kalyx: Eleuthero Root Extract, Starwest Botanicals, Certified Organic, 4 fl. oz. Kalyx: Eleuthero Root Extract, Health & Herbs, 8 fl. oz. TakeHerb: Siberian Eleuthero Tea, Sun Chlorella Products, 25 Tea Bags TakeHerb: Eleuthero Vascutone Herb Tea, Health King, 20 Tea Bags TakeHerb: Siberian Eleuthero, Imperial Ginseng, 2500 mg, 100 Caps TakeHerb: Eleuthero, NOW Foods, 500 mg, 250 Caps TakeHerb: Eleuthero Root, Starwest Botanicals, 470 mg, 100 Caps TakeHerb: Eleuthero Root, Starwest Botanicals, 470 mg, 500 Caps TakeHerb: Siberian Eleuthero Regular, Sun Chlorella Products, 300 Tabs TakeHerb: Siberian Eleuthero, Nature's Way, 235 mg Root & 250 mg Extract, 180 Caps TakeHerb: Eleuthero Root, Organic Cut & Sifted, Starwest Botanicals, 1 lb TakeHerb: Eleuthero Root Powder, Organic, Starwest Botanicals, 1 lb TakeHerb: Siberian Eleuthero Root Extract, Nature's Answers, Alcohol-Free, 2 fl. oz. TakeHerb: Eleuthero Root Extract, Gaia Herbs, 2 fl. oz. TakeHerb: Eleuthero Root Extract, Gaia Herbs, 4 fl. oz. HerbsPro: Siberian Eleuthero, Imperial Elixir - Ginseng Company, 10 ml Extract Vials, 30 Count PANAX GINSENG PRODUCTS Red Panax Ginseng is often used to increase energy. This extract is made from 6 year old Red Ginseng roots plants which are a precious natural product growing in the Mountains of Chang Pai in northern China. Considered by traditional herbals as the king of herbs, ginseng's adaptogenic properties (how it helps and balances and restores the body and mind when dealing with stress related conditions) are prized by many. If you are nursing or pregnant, consult with your midwife or health care provider before taking ginseng. Mountain Rose Herbs: Ginseng Root (Panax), Organic Bulk Herbs HerbsPro: Panax Ginseng Tea, Alvita Teas, 24 Bags HerbsPro: Panax Ginseng, Enzymatic Therapy, 50 mg, 60 Tabs HerbsPro: Panax Ginseng, Source Naturals, 10 Grain, 648 mg, 50 Tabs HerbsPro: Panax Ginseng Extract, Chinese Imports, 1.76 fl. oz.

ST. JOHN'S WORT PRODUCTS St. John's Wort is mainly used for the treatment of mild to moderate depression. It can also be used for chronic insomnia and anxiety related to depression. St. John's Wort may also be effective in relieving seasonal affective disorder (SAD). St. John's Wort extract is usually standardized to the substance hypericin. St. John's wort contains two substances, hypericin and pseudohypericin, that inhibit retroviral infections and could be useful in the treatment of AIDS. The recommended dose of St. John's Wort is 300 mg 3 times a day of an extract standardized to contain 0.3 percent hypericin; however, a few new products on the market are standardized to hyperforin content of 2 to 3 percent, instead of hypercin, and should be taken at the same dosage. If the herb bothers you, take it with food. It can take four weeks of usage to receive the full benefits of St. John's Wort. If you are taking antidepressant drugs, MAO inhibitors, SSRIs, and tricylics, or the drugs Tramadol or Imitrex, do not use St. John's Wort at the same time. Let your system completely flush those drugs out of your system before starting with the herb. If you are using Digoxin, cyclosporine, protease, inhibitors, oral contraceptives, amitriptyline, Coumadin (warfarin), theophylline, chemotherapy drugs, olanzapine or closapine, or any critical medication, St. John's Wort may cause the drugs to be less effective. St. John's Wort may have an additive effect if you are taking medications that cause sun sensitivity such as sulfa drugs, and the anti-inflammatory medication Feldene (piroxicam), as well as Prilosec or Prevacid. Caution: Individuals with HIV have an increased risk for sunburn and should avoid this herb. This herb may increase the chance of developing sun blisters if you are out in the sun too long. If you decide to use this herb, avoid sun exposure. Use with caution during pregnancy. Mountain Rose Herbs: St. Johns Wort, Certified Organic Bulk Herbs Mountain Rose Herbs: St. John's Wort Extract, Wild Harvested Herbal Extracts Starwest Botanicals: St. John's Wort Extract, Organic, 1 fl. oz. Starwest Botanicals: St. John's Wort Extract, Organic, 4 fl. oz. Starwest Botanicals: St. John's Wort Herb Capsules, 430 mg, 100 VCaps Starwest Botanicals: St. John's Wort Herb Capsules, 430 mg, 500 VCaps Starwest Botanicals: St. John's Wort Herb, Cut & Sifted, Organic, 1 lb. Starwest Botanicals: St. John's Wort Herb, Cut & Sifted, Wildcrafted, 1 lb. Starwest Botanicals: St. John's Wort Herb Powder, Organic, 1 lb. Starwest Botanicals: St. John's Wort Herb Powder, Wildcrafted, 1 lb. Kalyx: St. John's Wort, 0.3% Extract, Starwest Botanicals, 200 mg, 500 Caps Kalyx: St. John's Wort Extract, Starwest Botanicals, Certified Organic, 4 fl. oz. Kalyx: St. John's Wort Extract, Starwest Botanicals, Certified Organic 1 fl. oz. Kalyx: St. John's Wort Oil, Trinity Brand, 1 fl. oz. HerbsPro: St. John' s Wort Extract, Alcohol-Free, Black Cherry Flavor, Eclectic Institute Inc, 2 fl. oz. HerbsPro: Mood Balance (St.John' s wort & Lemon Balm), Alcohol-Free, 2 oz. TakeHerb: St. John's Wort Herb Powder, Wildcrafted, Starwest Botanicals, 1 lb TakeHerb: St. John's Wort, Oregon's Wild Harvest, Standardized 0.3% Hypercin, 90 Caps TakeHerb: St. John's Wort, Source Naturals, 450 mg, 90 Tabs TakeHerb: St. John's Wort, Source Naturals, 450 mg, 180 Tabs TakeHerb: St. John's Wort, NOW Foods, 300 mg, 250 Caps TakeHerb: St. John's Wort, Source Naturals, 300 mg, 120 Caps TakeHerb: St. John's Wort Extract, Time Release, Source Naturals, 900 mg, 60 Tabs TakeHerb: St. John's Wort Tea, Yogi Teas, 16 Bags TakeHerb: St. John's Wort Tea, Caffeine Free, Alvita Teas, 24 Bags TakeHerb: St. John's Wort Tea, Health King, 20 Bags TakeHerb: St. John's Wort Extract, Full Spectrum, Planetary Herbals, 2 fl. oz. TakeHerb: St. John's Wort Extract, Alcohol-Free, Nature's Answer, 1 fl. oz.

VALERIAN ROOT PRODUCTS Valerian root nourishes the nervous system and has soothing properties. Valerian is a safe and natural sleeping aid. It helps soothe rattled nerves and assists the body in relieving insomnia. After numerous scientific studies, Germany's Commission E approved Valerian root as a sleep aid. Mountain Rose Herbs: Valerian Root, Bulk Organic Herbs Kalyx: Valerian Plus Herbal Tea, Dr. Stuarts, 15 Tea Bags Kalyx: Valerian Extract, Standardized, Natures Way, 400 mg, 90 VCaps Kalyx: Valerian Root, Natures Way, 530 mg, 100 VCaps Kalyx: Valerian Root, Cut & Sifted, Certified Organic (Valeriana officinalis), Starwest Botanicals, 1 lb. Kalyx: Valerian Root, Cut & Sifted, Certified Organic, Frontier Bulk Herbs, 1 lb. Kalyx: Valerian Root Powder, Certified Organic, Starwest Botanicals, 1 lb. Kalyx: Valerian Root Powder, Certified Organic, Frontier Bulk Herbs, 1 lb. Kalyx: Valerian Root Extract, Certified Organic, Starwest Botanicals, 1 fl. oz. Kalyx: Valerian Root Extract, Certified Organic, Starwest Botanicals, 4 fl. oz. HerbsPro: Valerian Root Tea, Alvita Teas, 24 Bags HerbsPro: Valerian Mint Tea, Alvita Teas, 24 Bags HerbsPro: Valerian Extract, Alcohol Free, Eclectic Institute, 1 fl. oz. HerbsPro: Valerian Extract, Eclectic Institute, 2 fl. oz. HerbsPro: Valerian Extract, Herb Pharm, 4 fl. oz. HerbsPro: Valerian Glycerite Extract, Alcohol Free, Herb Pharm, 4 fl. oz. HerbsPro: Valerian Root, Now Foods, 500 mg, 250 Caps House of Nutrition: Valerian Extract, Wise Woman Herbal, 8 fl. oz.

VITAMIN C & BIOFLAVONOID PRODUCTS Vitamin C provides antioxidant protection for many of the body's' important enzyme systems. White blood cells utilize Vitamin C to help produce cytotoxic enzymes which they use to eliminate foreign matter. Kalyx: Vitamin C (Ascorbic Acid) Powder, Pure, Nutricology, 1000 mg, 120 Grams Kalyx: Vitamin C, Pure, Nutricology, 1000 mg, 100 Caps Kalyx: HerbaLozenges Orange C, Zand, 125 mg, 15 Per Bag Kalyx: Gummy Vitamin C Slices, Rainbow Light, 30 Single Serve Packets Kalyx: Fruit Snacks, 100% Vitamin C, Farley's & Sathers Candy Co., 5 lbs. Kalyx: Ester- C Powder With Citrus Bioflavonoids, American Health, 8 oz. Kalyx: Ester-C Liquid, American Health, 8 fl. oz. Kalyx: Ester-C Advanced Antioxidant Formula, American Health, 90 Vegetarian Tabs Kalyx: Ester-C Chewable Wafers, American Health, 250 mg, 125 Wafers HerbsPro: Maxi-C Complex Vitamin C, Country Life, 1000 mg, 180 Tabs TakeHerb: Ascorbic Acid Powder (Vitamin C), NOW Foods, 3 lbs. TakeHerb: Ascorbate C Powder, TwinLab, 2000 mg, 8 oz. TakeHerb: Liquid C With Rose Hips, Good'n Natural, 300 mg, 4 oz. TakeHerb: Alive! Organic Vitamin C Powder, Made With Organic Fruit, Nature's Way, 120 grams TakeHerb: Vitamin C-500 Complex With Bioflavonoids, Acerola & RoseHips, NOW Foods, 100 Tabs BIOFLAVONOID PRODUCTS Bioflavonoids are not true vitamins in the strictest sense, sometimes being referred to as vitamin P, and may be found in herbal plants, fruits, nuts and bark; and because they cannot be manufactured by the body, they must be supplied through the diet. The letter ''P'' represents permeability factor, and it was given to this group of nutrients because they improve capillary strength and permeability. Citrus Bioflavonoids are a class of flavonoids that includes Rutin, Hesperidin, Quercitin, Eriodictyl and Citron, and they are essential for the absorption of vitamin C, which should be taken simultaneously, so they may act synergistically for maximum benefit. Citrus fruits are well known for providing ample amounts of vitamin C, but they also provide Citrus Bioflavonoids, which are located in the white material just beneath the peel of citrus fruits and may be found in grapefruits, lemons, tangerines, limes and oranges. Other sources of bioflavonoids include apricots, nuts, peppers, buckwheat, blackberries, black currants cherries, grapes, plums, prunes and rose hips. In addition, several herbs also provide bioflavonoids, including Chervil, Elderberry, Hawthorne Berry, Horsetail and Shepherd's Purse. Kalyx: Citrus Bioflavonoids Powder, Herbal Extracts Plus, 1 lb. Bottle Citrus Bioflavonoids Powder - Approximately 600 mg. each capsule. 1/2 teaspoon of powder is about equal to one capsule. Powder can be consumed by sprinkling it over your food or mixing it with a syrup such as maple or chocolate. You could also mix it with orange juice. The citric acid in the orange juice will help to mask any unpleasant powder tastes. Sources: Lemon (Citrus limon) and Grapefruit (Citrus paradisi). Kalyx: Citrus Bioflavonoids, Country Life, 1000 mg, 250 Tabs Provides a unique citrus bioflavonoid complex from lemons, oranges and grapefruits. Includes Rutin. Certified Vegan. HerbsPro: Citrus Bioflavonoids Fluid Complex, Organic With Rosehips, Natures Answer, 5000 mg / Teaspoon, 8 fl oz. HerbsPro: Bioflavonoids Complex, FoodScience of Vermont, 1000 mg, 60 Tabs House of Nutrition: Bioflavonoids Complex, FoodScience of Vermont, 1000 mg, 60 Tabs A bioflavonoid complex supplement with Hesperidin, Rutin, and Bromelain. Bioflavonoids enhance the effectiveness of Vitamin C. Bioflavonoids support capillary strength and proper vascular function. House of Nutrition: Bioflavonoids Complex, Carlson Labs, 500 mg, 100 Tabs Each tablet contains 500 mg of Citrus Bioflavonoids Complelx providing not less than 250 mg of Bioflavonoids, in a base of Rose Hips. House of Nutrition: Quercetin Bioflavonoids, Allergy Research, 100 Caps Quercetin and other bioflavonoids extracted from lemon have made up the classical bioflavonoid nutritional supplements. By strengthening the outer cell membrane, these flavonoids may help stabilize cell surfaces. Contains 400 mg Lemon Bioflavonoids, 50 mg Quercetin, 50 mg Hesperidin, 50 mg Rutin, and 10 mg Ascorbyl Palmitate. Take 1 or 2 Caps 1 to 3 times daily with meals or as directed by healthcare provider. TakeHerb: Bioflavonoid Complex, Source Naturals, 60 Tabs TakeHerb: Citrus Bioflavonoid Complex, Now Foods, 700 mg, 100 Caps These Citrus Bioflavonoid Caps contain 40% total bioflavonoids. There are many varieties of bioflavonoids available and ours includes a number of flavonols, flavones, and flavanones including: Hesperidin, Eriocitrin, Naringen, Naringenin, and Quercitin. As a dietary supplement, take 2 capsules daily, preferably with meals. TakeHerb: C-Plus Citrus Bioflavonoid With Rutin, TwinLab, 1000 mg / 650 mg / 50 mg, 100 Caps TwinLab offers the highest bioflavonoid content concentrated from fresh lemons, oranges, grapefruits, limes and tangerines, along with the greatest number of individual bioflavonoids available from any manufacturer. Citrus Bioflavonoids Complex contains 50% total bioflavonoids consisting of flavanones [hesperidin, eriocitrin, naringen and naringenin], flavonols, flavones. TakeHerb: Citrus Bioflavonoid, TwinLab, 1400 mg, 100 Caps Contains the purest and highest potency source of citrus bioflavonoids available. Concentrated from fresh lemons, oranges, grapefruits, limes and tangerines. Citrus Bioflavonoids (Vitamin P) are found in whole portion of citrus fruits which may be helpful for bruising, varicose veins, spider veins, arthritis, hemorrhaging, phlebitis, cholesterol levels, herpes, cataracts, inflammation, bleeding gums, blood clots, scurvy, hemorrhoids, edema and hypertension. TakeHerb: Bioflavonoid Antioxidant Protection, Now Foods, 700 mg, 250 Caps

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