doi: http://dx.doi.org/10.11606/issn.1679-9836.v99i5p463-472 Rev Med (São Paulo). 2020 Sept-Oct;99(5):463-72.

Phytotherapeutic drugs: prevalence, advantages, and disadvantages of use in

clinical practice, profile and evaluation of users

Medicamentos fitoterápicos: prevalência, vantagens e desvantagens de uso na

prática clínica e perfil e avaliação dos usuários

Clara Oliveira Esteves1, Raquel Miguel Rodrigues2, Andréia Luísa Duarte Martins3, Rayana
de Almeida Vieira3, Juliana Lourenço Barbosa3, Júlia Barbosa Ferraz Vilela3
1.

Esteves CO, Rodrigues RM, Martins ALD, Vieira RA, Barbosa JL, Vilela JBF. Herbal medicines: prevalence, advantages and disadvantages
of use in clinical practice and profile and evaluation of users / Medicamentos fitoterápicos: prevalência, vantagens e desvantagens de
uso na prática clínica e perfil e avaliação dos usuários. Rev Med (São Paulo). 2020 Sept-Oct;99(5):463-72.
ABSTRACT: Introduction: This study aimed at reviewing the literature RESUMO: Introdução: Este trabalho realizou uma revisão de literatura
on the aspects of the use of phytotherapeutic drugs, medicinal products acerca de aspectos do uso de fitoterápicos, medicamentos compostos
made from the extraction of active compounds from unprocessed a partir da extração de matérias primas vegetais ativas, que passam
plants, undergoing industrial processes. Therefore, the most commonly por um processo de industrialização. Dessa forma, identificaram-se os
used phytotherapeutic substances, the prevalence of this practice, the fitoterápicos mais utilizados, a prevalência de utilização dessa prática,
advantages and disadvantages of its use, and the profile and evaluation vantagens e desvantagens de seu uso e o perfil e avaliação de usuários
of Universal Health Care users were identified. Material and Methods: do Sistema Único de Saúde. Material e Métodos: Realizou-se um
The bibliographic research comprised of articles published within the levantamento bibliográfico do período de 2014 a 2018 nas bases de
period from 2014 to 2018 in the SciELO and Lilacs databases. The dados SciELO e Lilacs. Foram utilizados os descritores “fitoterapia” e
keywords “fitoterapia” (phytotherapy) and “medicamentos fitoterápicos”
“medicamentos fitoterápicos”, sendo encontrados 353 artigos da base
(phytotherapeutic drugs) were used, three hundred and fifty-three articles
were found in SciELO database, yet only twenty-one were selected for SciELO, sendo somente 21 selecionados para leitura e 13 utilizados para
reading, and thirteen were used to write this article. In comparison, in formar o artigo, enquanto na base de dados Lilacs 1490 artigos foram
the Lilacs database, one thousand, four hundred and ninety articles were encontrados, 46 selecionados para leitura e 8 utilizados para elaborar o
located, forty-six selected for reading, and only eight were utilized for artigo. Os demais foram eliminados pelo título, por repetição ou por não
preparing the article. The others were eliminated based on their titles, se encaixarem nos critérios de inclusão. Resultados e Discussão: A partir
repetition, or because they did not adhere to the inclusion criteria. Results dos 21 artigos selecionados, o conteúdo destes foi agrupado em quatro
and Discussion: Four categories were created based on the twenty-one categorias: fitoterápicos mais utilizados, prevalência do uso da fitoterapia,
selected articles: the most commonly used phytotherapeutic medicine, vantagens e desvantagens da prática e perfil e avaliação dos usuários do
the prevalence of phytotherapy use, advantages and disadvantages of Sistema Único de Saúde. Conclusão: Os fitoterápicos mais utilizados
the practice, profile, and evaluation of Universal Health Care users. são o Guaco (Mikania glomerata), medicamentos à base de Passiflora,
Conclusion: The most commonly used phytotherapeutic medicine are chá verde e fitoterápicos a base de Curcuma. A prevalência do uso é
Guaco (Mikania glomerata), medication made of Passiflora (passion apontada como baixa pela maior parte dos estudos. Como desvantagem
fruit), green tea, and phytotherapeutic drugs extracted from Curcuma menciona-se o desconhecimento de profissionais de saúde e a menor oferta
(Turmeric). There is a low prevalence of the practice, as indicated by de medicamentos fitoterápicos pelo Sistema Único de Saúde, por outro
the majority of the studies. As a disadvantage, it is possible to mention lado, o estreitamento do vínculo médico-paciente é um aspecto positivo
the insufficient knowledge by health professionals and the inadequate do uso dos fitoterápicos. Os usuários que fazem mais uso da fitoterapia
supply of phytotherapeutic drugs by the Universal Health Care system.
são mulheres e indivíduos acima de 50 anos. São necessários mais estudos
On the other hand, the improvement of the doctor-patient bond is a
positive aspect of using phytotherapeutic medication. The user profile sobre a fitoterapia, buscando difundir uma produção de cuidado que se
includes women and individuals over 50 years old, who take the majority aproxime da população dentro de suas particularidades étnico-culturais.
of phytotherapeutic drugs. Further studies on phytotherapy are needed,
aiming at disseminating care provision that tightens the bond between
the population and its ethnic-cultural singularities. Descritores: Fitoterapia; Medicamentos fitoterápicos.

Keywords: Phytotherapy; Phytotherapeutic drugs.

1. Speech Therapist and Substitute Professor in the Undergraduate Course of Medicine at the “Universidade Federal do Rio de Janeiro”, Macaé
Campus. Doctoral Degree in Linguistics from the Federal University of Rio de Janeiro. ORCID: https://orcid.org/0000-0001-9979-7416. E-mail:
[email protected].
2. Physiotherapist and Assistant Professor in the Undergraduate Course of Medicine at the “Universidade Federal do Rio de Janeiro”, Macaé Campus.
Doctoral Degree in Bioethics, Applied Ethics, and Collective Health from PPGBIOS at the Federal University of Rio de Janeiro, National School
of Public Health, “Universidade Federal Fluminense” and “Universidade do Estado do Rio de Janeiro”. ORCID: https://orcid.org/0000-0002-4593-
6633. E-mail: [email protected].
3. Graduated in Medicine from the “Universidade Federal do Rio de Janeiro”, Macaé Campus. ORCID: ORCID: Martins ALD - https://orcid.org/0000-
0002-1163-0900; Vieira RA - https://orcid.org/0000-0003-4950-0615; Barbosa JL - https://orcid.org/0000-0002-7754-5821; Vilela JBF - https://
orcid.0000-0002-8701-2770. E-mail: [email protected], [email protected], [email protected], [email protected].
Correspondence: Raquel Miguel Rodrigues. Rua Manoel Soares da Silva, 1455, Itamambuca, Ubatuba, SP. CEP: 11680-000.

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Esteves CO, et al. Herbal Medicines: prevalence, advantages and disadvantages of use in clinical practice

INTRODUCTION results, from data collected from e-SUS and Electronic

Citizen Medical Records in 2016, there have been over two

I
million Integrative Practical appointments registered in the
n Brazil, the use of medicinal plants is mainly
Basic Healthcare Units (UBS), and among them, eighty-five
based on indigenous practices that, when
thousand were considered phytotherapy3.
associated with African and Portuguese cultures, generated
The National Essential Medicine Listing (Rename)
a vast popular experience1. The World Health Organization
includes a dozen phytotherapeutic drugs, originating from
(WHO) recognizes and encourages these practices, as they
standardized plant species: Artichoke (Cynara scolymus
make up what is called Traditional and Complementary
L.), “Aroeira” (Mastic) (Schinus terebinthifolius Raddi);
Medicine.
Aloe Vera (L.) Burm.f ); Chitticum bark (Rhamnus
According to WHO, the majority of the population
purshiana D.C.); “Espinheira-santa” (Maytenus officinalis
from developing countries “depend on traditional
Mabb.); Guaco (Mikania glomerata Spreng.); Devil’s
medicine for their primary care, considering that 80%
Claw (Harpagophytum procumbens); Spearmint (Mentha
utilize traditional practices for their basic health care
x piperita L.); Soy isoflavone (Glycine max (L.) Merr.);
and 85% among those people use plants or preparations
Plantago (Plantago ovata Forssk.); Willow (Salix alba
made from them”1. WHO had already warned regarding
L.); Cat’s claw (Uncaria tomentosa (Willd. ex Roem. &
the necessity of regulating the use of medicinal plants and
Schult)(4).
phytotherapy at the Alma-Ata conference in 1978, these
Despite their effectiveness and low operating
treatmentswere based solely on empirical knowledge and
costs5, phytotherapy is not uniformly employed throughout
popular experience until then, as mentioned1.
the entire country. It is still quite often an unfamiliar
Thus, the National Policy of Medicinal Plants and
topic for health professionals. These difficulties arise,
Phytotherapy, was stated in Decree # 5,813, dated June
ranging from the correct understanding of the difference
22nd, 2006, and implemented actions capable of promoting
between phytotherapeutic drugs and medicinal plants.
improvements in the well-being of the Brazilian population
These concepts are confused by the population as well
and thereby fostering, among other results, improvement
as by healthcare professionals. There is disagreement
in healthcare (1). That policy complies with Primary Care
by ANVISA6 stating that the population uses medicinal
as proposed by WHO, which focuses its attention on the
plants for therapeutic purposes, the effectiveness of which
person and not just the disease and addresses the most
is being proven through chemical and pharmacological
common problems in the community, providing prevention,
studies. Phytotherapeutic drugs are obtained by extracting
treatment, and rehabilitation services, maximizing health
the active materials from unprocessed plants through an
and well-being2. An Inter-ministerial Ordinance # 2,960,
industrialized process and present effectiveness based on
dated December 9th, 2008, approved the National Policy of
clinical evidence7.
Medicinal Plants and Phytotherapy and created the National
Besides that, according to ANVISA 6 , the
Committee of Medicinal Plants and Phytotherapy, it grants
industrialization process of phytotherapy standardizes the
safe and rational use of medicinal plants and phytotherapic
quality through the purification of microorganisms and
medicine by the population, making sure it is done safely,
foreign substances, thereby making it possible to provide
effectively, and with quality1.
enhanced safe usage.
Nineteen other integrative practices have been
The riches of the Brazilian plant species and biomes,
added to the Universal Healthcare System aside from
associated with ethnic-cultural diversity, imply extensive
phytotherapy, as stated by the National Policy of Integrative
usage of plants for curative purposes8. Factors, such as
and Complementary Practices – PNPIC (Decree GM/MS
easy access to these plants and cultural compatibility, are
#971 and Decree #849/2017). According to Lucas Gaspar extremely relevant to progress in using phytotherapeutic
Ribeiro, who was the coordinator of the Work Group drugs, attributing an excellent price-performance ratio to
(GT) of PICS at the Brazilian Association of Medicine such practices5. Primary care services are the leaders in
of Family and Community in 2018, integrative practices prescribing phytotherapy treatments, seeking to establish
are recommended for preventive or curative purposes, in ties between users and healthcare teams7. Thus, using
multiple situations, such as supportive care or primary phytotherapies promotes the tightening of these bonds
therapies for acute or chronic clinical conditions. The due to respect for the users’ culture and, thereby, “adding
presence of these practices in the Universal Healthcare meaning to the provision of healthcare and increasing
System is responsible for reducing the unnecessary use adhesion to its practices”7. That effect arises because
of medicines and, consequently, their adverse effects cultural competence, one of the derivative aspects of
and, thus, improves the resolution and effectiveness of primary healthcare, allows for the recognition of the
treatments and provides increased quality of life to users. cultural particularities of social groups, as well as an
The increased demand for these services by healthcare understanding of their different necessities and convictions
users has also been encouraging. When considering the about the health-disease process. Thereby, this facilitates

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the adhesion to the treatment by the user and, consequently, identify the most commonly used herbal medications, the
making increased effectiveness possible to its prescription2. prevalence of their use as an alternative practice, stating
Primary Care Professionals can provide specific their advantages and disadvantages, and mention the
services, varying according to place, time period, and profile of the Universal Health Care System Users and
that take into consideration variables and relationships. their evaluation of it.
Furthermore, they can modulate the agency the patient A total of three hundred and fifty-three articles were
will have in making decisions regarding aspects related to found in the SciELO database and, among those, there
the treatment, avoid repetition of exams, medications, and were seventy-seven articles that included the keyword
organize prescriptions from all specialists2. “medicamentos fitoterápicos” (phytotherapeutic drugs),
However, it is necessary to emphasize that the nine articles were excluded due to repetition, while two
actual institutionalization of the Integrative Practices in hundred and seventy-six articles were found including the
the Universal Healthcare System is an enormous challenge, keyword “fitoterapia” (phytotherapy), and six of them were
due to the reduced number of qualified human resources, excluded due to repetition. After applying the inclusion
insufficient funding, and limited institutional spaces for criteria, seventy-eight articles remained. Amidst those,
developing new practices and services. Regardless, due fifty-seven were eliminated by the title, as they did not
to cultural as well as scientific issues, there is a barrier meet the inclusion criteria, four of them for having included
to the inclusion of Integrative Practices to biomedicine9. both keywords. Out of the twenty-one selected articles,
The purpose of this work, through a literature review, is to thirteen were chosen to be read and used for preparing
identify the most commonly used phytotherapeutic drugs, this literary review.
the prevalence of alternative practices use, investigating A total of one thousand, four hundred, and ninety
their advantages and disadvantages, and elucidating the articles were found in the LILACS database, among those,
profile of Universal Healthcare users and evaluating their. four hundred and fifty-nine articles were detected through
the inclusion of the keyword “medicamentos fitoterápicos”
MATERIAL AND METHODS (phytotherapeutic drugs), one article was excluded due to
repetition. One thousand and thirty-one articles were found
This study is based on a literature review, it searched by researching the keyword “fitoterapia” (phytotherapy),
for articles through the Scientific Electronic Library Online out of which four were excluded due to repetition.
(SciELO) database, performed in the timeframe ranging Afterwards, with the inclusion criteria, three hundred and
from April 2019 to May of the same year, and, in the forty-five articles were focused on. Among those, two
LILACS database, in July 2019. hundred and ninety-nine were eliminated due to their title,
Advanced research was performed in each as they did not meet the inclusion criteria, and, in the midst
database by inserting the keywords separately and jointly, of these, eleven included both keywords. Amid the forty-six
corresponding to the classification of Health Science lingering eligible articles, eight already were in the SCIELO
Keywords (DeCS), in Portuguese, as: “Medicamentos database, thus they were excluded. Among the thirty-eight
Fitoterápicos” (Phytotherapeutic Drugs) and “Fitoterapia” remaining articles, eight were picked for reading and used
(Phytotherapy). The inclusion criteria for articles were for preparing this literary review.
as follow: they had to be written in Portuguese and must The selected articles from the two databases
have been published in the last five years. They had to encompass bibliographic reviews and original articles.

Figure 1: The flowchart describes the article

selection process applied to this bibliographic
review

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Esteves CO, et al. Herbal Medicines: prevalence, advantages and disadvantages of use in clinical practice

RESULTS AND DISCUSSION drugs through the analysis of original studies. The articles
were read, carefully selected, and described in this context,
The purpose of this study was to present and discuss according to Table 1.
findings in literature regarding the use of phytotherapeutic
Table 1: The listing of the selected articles based on their names, authors, publication magazine, article title, publication year
Authors Title/Year Findings Conclusion
96.2% of professionals believe in the medicinal
The city of Blumenau did not implement
effect of plants and phytotherapeutic drugs with
Medicinal plants and the National Policy entirely. Professionals
allopathic medications. 70.7% of professionals
phytotherapeutic drugs in Primary agree with the Ministry of Health’s
Mattoset al.10 report the population displays an interest in this
Health Care: perception of initiave, they believe in the therapeutic
practice. Nine out of twelve plants or herbal
professionals. 2018 effect of plants; however, they do not
medicines (75%) are known by less than half
prescribe them due to lack of knowledge.
(41.4%) of health professionals.
11% of the São Paulo State Healthcare units
provide phytotherapeutic drugs and medicinal It has been proven that phytotherapy
plants. Marilia city is noteworthy, in which forty- is present in cities well-rated in human
Availability of phytotherapeutic
four out of forty-five healthcare units provide development indicators. The increase in
drugs and medicinal plants at the
them; Campinas provides them at 65.1% of the scientific publications optimistic about
São Paulo State primary care units:
Caccia-Bava et al.7 units and Sorocaba, 50%. Guaco is the most these medications was emphasized, in
results from the National Program
commonly used medication. counterpart to detrimental essays regarding
of Improved Access and Basic Care
12% of the interviewed professionals certify that the use of industrialized medications
Quality (PMAQ). 2017
their team holds health educational activities instead of manipulated medications or
focusing on the use of medicinal plants and herbal drugs.
herbal medicines.
Ginkgo biloba and Aesculus hippocastanum
Research and extension activities
(horse chestnut) are mentioned as the most
in phytotherapy performed by the The importance of performing extension
commonly used herbal medications. 5.5% of those
“Rede FitoCerrado” (FitoCerrado activities for improving the usage of
interviewed took herbal medications, and 76.7%
Machado et al. 13
Network): the rational use of phytotherapy among the elderly and also
reported on taking some medicinal plants. 60.7%
medicinal plants and herbal for making scientific knowledge available
of the elderly declared that they did not inform
medications by the elderly in to the population.
the doctor of using medicinal plants and herbal
Uberlândia-MG. 2014
medications.
It emphasizes the use of phytotherapeutic drugs
by professionals who did not have access to The article demonstrated that the majority
these subjects in college, but they prescribe of interviewed doctors were familiar with
them based on their clinical experience. As herbal medications and recommended
Knowledge of herbal medicine and
follows: (1) anxiolytics and sedatives: Remilev, them to ESF users from Caicó. Despite the
Varela; Azevedo11 its practice by doctors in the family
Calman, Floriny, and Passiflorine, Ansiopax; lack of instruction regarding this type of
healthcare strategy. 2014
(2) Ginseng for anxiety and insomnia; (3) medication in the training of professionals,
female demographic: Mencirax, isoflavone, and they are receptive to herbal medication
Promensil; (4) Kronel, with antimicrobial, anti- practices in ESF.
inflammatory, and healing activities.
66.7% of the 96 graduated professionals did not
know the difference between phytotherapeutic and
homeopathic medicines. Training and motivation are necessary,
Evaluation of the knowledge and Despite that, 36.5% confirmed that they prescribe so that healthcare professionals become
perception of professionals from them; the majority of doctors are between 31and able to prescribe Medicinal Plants and
Nascimento Júnior et family healthcare strategy about 40 years old. 67% of these professionals were Phytotherapeutic drugs. It is essential to
al.12 the use of medicinal plants and not taught during their training how to these include subjects such as Phytotherapy in
phytotherapy in Petrolina-PE, medications. Guaco (Mikania glomerata S.), their curriculum, in order to cover this
Brazil. 2016 Maracugina, (Passiflora alata A., Erythrina subject and prepare professionals, as well
mulungu M., and Crataegus oxyacantha L.) and as promoting periodic update courses.
Tensart (Passiflora incarnata L.) were the most
commonly cited.
80% of the interviewed parties classify their
interest level in learning more about PNPIC, There is little knowledge of PM/
PEPIC, and Phytotherapy ranging from 8 to10. Phytotherapy and its policies in PHCS
Ethnopharmacological study
One hundred and two residents were also (primary healthcare services), as self-
regarding the urban forest as a
interviewed, 47% of them confirmed that they teaching is the most common mean for
Borcard et al.17 subsidy for the implementation
use PM/Phytotherapy, and they did not inform obtaining this type of knowledge. The
of Phytotherapy in the Universal
the doctor of their use. importance of this knowledge and its
Healthcare System. 2015
32 Local Specialists were interviewed, 95% of perpetuation into future generantions is
them shared their knowledge with others, mainly evident to local specialists.
with neighbors and family members.
70.8% of the interviewed students are in favor
Even though they were unfamiliar with
of adding medicinal plants and phytotherapy
Phytotherapy Subject Matter in the the integrative regulatory practices,
Feitosa et al.
21
subjects to their undergraduate medicine course.
Field of Healthcare Courses. 2016 most displayed self-taught interest on
The majority (81.3%) of the students confirmed
the subject.
they were unfamiliar with PNPIC.

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Table 1: The listing of the selected articles based on their names, authors, publication magazine, article title, publication year Continuation
Authors Title/Year Findings Conclusion
57.41% report that they use medicinal plants,
among those people, 93.37% drink tea as a Residents in Quixadá-Ceará frequently use
medication, and 6.63% use it as food. The age medicinal plants. Tea is mainly drunk by
Usage of medicinal plants by the
Oliveira; Lucena18 bracket ranging from 51 to 60 years old knows women and it is done for healing purposes
residents of Quixadá–Ceará. 2015
more information on medicinal plants. 97% are and disease prevention. The population is
unfamiliar with the toxicity risks from prolonged unaware as to the usage and dosages.
use of some medicinal plants, such as “boldo.”
Pharmacological evaluation and 35.7% of the samples of “boldo” tea and 57.7% of
assessment of the labeling of the samples of chamomile exceeded the maximum It is necessary to improve inspection and
“boldo” plant drugs (Peumus concentration of foreign material; 100% of intervention in the production and sale
Soares et al.22
boldus Molina) and chamomile the “boldo” samples and 96.6% of chamomile of these products to adhere to current
(Matricaria recutita L.) for sale in presented errors or missing information on the applicable standards.
Fortaleza, CE. 2015 labels.
Five reviews related to the use of herbal
Using herbal medications based on medications on the treatment of oral lesions “Aroeira” (mastic) was concluded as
“aroeira” (mastic) as an assistant conffirm the applicability of “aroeira” (mastic) displaying antifungal and antimicrobial
Dias et al.23
in the treatment of gingivitis: against gingivitis, except 1), one randomized activities and reduction of gum bleeding
Systematic Review. 2015 clinical study, one experimental study, and one rates.
descriptive observational study.
It performed a bibliographic review on the
Using oriental herbal medications It is necessary to know the risks,
evaluation of 12 studies, 11 of those reported
Kuba; Vattimo24 in renal lesions: integrative review. interactions, toxicity, active mechanisms,
on herbal medications effectiveness in either
2015 and adverse effects of these medications.
preventing or improving renal lesions.
It performed a bibliographic review on 57 selected
The utilization of medicinal plants
articles. It identified a total of 52 medicinal
Medicinal plants in the healing considers an important alternative in the
plants and an herbal mixture that were studied
Piriz et al.25 process of wounds: a literature treatment of wounds, showing the need
experimentally or clinically on its auxiliary
review. 2014 for performing further studies and updating
effects in the healing process, confirming that the
the subject.
majority (88.5%) displayed efficacy.
Based on the performed analysis, it was noticed
that the implementation of the National Policy on Despite the challenges, it focused on the
The National Policy on Medicinal
Medicinal Plants and Herbal Medications made Policy, as it is important for providing
Plants and Herbal Medications:
Figueredo et al.27 little progress regarding the hindrances to its means of complementary treatment,
construction, perspectives, and
use in SUS (Universal Health Care system), due which is accessible and favors public
challenges. 2014
to the insufficient knowledge of the healthcare engagement.
professionals.
Camellia sinensis was the most commonly used, Due to the recent regulation for nutritional
Prescription of herbal medication
due to its main purpose of controlling weight. health professionals, it is important to
David; Bello 14
by nutritionists in compounding
Its anti-obesity effect consists of a decrease in identify their preferences on the selection
pharmacies. 2017
adipose tissue, since it reduces adipocytes. of herbal medication.
The article mentions Glycine max (Soybeans),
Characterization of medicinal
Trifolium pratense (Red clover), Cimicifuga
plants and phytotherapeutic drugs Phytotherapeutic Drugs are presented as
Marques et al.15 racemosa (Black cohosh), and Curcuma longa
for the treatment of osteoporosis alternative medications.
(Turmeric) as alternatives in the treatment of
used in Brazil. 2016
osteoporosis in Brazil.
Traditional and Complementary Medicine can be
Traditional and Complementary The suggestion of expanding traditional
inserted in two or more factors of the network,
Medicine in Brazil: insertion in the and Complementary Medicine in SUS
Sousa; Tesser16 focusing its supply in primary care, and most
Universal Healthcare System and (Universal Healthcare System) so as to not
of that supply should be performed through the
integration with primary care. 2017 waste preexisting experiences.
Universal Healthcare System.
Difficulties faced by nurses in Absence of planning, insufficient skills of Increased investment by administrators
the applicability of herbal healthcare professionals, and non-valorization by in implementing integrative and
Araújo et al.20
medications in primary healthcare: the administration and the respective healthcare complementary practices, as well as in
an integrative review. 2015 team. the preparatory process.
Psyllium Mill, a laxative that increases the stool
bulk, castor oil, and anthraquinone compounds as There are awareness programs for
Utilization of herbal medications secretagogic laxatives, were cited. They include discussing adverse effects from taking
Darroz et al. 26
in the treatment of intestinal Aloe vera, Chitticum bark (Rhamnus purshiana), laxatives and the need for changes in diet
constipation. 2014
Chinese rhubarb (Rheum palmatum), and and lifestyle.
Alexandrian senna (Cássia angustifolia).
The PNPMF depends on intrinsic and extrinsic
Evaluating the impact on the
factors regarding education in order to achieve
Brazilian policy of medicinal It is essential to improve instruction on
the expected results. There has been little impact
Sá et al.19 plants and phytotherapeutic phytotherapy in college teaching, as well
on healthcare college curriculums in Ceará State.
compounds in healthcare college as other integrative practices.
Except for what has been done in pharmacy
education. 2018
courses.

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Esteves CO, et al. Herbal Medicines: prevalence, advantages and disadvantages of use in clinical practice

The selected articles were arranged in four the research essays14 is primarily prescribed by nutritionists
categories, based on the content analysis and the purpose of to promote weight loss. The literature15 also mentions
the discussion: A) Most commonly used phytotherapeutic phytotherapeutic drugs made of Curcuma (Turmeric) due
substances; B) Determination of prevalence of phytotheray to its bone protective properties, presenting as an alternative
usage; C) Advantages and disadvantages of using treatment for osteoporosis.
phytotherapeutic medication; D) The profile and evaluation
of users in the Universal Healthcare System regarding the Prevalence of phytotherapeutics usage
usage of phytotherapeutic drugs. The following topics will
discuss such categories. Around 25% of Brazilian cities, in 2008, offered
some approaches among Traditional and Complementary
Most commonly used phytotherapeutic substances medicines, based on the context and local needs16. In 2014,
only 16.1% primary healthcare units in São Paulo state
The Universal Healthcare System started to offered these drugs, as evidenced by a research study13
implement phytotherapy in 2006, when the Ministry of performed on 292 elderly people who were over 60 years old
Health launched the National Policy of Integrative and and were enrolled in Physical and Recreational programs
Complementary Practices (PNPIC)10, studies regarding for the Elderly in Uberlândia-MG. It confirmed that 5.5%
the use of this practice became more frequent, making it of the interviewed participants used phytotherapeutic
possible to make comparisons. drugs, while the majority of the interviewed did not know
The first analyzed article7 evaluated the availability that term. Conversely, 76.7% reported that they used some
of phytotherapeutic drugs in primary healthcare units in medicinal plants.
the state of São Paulo, “recommending Guaco (Mikania Patients commonly use medicinal plants, yet they
glomerata) traditionally broadly presented due to its do not report it to their doctors, as confirmed in one study17
expectorant and bronchodilator actions”7. performed among the 102 users of the Primary Healthcare
One study11 carried out in the family healthcare Unit in Juiz de Fora (MG), whereas 47% confirmed that
strategy framework in Caicó, in Rio Grande do Norte state, they did not report this fact. Medicinal plants are lower
focused on the proven anxiolytic and sedative activity, such as priced when compared to phytotherapeutic and allopathic
Remilev, made of valerian (Valeriana officinalis); Calman, drugs. Also, they are associated with traditions and
Floriny, and Passiflorine, prepared with “passiflora” publc knowledge, as evidenced in the same study (18) that
(passion fruit) (Passiflora incarnata); Ansiopax, extracted interviewed 32 local specialists in that same region. 95%
from kava kava (Piper methysticum); Ginseng (Panax of these people confirmed that they shared their knowledge
ginseng C. A. Mey.), used in treating anxiety and insomnia. with others, especially family members and neighbors.
Varela and Azevedo 11 also identified the use In the study, as mentioned earlier17 in Juiz de Fora
of phytotherapeutic medicine targeted to a female (MG), 142 healthcare professionals were interviewed, and
demographic, as Mencirax, made from a dry extract none of them knew how to define the term phytotherapy.
of “cimicífuga” (black cohosh) (Cimicifuga racemosa 58.4% were self-taught on their knowledge about the
L.); Kronel, prepared from “aroeira” (mastic) (Schinus subject, and only 13% confirmed to have obtained
terebinthifolius Raddi), which provides antimicrobial, that knowledge in university 17 . One study 12 on 96
anti-inflammatory, and healing properties; isoflavone, bachelors in Family Healthcare Strategy in Petrolina-PE
eases vasomotor symptoms, caused by menopause, and confirmed that 66.7% did not know the difference between
Promensil, prepared with red clover (Trifolium pratense), phytotherapeutic and homeopathic medications and, despite
however, it provides questionable efficacy, as it does that, 36.5% confirmed that they prescribed these drugs. The
not promote significant improvement of menopausal majority of these doctors were aged between 31 and 40.
symptoms; and tibolone. While in a similar research study10 performed from 2014 to
There was another research study12 performed on the 2015 in Blumenau-SC, analyzing 157 Family Healthcare
family healthcare strategy in Petrolina-PE, the medications professionals in the city, 85.4% of them did not know
cited in the interviews were: Guaco® (Mikania glomerata about the presence of phytotherapeutic medicine listed on
S.) (4 mentions); Maracugina® (made from passion fruit) the National Listing of Essential Medications and, despite
(Passiflora alata A., Erythrina mulungu M. and Crataegus this, 84.7% had already previously prescribed them to
oxyacantha L.) (2 mentions); Tensart® (Passion Fruit) their patients.
(Passiflora incarnata L.) (2 mentions)12, thus, these are in In Caicó (RN), there was a research study 11
agreement with the other analyzed articles. And finally, a performed in 2011, including nine doctors that suggested
study13 performed in Uberlândia-MG, focused on Ginkgo that they had little knowledge of phitotherapy and had little
biloba and Aesculus hippocastanum, as the most commonly instruction on this subject in their undergraduate course.
used Phytotherapeutics. But, contrary to other studies, the professionals, despite
Green tea, Camellia sinensis, according to one of not having technical preparation, confirmed that they were

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knowledgeable on specific drugs due to the many years and law # 14,903, dated February 6, 2009, on the creation
they had practiced medicine and their experiences, and they of the Phytotherapeutic and Herbal Medicine Program in
reported that they had prescribed them to their patients, São Paulo City. In counterpart, research study7 negatively
especially anxiolytic/sedative phytotherapeutic drugs to emphasizes the use of industrialized phytotherapeutic
substitute benzodiazepines medicine instead of compounded ones or herbal drug
Regarding the prevalence of phythotherapy related medications, displaying the need for this segment of the
knowledge by healthcare professionals, the southeast region Brazilian industry so that the use of these medications is
presents the largest number of specialists in phytotherapy not negatively impacted due to their absence on the market.
(42%), probably due to the higher concentration of According to the research study 13 on the Fitocerrado
healthcare professionals in these big healthcare centers. network on phytotherapeutic medicine, the mistakes
There are 20% in the northeast region, followed by 15% in in the preparation and identification of herbal species
the southern region, then 13% in the central-western, and, and excessive use might impose hazards, causing an
finally, 10% in the northern region19. overdose, absence of efficacy, undesirable effects, that
Almost all the studies indicated that the majority of can compromise the user’s health. Problems, such as
the components of either group — healthcare professional the absence of dialogue among Universities publishing
and users — use,or have already used, some medicinal scientifically about the subject and the population,
plants, mainly as teas. Regardless, they do not recommend propagating empirical knowledge, such as therapeutic
the use of phytotherapy for various treatments. recommendations, toxicity, contraindications, and possible
interactions, are also emphasized in the article12.
Advantages and disadvantages of using phytotherapeutic The study analysis 11 on phytotherapeutic knowledge
medicine and practices among doctors in primary healthcare stated
that this practice is beneficial to the economy, as around
Based on the analysis of the first article 10, a US$22 billion are transacted annually by the world-wide
detrimental outlook was placed on the outlook of users phytotherapeutic market, and Brazil is abundant in a
regarding medicinal plants, as they do not consider they great diversity of plants used as medication precursors,
might have any harmful effects since they are natural, showing its great potential in this market. The preference
leading to the user not informing the doctor of such use. Yet, of professionals is furthermore positively reinforced while
medication interactions may occur with allopathic drugs, prescribing phytotherapeutic medicine in cases of insomnia
as well as other toxic effects to the organism when used in and anxiety, which are considered as adequate, instead
excess13,18. Unfamiliarity is also stressed10, regarding the of using benzodiazepines and even associated with anti-
interviewed professionals on plants listed in RENAME, hypertensive drugs for preventing anxiety, as sometimes
thereby hindering their prescription. However, the study10, it is associated to this condition.
besides revealing that professionals believe in the practice However, this research study 11 also states
and confirm their utilization by the local population, some disadvantages as undergraduate medical courses fails to
medicinal plants have been emphasized, as they have introduce the budding doctor to integrative practices, and,
already gone through all the research study steps and, thereby, causes a low degree of adhesion of the professional
thereby, they are considered sufficiently effective to be to this therapy alternative. Associated to that, family
part of the medication arsenal of healthcare professionals. members and friends become the source of information on
Additionally, the phytotherapeutic practice allows for the phytotherapy, that can bring about various harmful effects,
population to be in contact with its history, recovering since there is not any medical basis, instead of getting that
traditional and cultural habits. information from a healthcare professional. 
An increase in scientific publications on phytotherapy Araújo et al. 20 pointed out that nurses find it
has been noted since 2003, through analyzing a study7 on the challenging to apply Phytotherapy in Primary Healthcare
availability of phytotherapeutic drugs in primary healthcare and that contributes to those negative aspects, being that the
in São Paulo State, especially on their insertion in primary main hindrances encountered are: the absence of planning in
healthcare, fostered by the regulatory approval of the the implementation of these and other integrative practices
practice in Brazil and after publications from PNPIC and in primary healthcare: the lack of professional healthcare
PNPMF. The article7 emphasizes the importance of using training and the recognition by the administration and the
phytotherapeutic drugs in primary healthcare in the cities of respective healthcare team20.
São Paulo, evolving from the main factor of the existence In counterpart, there is a research study21 on the
of municipal laws assuring that these programs remain insertion of phytotherapeutic contents in the segment of
independent from changes in political administrations, as healthcare courses, focused on interviewing students from
states law # 13,888 dated July 19, 2010, authorizing the medical, nursing, and dentistry courses, which are favorable
implementation of the Phytotherapeutic Municipal Program to the addition of course contents about phytotherapy in
in the Public Healthcare Network in the city of Campinas the undergraduate curriculum, even though they do not

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Esteves CO, et al. Herbal Medicines: prevalence, advantages and disadvantages of use in clinical practice

entirely know the efficacy and the recommendations of treatment, its structuring would incur investments in
this practice. This way, a professional can be expected professional qualification, setting up phytotherapeutic
to be more assured of acting in the Universal Healthcare drug manipulation, and the supply of precursor materials. 
System, thereby preserving the right of the users to choose
alternative treatments. The profile and evaluation of users of the Universal
The negative aspects of the practice are stated Healthcare System regarding the use of phytotherapeutic
in the article22, on the pharmacological evaluation and medicine
phytotherapeutic labeling, emphasizing the presence of dirt
and foreign organic matter in evaluated samples exceeding Although there is a limitation in the field of research
the acceptable limit and errors on the labels, such as the and there is no data on the subject on a national level, it
absence of the scientific names of the botanical species, is possible to find a public standard regarding the use of
batch identification, and preparation manner, among other phytotherapeutic medicine. However, there is a greater
items. It is necessary to employ stricter surveillance in prevalence of use among women and individuals over 50
controlling Phytotherapeutics to assure the quality and years of age. According to a study13 performed in Uberlândia
desired effect in the health of the consumer. (MG), the main contributing factors for the increased use
There is a positive emphasis on using among the elderly include low cost; easy access, difficult
phytotherapeutic medicine in specific bodily processes that access to medications in healthcare services; fewer adverse
were observed throughout the analyses. The antimicrobial effects when compared to conventional medicines; cultural
property of aroeira (mastic) extract23 is proven to show tradition, and preference for natural products13.
promising results in controlling microorganisms related Regarding the evaluation of the practice by users
to oral pathologies23 that justify its use in the treatment who were interviewed for the study28 in the Universal
of gingivitis. Similarly, the relevance of phytotherapy Healthcare System, they confirmed that the pharmacological
in renal alterations24 is emphasized, mainly by acting in action from synthetic medications is quicker than medicines
changing the nephrite genetic expression, modulation of made from plants, especially as they are “stronger,” they
the renal system - renal angiotensin, antioxidant effects, and also believe that they are more effective in more severe
modulation in the production of nitric oxide24. Likewise, cases. In counterpart, even though phytotherapeutic drugs
the benefit is emphasized in “the aqueous extract of are slower acting, they are gentler. On the other hand,
Stryphnodendron adstringens (Mart.) Coville, which is in a study29 performed in Palmares (RJ), 98% of those
traditionally used in Brazil for its healing properties”25. interviewed were unaware of the concept of phytotherapy
This study15 on phytotherapeutic medicine used and the possibility of this type of treatment in the Universal
primarily in the treatment of osteoporosis in young women, Healthcare System. Thus, despite the expansion of the
reveals the benefits of medications such as isoflavone, practice, it is possible to infer that the users also need to
or even phytotherapeutic drugs made of turmeric to be better informed regarding this subject.
“avoid major deterioration of the osseous structures and
produce beneficial changes in osseous remodeling”15, and CONCLUSION
diminishing osteoclastogenesis. Another study26 stresses
the advantage of using phytotherapy in the treatment of According to the evaluated profile and methodology
intestinal constipation, emphasizing medications distilled of the study, it is possible to establish Guaco (Mikania
from Senna, Chinese rhubarb, and Chitticum bark that glomerata) and phytotherapeutic medicine made of
act as laxatives, as well as castor oil and derivatives of Passiflora (passion fruit) as the most commonly used plant
aloe vera. based treatments; the former, due to its bronchodilator
One study27 on the construction, perspective, and and expectorant action and the latter for its anxiolytic
challenges of PNPMF also expresses the benefits from the properties. The literature also mentions green tea, Camellia
use of medicinal plants and phytotherapeutic medicine as sinensis, which is prescribed by nutritionists for promoting
they can be used in the manufacturing of industrialized weight loss, and phytotherapeutic substances distilled from
medications, compounded medication, or by using plants, Turmeric, due to its osseous protective effect.
through homemade preparations27. The article27 states Regarding the prevalence of phythotherapy related
that phytotherapeutic substances from eleven plants are knowledge by healthcare professionals, the southeast
included in the list of pharmaceutical treatment medications region has displayed a more significant number of
in primary healthcare, and it identifies funding as one of specialists in phytotherapy (42%), probably due to the
the hindrances in obtaining access to the practice. The higher concentration of health professionals in large
authors report that the Universal Healthcare System is city centers. However, in the general, the studies have
inserted in a model that uses synthetic medication, and pointed out unawareness by users and health professionals
the implementation of a new dynamic would imply regarding phytotherapy, and related to that is the fact that
new costs. Even though phytotherapy is a low-cost the Universal Healthcare System offers a smaller quantity

470
 Rev Med (São Paulo). 2020 Sept-Oct;99(5):463-72.

of phytotherapeutic drugs compared to allopathic drugs. gentler. However, the literature states that the greatest
In counterpart, the tightening of the bond with the patient, majority of users are unaware of the possibilities of
related to their cultural roots and family members, is using phytotherapy. Thus, it emphasizes the necessity for
emphasized as a positive aspect in taking Phytotherapeutics. fostering more studies on the practice, seeking to expand
The user profile taking phytotherapy includes women and knowledge, and encouraging alternative forms of careful
individuals over 50 years of age. Users declared that they production, so that it adjoins the population within its
prefer taking phytotherapeutic medicine in less severe ethnic-cultural peculiarities.
situations, as they believe their actions are slower and
Authors participation: Esteves CO: research counselor, participated throughout all phases. Rodrigues RM: research counselor,
participated throughout all stages. Martins ALD: bibliographic research, data collection, data analysis, data discussion, manuscript
preparation, updated bibliographic references. Vieira RA: bibliographic research, data collection, data analysis, data discussion,
manuscript preparation, updated bibliographic references. Barbosa JL: bibliographic research, data collection, data analysis, data
discussion, manuscript preparation, bibliographic reference updating. Vilela JBF: bibliographic research, data collection, data analysis,
data discussion, manuscript preparation, updated bibliographic references.

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