Natural Standard Featured CE/CME: Cranberry

Natural Standard's featured CE/CME for the month of February is Cranberry: Safety & Effectiveness.

Cranberries come from small evergreen shrubs with tart, red, edible berries. The berries are used in sauces, jellies and drinks. There is some human evidence supporting the use of cranberry juice and cranberry supplements to prevent urinary tract infection (UTI), although most available studies are of lesser quality. Clear dosing guidelines are lacking, but given the safety of cranberry, it may be reasonable to recommend the use of moderate amounts of cranberry juice cocktail to prevent UTI in non-chronically ill individuals.

Natural Standard offers CE/CME modules for multidisciplinary healthcare professionals. Students and other users may take courses for training purposes without generating credit certificates. Continuing Education requirements differ based on discipline, license and location. If you are unsure of your specific needs, please contact your local agency.

Comments

[deb]

Through out pharmacy school, I heard so much about cranberry juice is used for the prevention of UTI but never actually heard how effective it is. Although its mechanism of action makes perfect sense (provides antioxidants, increase immunity, decrease urine pH) but the exact efficacy is probably dependent on individuals. As a future pharmacist, I will not hold back on suggesting cranberry juice since it has such good adverse effect profile.

[NBF]

I think ki brings up an interesting point on cranberry and drug interactions. Cranberry may increase the risk of bleeding so it is important that patients are aware of this interaction and know to look for signs/symptoms of bleeding and to get their INR checked frequently if they consume large quantities of cranberry juice. Cranberry may also reduce the effectiveness of proton pump inhibitors (PPI) and H2 receptor agonist (H2RA) so it is important to advise patients to avoid regular use of cranberry juice while taking a PPI or H2RA. Often times people forget that "natural" products can also interact with prescription and over the counter medications and can lead to adverse effects.

[kj]

I'm very impressed to see all the comments about warnings in diabetic patients and sugar levels after consuming juices like cranberry juice. I think that many people don’t picture cranberry juice as one with high amounts of sugar compared to other drinks such as sodas so they think its ok to consume. The list of scientific evidence for cranberry is long, and even though it has a Natural Standard evidence grade of C these conditions vary from UTI prevention to cardiovascular disease. I think taking cranberry pills versus the very bitter cranberry juice would be a viable option for many patients seeking their benefits.

[Sabrina]

I agree with the other comments regarding the use of cranberry juice in diabetic patients. It is important to be aware of this. It makes sense that the fruit juice concentrate should not generally be recommended and instead organic, unsweetened cranberry juice should be tried instead. Also, cranberries may not always be effective as this article mentions; http://www.cbsnews.com/8301-204_162-57534500/cranberries-may-not-be-effective-against-utis/

[bz]

I am curious about the post by Zach. What was the nature of her stones that prevented her from benefiting from urine acidification? I often assist patients in finding cranberry or even vitamin c after their doctors recommended it for kidney stones, and I've learned that acidifying urine can be helpful for kidney stone dissolution. I wonder what made hers different?

[bp]

This is such a great topic because so many people have at least heard of it. I was really surprised to see that it only has an evidence grade of C for UTI prevention. I even drank cranberry juice every day for a while until I thought about how much sugar was in fruit juices. Another reason it would be great to have some standardized supplements out there! But people are right, there are definitely some counseling points out there - the biggest being diabetes. I stopped just because of a family history of diabetes, and there have been some reports that drinking a lot (not really sure how much this refers to!) of fruit juices increases diabetes risk. However, if someone does want to drink juice rather than take a pill, there are juices, usually available at health food stores, that are pure extracts, without sweeteners. They may not taste as good, but the liquid volume would be there for flushing purposes, and they don't have as much sugar!

[Zach]

I have heard that cranberry concentrate capsules are far less effective than actual cranberry juice at preventing UTIs....maybe it has to do with creating additional fluid for excretion? Does anyone else have any information regarding this?
A second thing I wanted to mention - my grandmother has uric acid kidney stones and the physician assumed they were calcium oxalate (as they typically are) and they told her to drink lots of acidic juices like cranberry juice. Well it turns out, due to the nature of her stones that she may have been doing more harm than good! Be sure to consider this before suggesting cranberry juice for kidney stone dissolution by urine acidification.

[SB]

This is something I first heard about years ago. I remember my grandma giving me cranberry juice as a little girl, because she claimed it would get rid of my bladder infection problems. However, as a child, I though drinking the bitter juice was a terrible punishment, but I must have acquired a taste for it along the way, as there is always a bottle in my fridge.

[bz]

Cranberry is such a useful product, I am glad to see it is getting some attention on this blog! I have an older patient who used to get UTIs at least once a month. She was drinking cranberry juice cocktail but it was increasing her blood sugar too much. She is now taking cranberry pills daily and it has made all the difference! No blood sugar issues and she hasn't had a UTI in 9 months! I didn't realize how effective it could be!

[SS]

It would be interesting to see more research done on this topic. Many people come into the pharmacy looking for cranberry for a UTI. I think an important distinction to make, however, that I don't think most people realize, is that cranberry is supposed to be used for the prevention. Often time the patients asking for cranberry already have a UTI and are using it for an initial treatment. Since it is safe to take it doesn't harm them if they wish to try but that is not how it is intended to work.

[a]

The cranberry is one of Massachusetts' top agricultural commodity crop. There are several cranberry bogs throughout Massachusetts (over 14,000 acres worth of land!) such as in Plymouth, Sandwich, Kingston, Middleboro, and Carver. Many of them offer tours of the cranberry bogs during the harvest season and it's a cool experience if you haven't been. More information is available here: http://www.cranberries.org/visit/index.html

[AM]

While working in community pharmacy, many of the patients that I interacted with were surprised that cranberry juice could be used to help prevent UTI--especially since it is so easy to incorporate this into one's everyday diet. However, for patient's on drugs such as warfarin, it is still important for them to consult their primary care physician before consuming large amounts of cranberries, because it may increase the time that warfarin acts in the body. This can result in increased bleed risk.

[AR]

Cranberry is a very interesting and relevant CE topic. Patients are always coming into the pharmacy asking about the effectiveness of cranberry juice and Azo®. I have heard that high amounts of cranberry extract may help prevent urinary tract infections. It would be interesting to hear about more recent data on the use of cranberry for urinary tract infections.

[bc]

I think it is great that natural standards offers CE courses to keep up to date information on natural supplements such as cranberry. I am definitely interested in taking advantage of this CE to learn more about cranberry and its uses.

[bz]

While recommending cranberry juice to prevent UTI is helpful, I think it is important to note whether the patient is diabetic before making this recommendation. Cranberry juice is high in sugar and not advisable to use in large amounts in diabetic patients. These patients may be better off using cranberry tablets in place of these high sugar drinks.

[kl]

On my very first pharmacy rotation, I met a man who had just recently started taking Coumadin for atrial fibrillation. He mentioned how upset he was that he could no longer have cranberries as his evening snack. I had never heard of the interaction between cranberries and Coumadin, so I looked into it and found some research showing increased INR and bleeding rates in patients taking Coumadin after the consumption of cranberries. However, other studies have shown that moderate cranberry consumption has a lack of effect on the anticoagulation effects of warfarin or INR. Overall, the available scientific research is conflicting, and I concluded that if I were to ever see him again I would tell him that as long as his INR is stable, it is okay for him to consume small amounts of cranberries. I would also counsel him to be consistent with his daily intake, monitor for signs of bleeding, and contact his physician if he noticed any changes.

[kl]

I will never forget the day we learned about urinary tract infections (UTIs) in pharmacy school. The professor brought in two large bottles of pure, unsweetened cranberry juice for the entire class to taste. It was quite a shock to taste how bitter, dry, and tangy pure cranberry juice actually is compared to the cranberry juice cocktails I have had. When considering taking cranberry juice to help with UTIs, it is important to consume the unsweetened cranberry juice not fruit juice concentrate. Cranberries contain many antioxidants, which may help promote healthy immune and cardiovascular systems. Pure cranberry juice may acidify the urine and alter the ability of bacteria to attach to surfaces within the urinary tract. Healthcare professionals should brush up on their cranberry knowledge and take get the CE hours at the same time.