Use of guaco (Mikania glomerata) in primary health care in Rio Grande do Sul/BrazilAbstract
Mikania glomerata (guaco) is included in Brazil’s National List of Essential Drugs (RENAME) with expectorant and bronchodilator indications. This research aims to describe the profile of patients and prescribers of guaco-based herbal medicines within the Unified Health System in the municipalities of Rio Grande do Sul (RS)/Brazil, quantify the consumption and cost of this product, and assess the prescriber’s experience with guaco and herbal medicine. A cross-sectional observational study was conducted based on questionnaires applied to prescribers and guaco usage data in primary care in RS municipalities (May 1, 2020 - April 30, 2021). 44 municipalities (40%) were identified dispensing guaco syrup in the sample. The results showed a prevalence of women users (57.4%) and patients between 19 and 59 years of age (58.2%). All participating prescribers were physicians, and 37% of the responses indicated daily doses of coumarin lower than recommended. The syrup consumption per 1,000 inhabitants ranged from 0.3 to 36.6 bottles, and the monthly cost per municipality varied from $0.50 to $247.78. Only five prescribers (21.7%) were familiar with the herbal medicines in RENAME, and only one had formal training for prescribing herbal medicines, highlighting the need for instruction and dissemination of programs for using herbal medicines.
Keywords:
Mikania glomerata; Guaco; Herbal medicines; Unified Health System; Phytotherapy
INTRODUCTION
In Brazil, the Ministry of Health (MS), through Ordinance n° 971/2006, has sanctioned the National Policy of Integrative and Complementary Practices (PNPIC), aligning with the guidelines of the World Health Organization (WHO). This policy incorporates medicinal plants and phytotherapy into the Unified Health System (SUS) (Brazil, 2006a).
The National Policy of Medicinal Plants and Herbal Medicines (PNMPF), established by Presidential Decree N° 5.813/2006, and the Intersectoral Policy on Medicinal Plants and Herbal Medicines of Rio Grande do Sul (PIPMF/RS - State Law N° 12.560/2006), in concurrence with the PNPIC, State Policy on Integrative and Complementary Practices of RS (PEPIC/RS), and the National Policy on Pharmaceutical Assistance (Resolution CNS/MS nº 338/2004) are the primary references for the implementation of phytotherapy in the SUS/RS. Phytotherapy is a multidisciplinary practice that fosters closer collaboration between healthcare professionals and the community, and it encompasses various fields of knowledge, permeating different policy sectors (Rio Grande Do Sul, 2020).
Mikania glomerata Spreng. (M. glomerata), commonly known as guaco, is listed in Brazil’s National List of Essential Drugs (RENAME) (Brazil, 2022). According to the National Health Surveillance Agency (ANVISA), it is classified as a traditional herbal product with expectorant and bronchodilator indications without a medical prescription (Brazil, 2014a). Guaco syrup has been identified as the most prescribed phytotherapeutic in primary care units in the State of São Paulo/Brazil (Caccia-Bava et al., 2017), in the municipalities of Petrolina-PE/Brazil (Nascimento Júnior et al., 2016) and the metropolitan region of Curitiba-PR/Brazil (Gribner et al., 2019).
Pre-clinical and clinical research conducted by the Center of Medicines (CEME) has provided evidence of the safety and efficacy of guaco leaves tea (M. glomerata) at the tested doses (5, 10, and 15 g in 200 ml of water) and demonstrated its bronchodilator and antitussive effects (Brazil, 2006b).
In a study conducted by Garcia and colleagues (2020), the bronchodilator activity of guaco syrup (M. glomerata) was evaluated through a randomized, crossover, double-blind clinical trial involving volunteers with mild or moderate asthma. The investigation concluded that guaco syrup did not exhibit significant bronchodilator activity over the four-hour evaluation period. It’s worth noting that the dose administered in the study represents 0.5 mg of coumarin, which falls within the minimum daily dose recommended by ANVISA, ranging between 0.5 and 5 mg of coumarin (Brazil, 2022).
Two clinical trials of industrialized syrups containing an association of M. glomerata and other plants did not show signs of systemic toxicity, confirming the safety of the preparations (Soares et al., 2006; Tavares et al., 2006). A recent study by Bertol et al. (2024) evaluated the safety of oral solutions from M. glomerata and M. laevigata, two species usually interchangeably in Brazilian ethno- medicine, in healthy volunteers in a randomized, open-label, multiple-dose, two-arm trial across two weeks, with two different doses (15 and 30 mL of oral solutions twice a day). Both species were considered safe for humans under the dose regimen tested. However, for M. glomerata, even at the highest daily dose, the minimum therapeutical concentration of coumarin was not achieved. On the other hand, for M. laevigata, the safety was confirmed with a coumarin dosage of up to 144% of the maximum concentration recommended by ANVISA.
Differences in coumarin content and other bioactive components have been reported between species and from different commercial formulations (Bertol et al., 2024; Bertolucci et al., 2013; Costa et al., 2018; Czelusniak et al., 2012; De Lazzari Almeida et al., 2017; Gasparetto et al., 2015; Ueno, Sawaya, 2019). This has raised concerns among health professionals about the standardization and quality control of the products, posing a challenge to integrating phytotherapy into the SUS.
Therapeutic resources in phytotherapy are largely based on scientific, institutional, and legal references available to professionals for guidance and support. According to the Federal Council of Medicine, phytotherapeutics are recognized as a therapeutic approach encouraged by national health agencies and can be employed by physicians (CFM, 2008). Various health professionals can recommend it within the scope of the healthcare network. As a complementary practice, a specialist title is not mandatory, although it is preferable, and some professional councils may require this title for their members (Rio Grande do Sul, 2020; Brazil, 2014a).
In light of recent regulations allowing the prescription of phytotherapeutics by the Federal Councils of Physiotherapy (COFFITO, 2010), Dentistry (CFO, 2008), Pharmacy (CFF, 2008; CFF, 2013), and Nutrition (CFN, 2013; CFN, 2015), which have published specific resolutions acknowledging the integration of Integrative and Complementary Practices in Health (PICS) into their professionals’ scope of practice (Felten et al., 2015; Barreto, Silveira, 2014), it becomes relevant to assess the use of these products and the profile of phytotherapeutic prescribers. These regulations could significantly impact the use of Mikania glomerata (guaco) in healthcare.
This study aims to provide an overview of patients and prescribers of herbal medicines, specifically those based on the Mikania glomerata species (guaco) in the SUS in municipalities in Rio Grande do Sul (RS)/Brazil. Additionally, it seeks to measure the consumption and cost of these products and to evaluate the patient characteristics and the experience of prescribers in health services related to guaco prescription and phytotherapy. The findings of this study will not only enhance the current body of knowledge but also have practical implications for healthcare professionals, researchers, and policymakers interested in integrative and complementary practices in health.
MATERIAL AND METHODS
Study Design
A cross-sectional observational study with a quantitative descriptive approach was conducted based on a survey of guaco usage data in primary care within municipalities of RS from May 1, 2020, to April 30, 2021. Data were sourced from municipal pharmacy consumption reports, prescriptions, and prescriber interviews. The research project received approval from the Research Ethics Committee of UFRGS (CAAE 40784820.7.0000.5347). We assessed the data from the State of RS due to the regionality, once the University is based in the State, facilitating in-person access for field research. Additionally, guaco is included in RENAME with expectorant and bronchodilator indications, and the RS State is prone to respiratory diseases during the winter cold climate. To the best of our knowledge, this is the first report concerning the consumption of herbal medicines based on the Mikania glomerata species in the SUS in municipalities of RS/Brazil.
Municipality Selection
All municipalities in RS with a population exceeding 20,000 inhabitants, as per the 2020 census conducted by the Brazilian Institute of Geography and Statistics (IBGE, 2020), were included in the selection process. Afterward, an online inquiry was conducted either through the municipality’s website or by contacting the Health Departments via email or phone to request data from the Municipal Medication List (REMUME) or its equivalent. Municipalities that included guaco syrup in the REMUNE and its pharmaceutical presentation were identified. Access to consumption reports, acquisition costs, and guaco prescriptions were requested. The data collection phase from patients and prescribers considered municipalities with identifiable and traceable prescriptions or consumption reports.
Sample Selection of Patients and Prescribers
In municipalities with up to 600 identified guaco syrup prescriptions, 200 prescriptions were randomly selected for collecting patient and prescriber data. In municipalities with more than 600 prescriptions, data from 25% of them were collected.
After identifying all prescriptions containing guaco syrup, a complementary search was carried out in the computerized medical records or physical records of patients who used the syrup to assemble patient characterization data and identify the prescriber.
Prescriber Interviews
Identified prescribers were invited to participate in the interview phase. They received a link to the Informed Consent Form and confirmed their agreement and awareness via email or WhatsApp®. Subsequently, a link to a structured electronic questionnaire was sent to them. Invitations were extended to up to three prescribers per municipality.
Data Collection and Analysis
Data collection involved gathering details on municipalities dispensing guaco syrup and its pharmaceutical presentation, as well as information on consumption and acquisition costs. Additionally, patient data included gender and age, while prescriber data encompassed socio-demographic information, details of their training in phytotherapy, length of professional experience, and practice locations. Information regarding guaco and phytotherapy prescriptions was also obtained. The results of the data analyses are presented descriptively.
RESULTS AND DISCUSSION
A total of 109 municipalities in the RS State, with over 20,000 inhabitants, were identified, of which 44 (40%) dispensed guaco syrup during the research period. Among these, 02 municipalities provided manipulated guaco syrup, while 42 municipalities dispensed industrially manufactured pharmaceutical formulations. Of the 44 municipalities dispensing guaco syrup, only 40 had computerized and traceable data (Figure 1).
Out of 40 municipalities with computerized and traceable data, 25 (62.5%) agreed to participate in the research, providing quantitative consumption data (Alegrete, Bento Gonçalves, Camaquã, Campo Bom, Candelária, Flores da Cunha, Igrejinha, Ivoti, Lagoa Vermelha, Lajeado, Novo Hamburgo, Palmeira das Missões, Parobé, Portão, Santo Ângelo, São Borja, São Francisco de Paula, São José do Norte, São Leopoldo, São Lourenço do Sul, Taquara, Torres, Tramandaí, Vacaria, Vera Cruz). Igrejinha and Lajeado provided manipulated syrups to the population, while the other 23 municipalities supplied industrially manufactured pharmaceutical formulations. Bento Gonçalves, Camaquã, and São Leopoldo dispensed the pharmaceutical product from laboratory 02 (brand 02), while the other municipalities dispensed the manufactured pharmaceutical formulation from laboratory 01 (brand 01).
Patient Profile
In 22 municipalities with accessible patient data (Figure 1), a total of 9,760 syrup prescriptions were identified, and 4,434 (45%) were comprehensively evaluated. Across 19 municipalities, the gender of 4,280 patients was reported, showing a prevalence of women users, representing 2,457 (57.4%) of the sample. This corroborates findings from the study conducted by Moura, Cohn, and Pinto (2012) in Santos (SP), which also indicated a higher prevalence of use among women. Similarly, Esteves et al. (2020) reported a greater number of women using phytotherapy.
The age of patients from 3,217 prescriptions was determined, revealing a distinct pattern in usage. Notably, the syrup prescription was considerably low among children and adolescents (0 to 18 years) (299 prescriptions - 9.3%). The primary users were individuals between 19 and 59 (1,871 prescriptions - 58.2%), followed by those aged 60 or older (1,047 prescriptions - 32.5%). This age distribution provides valuable insights into the target population for prescription syrup usage.
Prescriber Profile
Twenty-three prescribers from 16 municipalities agreed to participate in the interview. All of them were physicians, despite resolutions authorizing the prescription of phytotherapeutics and medicinal plants for other healthcare professionals (CFF, 2008; CFF, 2013; CFO, 2008; COFFITO, 2010; CFN, 2013). This data differs from a study conducted in Maringá-PR/Brazil, which identified herbal medicine prescriptions by physicians and nurses working in primary health care (Lopes, Obici, Albiero, 2012). Additionally, a study in Blumenau-SC/Brazil indicated prescriptions by dentists, nurses, physicians, and nursing or oral health technicians (Mattos et al., 2018).
In the present study, 52.2% of the prescribers were men (Table I), consistent with other literature reporting a prevalence of male prescribers (60% and 54.4%) (Nascimento Júnior, 2016; Gribner, 2022).
The average age among men prescribers was 44.8±12.5 years, ranging from 27 to 66, and among women prescribers, it was 35.6±6.9 years, ranging from 28 to 49, reflecting a diverse spectrum of experience and perspectives.
The average length of employment for prescribers in the SUS was 9.77±10.3 years. Fifty percent (11) had worked for less than 5 years. When considering the length of work at the health unit, 43.5% (10) had been working for less than 1 year, while 26.1% (6) had been there for less than 5 years. The brief period of service indicates a high turnover of professionals in the health service. Most physicians (14-66.7%) have a workload of 31 to 40 hours per week in the SUS. Regarding specialties, the majority were general medicine/internal medicine (65.2%) and community/family doctors (30.4%).
Eighteen prescribers (78.3%) indicated other herbal medicines besides guaco, with Passiflora incarnata being the most commonly remembered. Of the 12 herbal medicines listed in the RENAME (Brazil, 2022), the interviewees recalled 05: Plantago ovata (Plantago), Harpagophytum procumbens (devil’s claw), Glycine max (soy isoflavone), Aloe vera (aloe), and Rhamnus purshiana (cascara-sagrada).
Only 05 prescribers (21.7%), all women, were aware of the list of herbal medicines in RENAME, and 06 (26.1%) were familiar with PNPIC. The lack of knowledge about the list of herbal medicines by 78.3% of prescribers in our study aligns with another study’s findings, which reported that 85.4% of prescribers were unfamiliar with the herbal medicines from RENAME and 80.3% with plants in the National List of Medicinal Plants of SUS concern (RENISUS) (Mattos et al., 2018; Brazil, 2006a; Brazil, 2018; Rio Grande Do Sul, 2013).
All respondents who claimed acquaintance with PNPIC also indicated the following reasons for supporting this initiative: expansion of therapeutic options, promotion of comprehensive care through other complementary practices, and the cultural aspect of the population regarding the use of herbal medicines.
Only 01 interviewed professional had formal training for the prescription of medicinal plants or herbal medicines, highlighting the need for training, as well as encouragement from Professional Councils and Universities responsible for undergraduate courses. This is particularly important given the existence of a national policy that encouraging the use of herbal medicines and medicinal plants by the SUS.
The indications for using the syrup are detailed in Table II and are in line with the literature, including its expectorant (Brazil, 2014a), bronchodilator (Brazil, 2014a, Freitas et al., 2008), anti-inflammatory (Freitas et al., 2008), antibacterial against Streptococcus mutans (Yatsuda et al., 2005), antitussive (Brazil, 2011), and antiulcerogenic (Bighetti et al., 2005) properties.
We identified 02 pharmaceutical formulations in the municipalities: syrup brand 01 (35 municipalities) and syrup brand 02 (07 municipalities). Syrup brand 01 contains 35 mg of guaco fluid extract per milliliter (mL), equivalent to 0.02625 mg of coumarin per mL of syrup. Syrup brand 02 comprises Mikania glomerata Tincture 0.1 ml/ml, equivalent to 80 µg/mL of coumarin, approximately 03 times higher than the coumarin concentration of brand 01 syrup. Despite the differences between the 02 commercial pharmaceutical formulations available in the municipalities (brands 01 and 02), it is important to note that the dosages suggested by the manufacturers result in daily coumarin levels within the range recommended by RENAME (Brazil, 2022) and ANVISA’s Instruction No. 02/2014 (Brazil, 2014a), as long as the dosages adhere to the instructions provided by the suppliers.
One of the manipulated formulations consists of a mixture of components with the following ingredients: Watercress fluid extract 1%, Propolis Tincture 1%, Tolu balsam Tincture 2%, guaco fluid extract 2%, and citric acid 0.2% in expectorant syrup. The second manipulated formulation contains 8% guaco fluid extract in syrup. For both manipulated syrups, it was not possible to calculate the coumarin content, as these medications have no leaflet, and the dosage is specified by the prescriber for each patient.
Prescribers reported diverse methods of administration for the medication, as indicated in Table III. All responses were related to municipalities dispensing syrup brand 01 (equivalent to 0.02625 mg of coumarin/mL of syrup). Considering the RENAME recommended daily dose of 0.5 to 5 mg of coumarin (Brazil, 2022; Brazil, 2014a), 37% of responses indicated daily doses of up to 15 mL, providing a daily coumarin dose lower than recommended. This practice leads to subtherapeutic dosage, lack of effectiveness, and resource waste. This finding is relevant because out of the 42 municipalities that distributed the industrialized syrup, 35 (83.3%) had syrup brand 01, while only 7 (16.7%) had syrup brand 02, which contains higher coumarin content.
It is worth noting that for syrup brand 01, the manufacturer disposed of a second commercial presentation in addition to the one available in the municipalities, which contains 117.6 mg of guaco fluid extract per milliliter, equivalent to 0.0882 mg of coumarin/mL of syrup. In this case, if the municipalities acquired this commercial presentation with a higher concentration, all prescriptions reported by the interviewed prescribers would be within the recommended dosages. However, this presentation was not found in the evaluated municipalities. The same would apply to brand 02 if it were available in the health unit for the prescribers.
In this scenario, prescribers should be aware of the different pharmaceutical formulations available for dispensing and their coumarin concentration. This is particularly important given that there are two formulations (brands 01 and 02) with varying coumarin contents, and some municipalities distribute manipulated pharmaceutical forms. In this context, the pharmacist’s integration with the health team and other prescribers for guidance becomes essential.
Only 01 prescriber recommended a usage limit of 7 days for acute cases and 14 days for chronic cases, complying with the recommendations of the Pharmacopoeia Herbal Medicines Formulary (Brazil, 2021).
Regarding the main barriers to prescribing guaco syrup, prescribers have mentioned allergy to coumarin, concurrent use of anticoagulants, decompensated hypertension, liver disorders, diabetes, lack of confidence in efficacy, and patients’ prejudice against phytotherapy. On a positive note, prescribers have mentioned the ease of acquisition or supply by SUS.
The literature reports that M. glomerata extracts are contraindicated for patients with a history of hypersensitivity and known allergy to the species or other species of the same family (Asteraceae) (Brazil, 2021; Brazil, 2014b). Contraindication for simultaneus use with anticoagulants are described, as coumarins may enhance these effects (Brazil, 2021; Brazil, 2014b). Similar precautions should be taken with non-steroidal anti-inflammatory drugs. Guaco is also contraindicated in chronic liver diseases and severe arterial hypertension (Saad et al., 2018). Diabetic patients should avoid the syrup formulation due to the high sugar content, and pregnant or lactating women and children under two years old should not use the tincture (Brazil, 2011; Brazil, 2021; Brazil, 2014b). The production of sugar-free syrup can address the contraindication for sugar in syrups, a procedure already adopted by syrup brand 01, and the manipulated formulation of one municipality by using saccharin instead of sucrose in their formulation.
A total of 21 (91.3%) prescribers indicated that patients expressed interest in using medicinal plants and herbal medicine. This finding aligns with the observations made by Lopes and collaborators (2015), who also noted a favorable acceptance of herbal medicines among the population. Efficacy or positive therapeutic response was the most frequently cited reason (39%) by prescribers as the motivation to prescribe guaco syrup. Corroborating that, a clinical trial conducted by CEME assessed the effectiveness of M. glomerata tea in respiratory diseases, demonstrating its safety and the bronchodilator and antitussive effects (Brazil, 2006b).
According to the interviewees, the main challenges in prescribing guaco were the lack of access to herbal medicine in health services (8.7%) and poor adherence to treatment (4.3%). On the other hand, 18 (78%) of the prescribers mentioned medication availability in the health service as a facilitator for prescribing guaco syrup, demonstrating that availability is not homogeneous among the municipalities.
Survey of the quantity and cost analysis of guaco syrup bottles
The individual value of industrialized guaco syrup bottles ranged from $0.34 to $0.73, based on the dollar on 05/15/2024 (US$1=R$5.14) (Central Bank of Brazil, 2024). The average value per bottle was $0.43±0.08, with no variation between manufactured pharmaceutical formulations. The individual value ranged from $0.16 to $0.36 among manipulated guaco syrup bottles.
The monthly consumption per municipality ranged from 1.2 to 646 bottles, with an average of 83.98±144.49, and the monthly cost ranged from $0.50 to $247.78, with an average of $34.54±54.24. According to Mello and collaborators (2019), the production of herbal medicines offers the best cost-benefit ratio compared to other products due to their low side effects and lower production costs. The major benefits of using medicinal plants are their low cost and easy availability, making them more accessible to the population.
The total consumption per patient during the study period ranged from 1.17 to 3.5 bottles, with the highest consumption in the municipality of Camaquã. The cost per patient ranged from $0.29 to $1.35. The syrup consumption per 1,000 inhabitants varied from 0.3 to 36.6 bottles (Figure 2), with most municipalities (n=18, 72%) consuming up to 13 bottles per 1,000 inhabitants.
Consumption of guaco syrup bottles per 1,000 inhabitants per municipality in the Rio Grande do Sul State/Brazil.
Integration Challenges and Policy Implications
The use of medicinal plants and herbal medicines aims to introduce complementary therapeutic options, reduce costs, reclaim traditional knowledge, preserve biodiversity, stimulate social growth, and should be encouraged in health education (Nascimento Júnior et al., 2016).
Incorporating complementary and integrative health practices into public healthcare is gradually becoming a reality. However, integrating phytotherapy into the SUS presents challenges arising from the need to ensure its quality, effectiveness, safety, and reproducibility (Ormond, Fernandes, Diniz, 2022). It is also essential to make it accessible to both prescribers and patients.
During the bidding process, it’s important to consider technical specifications such as dosage form, concentration, and marker specifications when preparing the tender and conducting subsequent technical analysis of proposals. When well executed, these analyses attribute significant value to the health service, characterizing it as a pharmaceutical service (Campese, Carvalho, Farias, 2017).
In order to improve effectiveness, it is crucial to verify the concentration of herbal medicine markers in the pharmaceutical products provided by municipalities and standardize the prescribed dosage according to this information. Implementing this straightforward process in the municipalities can prevent underdosing, potential loss of effectiveness and the waste of public funds.
According to this study, less than 50% of the sampled municipalities dispense guaco syrup, one of the most prescribed herbal medicines in primary care. This scenario highlights the need to strengthen Integrative and Complementary Health Practices by mobilizing institutional resources to expand therapeutic options based on the National Policy of herbal medicines and medicinal plants in the SUS. This includes promoting formal training for prescribing herbal medicines for healthcare professionals other than physicians, encouraging dialogue on the topic, and disseminating policies and programs to expand the use of herbal medicines in the State.
The limitations of this study are inherent to cross-sectional studies and real-world data of this magnitude, including the lack of standardization in the data organization, restrictions on access and data collection, and remote interviews with prescribers. On the other hand, the study’s strengths include the fact that it was a first-of-its-kind to cover such a large region of RS on the use of guaco, providing data on consumption, costs, patients’ and prescribers’ characteristics, and prescribers’ perceptions regarding the use of herbal medicine.
ACKNOWLEDGMENTS
We express our gratitude to the municipalities and physicians who willingly participated the study.
REFERENCES
- Barreto BB, Silveira D. Inclusion of courses on phytotherapy in undergraduate curriculum of health-related courses. J Med Plant Res. 2014 Dez; 8(47): 1374-1386.
- Bertol G, Cobre AF, Campos ML, Pontarolo R. Safety evaluation of Mikania glomerata and Mikania laevigata in healthy volunteers: A randomized, open label and multiple dose phase I clinical trial. J Ethnopharmacol. 2024; 318(117018).
- Bertolucci SKV, Pereira ABD, Pinto JEBP, Oliveira AB, Braga FC. Isolation and HPLC quantitation of kaurane-type diterpenes and cinnamic acid derivatives of long-term stored leaves of Mikania laevigata and Mikania glomerata. An Acad Bras Cienc. 2013; 85(2): 473-485.
- Bighetti AE, Antônio MA, Kohn LK, Rehder VLG, Foglio MA, Possenti A, et al. Antiulcerogenic activity of a crude hydroalcoholic extract and coumarin isolated from Mikania laevigata Schultz Bip. Phytomedicine 2005; 12: 72-77.
- Brazil. Ministério da Saúde. Portaria n. 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 04 maio 2006a.
- Brazil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica. A fitoterapia no SUS e o Programa de Pesquisa de Plantas Medicinais da Central de Medicamentos/Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Assistência Farmacêutica. Brasília: Ministério da Saúde, 2006b.
- Brazil. Agência Nacional de Vigilância Sanitária. Formulário de Fitoterápicos da Farmacopéia Brasileira/Agência Nacional de Vigilância Sanitária. Brasília: ANVISA, 2011.
- Brazil. Ministério da Saúde e ANVISA. Instrução normativa nº 2, de 13 de maio de 2014a. Publica a “lista de medicamentos fitoterápicos de registro simplificado” e a “lista de produtos tradicionais fitoterápicos de registro simplificado”.
-
Brazil. Ministério da Saúde e ANVISA. Monografia da espécie Mikania glomerata (GUACO). Brasília, 2014b. Available: <Available: http://portalarquivos2.saude.gov.br/images/pdf/2016/fevereiro/05/Monografia-Mikania.pdf > Accessed at August 3rd, 2018.
» http://portalarquivos2.saude.gov.br/images/pdf/2016/fevereiro/05/Monografia-Mikania.pdf -
Brazil. Ministério da Saúde. RENISUS. Relação nacional de plantas medicinais de interesse ao SUS. Espécies vegetais. Available: <Available: http://portal.saude.gov.br/portal/arquivos/pdf/RENISUS.pdf > Accessed at August 1st, 2018.
» http://portal.saude.gov.br/portal/arquivos/pdf/RENISUS.pdf - Brazil. Agência Nacional de Vigilância Sanitária. Formulário de Fitoterápicos da Farmacopéia Brasileira 2ed/Agência Nacional de Vigilância Sanitária. Brasília: ANVISA, 2021.
- Brazil. Ministério da Saúde. Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Relação Nacional de Medicamentos Essenciais Rename 2022 [recurso eletrônico]/Ministério da Saúde, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Departamento de Assistência Farmacêutica e Insumos Estratégicos. Brasília: Ministério da Saúde, 2022.
- Caccia-Bava MCGG, Bertoni BW, Pereira MAS, Martinez EZ. Disponibilidade de medicamentos fitoterápicos e plantas medicinais nas unidades de atenção básica do Estado de São Paulo: resultados do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). Ciência Saúde Coletiva. 2017; 22(5): 1651-1659.
- Campese M, Carvalho MM, Farias MR. Serviços farmacêuticos na seleção e aquisição fitoterápicos para o Componente Básico da Assistência Farmacêutica no SUS: desafios e reflexões. Rev Bras Pl Med, São Paulo. 2017; 19(4): 506-512.
-
Central Bank of Brazil. “Taxas de câmbio” - Dólar Americano. Available: <Available: https://www.bcb.gov.br/conversao > Accessed at May, 2024.
» https://www.bcb.gov.br/conversao -
CFF. Conselho Federal De Farmácia. Resolução CFF nº 477, de 28 de maio de 2008. Dispõe sobre as atribuições do farmacêutico no âmbito das plantas medicinais e fitoterápicos e dá outras providências. Available: <Available: http://www.cff.org.br/userfiles/file/resolucoes/res477_2008.pdf > Accessed at October 14, 2019.
» http://www.cff.org.br/userfiles/file/resolucoes/res477_2008.pdf -
CFF. Conselho Federal De Farmácia. Resolução nº 586 de 29 de agosto de 2013. Ementa: Regula a prescrição farmacêutica e dá outras providências. Available: <Available: http://www.cff.org.br/userfiles/file/noticias/Resolu%C3%A7%C3%A3o586_13.pdf > Accessed at October 14, 2019.
» http://www.cff.org.br/userfiles/file/noticias/Resolu%C3%A7%C3%A3o586_13.pdf -
CFM. Conselho Federal De Medicina. Parecer CREMEC Nº 33/2008 de 11/10/2008. Uso de Fitoterápicos em Atenção Primária. Available: <Available: https://sistemas.cfm.org.br/normas/visualizar/pareceres/CE/2008/33#search=“fitoterapia” > Accessed at October 13, 2019.
» https://sistemas.cfm.org.br/normas/visualizar/pareceres/CE/2008/33#search=“fitoterapia” -
CFN. Conselho Federal De Nutrição. Resolução CFN Nº 525 DE 25/06/2013. Regulamenta a prática da fitoterapia pelo nutricionista, atribuindo-lhe competência para, nas modalidades que especifica, prescrever plantas medicinais, drogas vegetais e fitoterápicos como complemento da prescrição dietética e, dá outras providências. Available: <Available: ftp://ftp.saude.sp.gov.br/ftpsessp/bibliote/informe_eletronico/2013/iels.jun.13/Iels121/U_RS-CFN-525_250613.pdf > Accessed at October 14, 2019.
» ftp://ftp.saude.sp.gov.br/ftpsessp/bibliote/informe_eletronico/2013/iels.jun.13/Iels121/U_RS-CFN-525_250613.pdf -
CFN. Conselho Federal De Nutrição. Resolução CFN Nº 556 DE 11/05/2015. Altera as Resoluções nº 416, de 2008, e nº 525, de 2013, e acrescenta disposições à regulamentação da prática da Fitoterapia para o nutricionista como complemento da prescrição dietética. Available: <Available: https://www.legisweb.com.br/legislacao/?id=284698 > Accessed at October 14, 2019.
» https://www.legisweb.com.br/legislacao/?id=284698 -
CFO. Conselho Federal De Odontologia. Resolução CFO-82/2008. Reconhece e regulamenta o uso pelo cirurgião-dentista de práticas integrativas e complementares à saúde bucal. Available: <Available: http://www.croma.org.br/normas/F/federal_2008_109.pdf > Accessed at October 13, 2019.
» http://www.croma.org.br/normas/F/federal_2008_109.pdf -
COFFITO. Conselho Federal De Fisioterapia E Terapia Ocupacional Resolução Coffito nº. 380, de 3 de novembro de 2010. DOU nº. 216, Seção 1, em 11/11/2010, página 120. Regulamenta o uso pelo Fisioterapeuta das Práticas Integrativas e Complementares de Saúde e dá outras providências. Available: <Available: https://www.coffito.gov.br/nsite/?p=1437 > Accessed at October 13, 2019.
» https://www.coffito.gov.br/nsite/?p=1437 - Costa V, Borghi A, Mayer J, Sawaya A. Comparison of the Morphology, Anatomy, and Chemical Profile of Mikania glomerata and Mikania laevigata. Planta Medica. 2018; 84(03): 191-200.
- Czelusniak KE, Brocco A, Pereira DF, Freitas GBL. Farmacobotânica, fitoquímica e farmacologia do Guaco: revisão considerando Mikania glomerata Sprengel e Mikania laevigata Schulyz Bip. ex Baker. Rev Bras Plantas Med. 2012; 14(2): 400-409.
- De Lazzari Almeida C, Xavier RM, Borghi AA, dos Santos VF, Sawaya ACHF. Effect of seasonality and growth conditions on the content of coumarin, chlorogenic acid and dicaffeoylquinic acids in Mikania laevigata Schultz and Mikania glomerata Sprengel (Asteraceae) by UHPLC-MS/MS. Int J Mass Spectrom. 2017; 418: 162-172.
- Esteves CO, Rodrigues RM, Martins ALD, Vieira RDA, Barbosa JLI, Vilela JBF. Medicamentos fitoterápicos: prevalência, vantagens e desvantagens de uso na prática clínica e perfil e avaliação dos usuários. Rev Med (São Paulo). 2020; 99(5): 463-72.
- Felten R, Magnus K, Santos L, Hubner de Souza A. Interações medicamentosas associadas a fitoterápicos fornecidos pelo sistema único de saúde. Inova Saúde. 2015 Jul 31; 4(1).
- Freitas TP, Silveira PC, Rocha LG, Rezin GT, Rocha J, Citadini-Zanette V, et al. Effects of Mikania glomerata Spreng. and Mikania laevigata Schultz Bip.ex Baker (Asteraceae) Extracts on Pulmonary Inflammation and Oxidative Stress Caused by Acute Coal Dust Exposure. J Med Food. 2008; 11(4): 761-766.
- Garcia CG, Leonart LP, Lenzi L, Bertol G, Gasparetto JC, Barros JA, et al. Evaluation of the bronchodilator effect of guaco syrup: A randomized, double-blind, crossover clinical trial. Rev Bras Farmacog. 2020; 30(1): 111-17.
- Gasparetto JC, Peccinini RG, de Francisco TMG, Cerqueira LB, Campos FR, Pontarolo R. A kinetic study of the main guaco metabolites using syrup formulation and the identification of an alternative route of coumarin metabolism in humans. PLOS ONE. 2015; 10(3): e0118922.
- Gribner C, Rattmann YD, Gomes EC. Fitoterápicos na atenção básica à saúde: uma experiência na Região Sul do Brasil. Visão Acadêmica. 2019; 20(2): 4-16.
- Gribner C, Moura PF, Rigoni AAR, Clemente M, Rattmann YD, Gomes EC. Herbal medicines from the industry in the unified health system: challenge faced by medical professionals. Braz J Pharm Sci. 2022; 58: e18701.
-
IBGE - Instituto Brasileiro de Geografia e Estatística. Disponível em: <Disponível em: https://www.ibge.gov.br/ > Accessed at November, 2020.
» https://www.ibge.gov.br/ - Lopes MA, Obici S, Albiero ALM. Conhecimento e intenção de uso da fitoterapia em uma Unidade Básica de Saúde. Interfaces Científicas - Saúde Ambiente. 2012; 1(1): 52-59.
- Lopes MA, Nogueira IS, Obici S, Albiero ALM. Estudo das plantas medicinais, utilizadas pelos pacientes atendidos no programa “Estratégia saúde da família” em Maringá/PR/Brasil. Rev Bras Pl Med. 2015; 17(4) supl. I: 702-706.
- Mattos G, Camargo A, Sousa CAD, Zeni ALB. Plantas medicinais e fitoterápicos na Atenção Primária em Saúde: percepção dos profissionais. Ciência Saúde Coletiva. 2018; 23(11): 3735-3744.
-
Mello BM, Rodrigues JA, Morelli MH, Melo SFD. A importância do uso de fitoterápicos no Sistema Único de Saúde. Rev Cient Multidiscip Núcleo Conhecimento. 2019 Ano 04, Ed. 11; 05: 118-131. Available <Available https://www.nucleodoconhecimento.com.br/saude/uso-de-fitoterapicos > Accessed at August, 2022.
» https://www.nucleodoconhecimento.com.br/saude/uso-de-fitoterapicos - Moura BV, Cohn A, Pinto RMF. Farmácia: a porta de entrada para o acesso a medicamentos para idosos residentes em Santos. Saúde Soc. 2012; 21(2): 399-409.
- Nascimento Júnior BJ, Tínel LO, Silva ES, Rodrigues LA, Freitas TON, Nunes XP, et al. Avaliação do conhecimento e percepção dos profissionais da estratégia de saúde da família sobre o uso de plantas medicinais e fitoterapia em Petrolina-PE, Brasil. Rev Bras Pl Med. 2016; 18(1): 57-66.
- Ormond TS, Fernandes DDS, Diniz PHGD. An eco-friendly analytical methodology based on digital images for quality control of commercial Mikania glomerata syrups. Microchem J. 2022; 1(178): 107338-8.
- Rio Grande Do Sul. Resolução nº 695/13 - CIB/RS. Aprova a Política Estadual de Práticas integrativas e Complementares PEPIC/RS, 2013.
-
Rio Grande Do Sul. Departamento de Ações em Saúde. Nota Técnica 01/2020 Fitoterapia Na Rede De Atenção à Saúde. Available: <Available: https://atencaobasica.saude.rs.gov.br/upload/arquivos/202010/02083859-nota-tecnica-fitoterapia-n-01-2020-pipmf-e-pepic-rs.pdf > Accessed at Abril 3rd, 2024.
» https://atencaobasica.saude.rs.gov.br/upload/arquivos/202010/02083859-nota-tecnica-fitoterapia-n-01-2020-pipmf-e-pepic-rs.pdf - Saad GDA, Léda PHDO, Sá IMD, Seixlack ACDC. Fitoterapia contemporânea: tradição e ciência na prática clínica. 2. ed. Rio de Janeiro: Guanabara Koogan, 2018.
- Soares AKA, Carmo GC, Quental DP, Nascimento DF, Bezerra FAF, Moraes MO, et al. Avaliação da segurança clínica de um fitoterápico contendo Mikania glomerata, Grindelia robusta, Copaifera officinalis, Myroxylon toluifera, Nasturtium officinale, própolis e mel em voluntários saudáveis. Rev Bras Farmacog. 2006; 16(4): 447-54.
- Tavares JP, Martins IL, Vieira AS, Lima FAV, Bezerra FAF, Moraes MO, et al. Estudo de toxicologia clínica de um fi toterápico a base de associações de plantas, mel e própolis. Braz J Pharmacog. 2006; 16(3): 350-56.
- Ueno VA, Sawaya ACHF. Influence of environmental factors on the volatile composition of two Brazilian medicinal plants: Mikania laevigata and Mikania glomerata. Metabolomics. 2019; 15(6): 91.
- Yatsuda R, Rosalen PL, Cury JA, Murata RM, Rehder VLG, Melo LV, et al. Effects of Mikania genus plants on growth and cell adherence of mutans streptococci. J. Ethnopharmacol. 2005; 97: 183-189.
