Hepatitis associated with Chinese herbs

Traditional Chinese herbal medicines are widely available in Western society and are popular as a form of 'natural' alternative medicine. Their use is increasing, as they are perceived to be free of side effects, but they remain largely unregulated. We describe two patients who suffered severe hepatitis, one of whom died, after taking Chinese herbal remedies for minor complaints. We also review the English-language literature on hepatitis associated with Chinese herbs. Two products appear to be implicated frequently: Jin bu huan was taken by 11 patients, and Dictamnus dasycarpus was taken by six patients, including both fatal cases. It is difficult to provide conclusive evidence of what caused hepatitis, as these products are mixtures that may contain adulterants. These cases highlight not only the potential dangers of these products to consumers but also the need for greater control of their manufacture and use.     

Herbal therapies in rheumatology: the persistence of ancient medical practices

OBJECTIVE: To determine how frequently herbal remedies are employed as alternative therapies in rheumatic diseases, and the historical justification for their use. METHODS: We conducted a survey in 250 outpatients in the rheumatology clinic of a teaching hospital in México. We registered general demographic information and the previous use of herbal remedies for rheumatic conditions, how effective they were, and the presence of adverse effects during their use. We identified the herbs employed, and cross-checked them with medical texts from the 16th through the 18th centuries on the use of herbal remedies. RESULTS: Of 250 surveyed patients, 126 (51%) had used herbal remedies for their rheumatic conditions. 63% of all users reported them to be effective for the purpose they had been prescribed. 12% reported adverse effects, none of them life-threatening. Being a user had no relation with the patients' formal education. Three patients did not answer the survey. We were able to identify 67 plants. One third of these are either prescribed for rheumatic conditions in the consulted bibliography, or else were used for the same purpose by ancient Mexican cultures. CONCLUSION: Herbal remedies are frequently used for rheumatic conditions. Some of them have an historical antecedent for their use in rheumatic conditions. They deserve a cautious evaluation as adjunctive therapies in rheumatic diseases.     

Rhabdomyolysis in response to weight-loss herbal medicine

The authors report rhabdomyolysis following the ingestion of weight-loss herbal medicine in an otherwise healthy 54-year-old woman. Three hours after ingestion of the herbal medicine, the patient suffered chest pain that continued for 2 hours and resolved gradually. Laboratory investigation showed the presence of rhabdomyolysis with peak serum creatine kinase (CK) of 1028 IU/L, which gradually decreased and normalized after the herbal medicine was discontinued. The pharmacological effects of the active ingredients of the herbal medicine, ma huang (ephedrine), guarana (active alkaloid caffeine), chitosan, Gymnena sylvestre, Garcinia cambogia (50% hydroxycitric acid), and chromium, are discussed, and similar case reports are reviewed. The elevation of CK in this case is of concern, as it may denote that muscle breakdown may be one of the mechanisms of weight loss in these herbal remedies. Further studies are needed to investigate their effects on muscle bulk or CK. Physicians should be aware of the potential side effects of many herbal medicines. It may be advisable to measure serum CK enzyme for patients who admit using weight-loss herbs.     

Herbal remedy use as health self-management among older adults

OBJECTIVES: Guided by the self-regulatory model, we describe the proportions of older adults who include herbal remedies in their health self-management, determining differences in herb use in terms of personal and health characteristics, indicators of culture, and personal resources. METHODS: Data were from the 2002 National Health Interview Survey, which included a supplement on the use of herbal remedies. We limited the present analysis to adults aged 65 and older who were Black, Hispanic, Asian, or White. RESULTS: Herbs were an important component of the health self-management of older adults. Whereas about one quarter of Asian and Hispanic elders used herbal remedies, about 10% of Black and White elders used them. Older adults differed by ethnicity in the herbs they used and their reasons for using herbs. Predictors of herb use included gender, age, and health status. Ethnicity and region of the country, indicators of culture, and education, a personal resource, were significant predictors of herb use when personal and health characteristics were controlled. DISCUSSION: A complex set of factors is associated with the inclusion of herbs in the health self-management of older adults, with cultural and personal resources being extremely important.     

Liver toxicity of drugs of plant origin

Herbal drugs are widely used and often contain highly active pharmacological compounds. Recently, reports have mounted about hepatotoxicity of herbal remedies which ranges from mild liver enzyme alterations to chronic liver disease and liver failure. Hepatotoxicity of Chinese herbs has been recognized, e.g. during treatment of patients with atopic eczema. However, the toxic compounds remain to be determined. Hepatic veno-occlusive disease may result from pyrrolizidine alkaloids which are contained in numerous plants worldwide. Teucrium chamaedrys, commonly referred to as germander, may cause hepatitis and even liver cirrhosis. Significant hepatotoxicity has also been observed after the ingestion of chaparral. Recently, greater celandine, which is widely used for biliary disorders and dyspepsia, was identified as a cause of cholestatic hepatitis. Hepatotoxic reactions have also been observed after the ingestion of Atractylis gummifera, Callilepsis laureola, Senna, Kavapyrone and Pulegium. The aim of this review is to summarize potentially hepatotoxic herbal remedies, to further elucidate their mechanisms of toxicity and thereby underline the likelihood of plants to be the cause of liver damage.     

When is a herb a drug?

With the growing popularity and use of herbal remedies in the industrial countries there has been an increasing recognition and reporting of adverse reactions. Drug development represents discovery and characterization of naturally occurring plant metabolites or their synthetic analogues. Therefore, a herbal remedy should be considered a drug for all clinical purposes. The liver, being central to the metabolism of virtually all xenobiotics, is inevitably exposed to reactive metabolites and liver injury is a potential complication of nearly every medication, including herbal remedies. Recognition of herb induced hepatotoxicity depends on clinical awareness of the problem, a suspicion that a herbal preparation is involved, and detailed enquiry regarding the use of all supplements and remedies. Herbal medicines should be regulated more systematically and monitoring for adverse reaction should improve.     

Ma huang associated acute liver failure requiring liver transplantation

An ever increasing number of herbal remedies are recognized as potentially hepatotoxic. We report a case of fulminant hepatic failure requiring liver transplantation associated with the use of Ma huang, a traditional Chinese remedy containing ephedrine-type alkaloids. The literature surrounding the potential liver toxicities of Ma huang is reviewed and the proposed pathogenetic mechanisms are critically examined.     

Cardiotoxicity from 'safe' herbomineral formulations

Many herbomineral preparations are currently being used as therapeutic remedies for common ailments. Commonly known cardiotoxic herbs are Aconitum ferox (aconite), Areca catechu (betel nut), Thevetia peruviana (yellow oleander) and Cleistanus collinus (oduvan). Herbs mixed with lead, copper and/or mercury are known to be highly toxic. They produce cardiac arrhythmias, mainly ventricular ectopics, ventricular tachycardia and various degrees of arterioventricular (AV) blocks. We report 12 such successive cases where the patients developed vague feelings of discomfort, dizziness, chest discomfort and ventricular arrhythmias following herbal drug ingestion which warranted the immediate discontinuation of the drug. Three of the patients died. This paper emphasizes the risk of unsupervised use of herbomineral preparations by patients who believe that the remedies are always 'safe' and the urgent necessity for the pharmacognostic identification of the constituent herbs, their toxicological studies, uniform nomenclature, authenticity and standardization of plants and their parts before advocating them for therapeutic use.     

Factors influencing adherence to medications in a group of patients with systemic lupus erythematosus in Jamaica

The objective of this study was to examine the factors influencing adherence to medications in a group of patients with systemic lupus erythematosus (SLE) in Jamaica. A qualitative study was designed using a screening questionnaire and semi-structured interviews. The study was conducted in the rheumatology clinic at the University Hospital of the West Indies, Kingston, Jamaica. 75 patients with SLE including 20 interviewees, who had SLE for at least 1 year participated in the study. The main outcome measures were: (i) level of self-reported adherence in a sample of the clinic attendees and (ii) interviewees explanations of the reasons for taking or not taking drugs as prescribed by their physician. 56% of the 75 study participants reported taking their medications more than 85% of the time. High cost and poor availability of medications were the main reasons for poor adherence, but some patients chose not to take their medications because of side effects, perceived mild severity of their disease and/or a preference to take drugs only when symptomatic. Patients used herbal medicines to counteract side effects of Western medicines, to 'purge the blood' and to manage lupus symptoms when they had no medications. Religious beliefs were used as a coping strategy. Traditional use of herbal medicines is common particularly in patients from rural Jamaica, and may explain the observed use of herbal medicines in those who have emigrated to developed countries. Socio-economic constraints and poor drug availability are particularly important influences on poor adherence in Jamaican patients with SLE. Religious beliefs and use of herbal remedies do not seem to affect adherence adversely but are used when drugs cannot be obtained.     

Herbal pharmacology and medical therapy in the People's Republic of China.

A scientific delegation visited the People's Republic of China for the purpose of assessing the current status of herbal pharmacology and medicine there. China is attempting to wed traditional and Western medicine so as to take advantage of the potential contributions of both. This wedding seems possible at the empiric level despite theoretical contradictions. Traditional remedies are widely prescribed, but the actual impact of such medication on disease is difficult to assess, because of the failure of the Chinese up until now to evaluate such remedies by modern clinical trial methodology. All Western drugs are readily available in China, and indeed are manufactured for export as well as for use within the country. The current chinese approach to the patient-doctor relation, and some novel ideas with regard to both medical and surgical therapy pose provocative questions for Western physicians.     

Obstetrician–gynecologists’ perspectives towards medication use during pregnancy: A cross-sectional study

A vast majority of studies evaluated pregnant women’s knowledge and attitudes towards using medications during their pregnancy, with few global and lack of regional studies conducted to spot obstetrician-gynecologists practices in this regard. This study aims to assess Obstetrician–gynecologists’ knowledge of medication teratogenicity potential, their frequently used resources, and their residency training contribution to medication use during pregnancy. This is a cross-sectional, survey-based study targeting licensed Obstetrician–gynecologists who are practicing in Saudi Arabia using a validated self-administered web-based questionnaire developed by the American College of Obstetricians and Gynecologists. A total of 60 obstetrician-gynecologists were included in the study. Most participants were female (72%) with median age and clinical experience of 42 and 13 years, respectively. The majority (87%) agreed that Isotretinoin is contraindicated, while around 60% of respondents were unsure about the safety of herbal remedies use. Online databases (e.g., Lexi-Comp and Micromedex) were chosen as the top utilized medication resources (45%). Around 48% strongly agreed that liability is a concern if there were adverse pregnancy outcomes following the use of medications. Regarding their training assessment, obstetrician-gynecologists who had been in practice for more than 15 years were significantly more likely to rate themselves as well qualified (P value < .05). The majority adequately and significantly rated their training on prescribed medications (58.3%), OTC medications (45%) and dietary supplements or herbal remedies (32%) (P value < .05). Obstetrician–gynecologists showed a different level of knowledge about the risks and safety of medications when used during pregnancy. More efforts are needed to optimize medication selection, herbal avoidance, and training performance.     

Herbal hepatoxicity from Chinese skullcap: A case report

The use of herbal supplements has increased considerably over the last decade. We report a case of an elderly woman who began taking Move Free Advanced for arthritis, which in addition to glucosamine and chondroitin, contained two herbal ingredients, Chinese skullcap and Black Catechu. Our patient presented with significant cholestasis and hepatitis which significantly improved after discontinuation of the supplement. Since neither the patient nor the treating physician recognized this supplement as a potential hepatotoxin, she resumed taking the supplement and again suffered from considerable hepatotoxicity. Liver biopsy at that time was consistent with acute drug induced liver injury. She, once again, recovered after discontinuation of the supplement. Review of the literature confirms that Chinese skullcap has been implicated as a possible hepatotoxic agent which was demonstrated in this case.     

Alternative therapies: what role do they have in the management of lupus?

Systemic lupus erythematosus (SLE) is an autoimmune disease with higher morbidity and mortality among ethnic Chinese patients than Whites. Corticosteroid and other immunosuppressive drugs, including cyclophosphamide, azathioprine, and hydroxychloroquine are traditional therapies for this disease. Since the year 2000, mycophenolate mofetil and rituximab have been widely used in refractory SLE or severe lupus nephritis. Because the high disease activity remains, even after active therapy, and serious side effects from Western medicines may develop, more than 40% of SLE patients in Western countries are pursuing complementary and alternative therapies (CATs). CAT remedies are multiplex, and include herbal medicines, diets and vitamins, acupuncture, chiropractice, folk medicine, massage, spiritual healing, etc. Many herbal formulas have been used but in general their efficacy in treating lupus is doubted because of the lack of strong evidence. Tripterygium (T2) has demonstrated good efficacy in rheumatoid arthritis (RA) and SLE, but widespread use is limited due to the side effects. Through randomized clinical trials, we hope in the future that some Chinese medicines may be found helpful as CATs for SLE.     

Intersection of Inflammation and Herbal Medicine in the Treatment of Osteoarthritis

Herbal remedies and dietary supplements have become an important area of research and clinical practice in orthopaedics and rheumatology. Understanding the risks and benefits of using herbal medicines in the treatment of arthritis, rheumatic diseases, and musculoskeletal complaints is a key priority of physicians and their patients. This review discusses the latest advances in the use of herbal medicines for treating osteoarthritis (OA) by focusing on the most significant trends and developments. This paper sets the scene by providing a brief introduction to ethnopharmacology, Ayurvedic medicine, and nutrigenomics before discussing the scientific and mechanistic rationale for targeting inflammatory signalling pathways in OA by use of herbal medicines. Special attention is drawn to the conceptual and practical difficulties associated with translating data from in-vitro experiments to in-vivo studies. Issues relating to the low bioavailability of active ingredients in herbal medicines are discussed, as also is the need for large-scale, randomized clinical trials.     

Herbal antitussives

The mechanisms of actions of cough medicines are not always known. The problem is exacerbated for herbal medicines, where the effectiveness of the plant or its phytochemicals have rarely been carefully evaluated. Moreover, the most active phytomedicinal constituent is difficult to identify, and the expense and difficulty of such studies discourages sponsors who may not be able to benefit by subsequent exclusive marketing of the herbal remedy. Most popular herbs used as cough medicines appear to be demulcents whose action is confined to the oropharynx. It is probable that the vast majority of allegedly effective herbal cough medicines act as non-specific emetic-expectorants. The proof of activity of even marketed herbal derivatives such as guaifenesin and codeine is difficult to obtain. It is therefore likely that herbal cough medications will never be shown to be more active than placebos. Nevertheless, these plant products will continue to be popular remedies for patients and their health care advisors.     

Acute hepatitis induced by Shou-Wu-Pian, a herbal product derived from Polygonum multiflorum

Herbal preparations are widely available and generally regarded by the public as harmless remedies for a variety of medical ailments. We report the first case in Australia of acute hepatitis associated with the Chinese herbal medicine Shou-Wu-Pian, prepared from Polygonum multiflorum. Cholestatic hepatitis developed in a Chinese woman taking this preparation for the greying of her hair, and liver biopsy was consistent with a toxic reaction. Clinical and biochemical resolution occurred following cessation of the drug.     

Herbal preparation-induced liver injury]

Recently the use of herbal preparations as remedies for various medical conditions, has been rapidly increasing in Korea. In our previous study, 38.9% of patients with chronic liver disease were found to use some sorts of herbal preparations. They believe herbal preparations are safe although the ingredients has never been rigorously substantiated. Toxicities of certain herbal preparations are caused by their contaminants and adulterated ingredients or concurrently used conventional drugs rather than specific components of the herbal preparations. Furthermore, in most instances, multiple herbal ingredients are used by the prescribers of oriental medicine. All of these conditions frequently impose diagnostic difficulties. There are myriads of plant-derived hepatotoxic substances which may or may not cause liver injury in individuals. The severity of liver injury depends largely on the toxicity of the substance, the amount of exposure and the individual's susceptibility. These toxic substances cause liver injury not only through the mechanism of intrinsic hepatotoxicity but also through the idiosyncrasy as in conventional drug-induced injury. Therefore, theoretically, it is possible to apply pre-existing CAMs (Causality Assessment Methods) to the assessment of causality in cases with diagnostic difficulties.     

Complementary and alternative medicine in inflammatory bowel diseases: what is the future in the field of herbal medicine?

The use of complementary and alternative medicine is wide-spread not only in Eastern countries, but also in the Western world. Despite the increasing evidence on the harmful effects induced by several naturopathic/homeopathic products, patients seem to appreciate these remedies, in particular because they consider them to be absolutely safe. This same phenomenon is common among inflammatory bowel disease (IBD) patients. As a result there is a significant request for scientific data to evaluate both the efficacy and safety of these remedies, and to support the use of such medications as adjuvant treatments to biological and synthetic drugs. We aimed to review the current evidence on efficacy and safety of some natural products that are believed to be effective in inflammatory bowel disease. Further perspectives for the clinical use of herbal products and strategies for improving knowledge about herbal products in IBD are also discussed.