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Collected Abstracts: Patent Medicines
But PP. Herbal poisoning caused by adulterants
or erroneous substitutes. J Trop Med Hyg 1994 Dec;97(6):371-374
Abtract: Six cases of herbal poisoning involving six patients
in Hong Kong, Taipei and Kuala Lumpur are reported. The sources of poisoning
were identified as adulterants (Podophyllum emodi) or erroneous substitutes
(Datura metel). In cases of suspected herbal poisoning, it is recommended
that the prescriptions, herbal residues and herb samples should be collected
for pharmacognostical and chemical analysis to substantiate the cause of
poisoning. Insofar as it is possible, an estimate of the amount of herbs
consumed should also be obtained, to establish whether the amount of toxin
present is sufficient to account for the symptoms.
Chan TY, Critchley JA. Usage and adverse effects
of Chinese herbal medicines. Hum Exp Toxicol 1996 Jan;15(1):5-12
Abstract: The great majority of Chinese herbal preparations are
safe, and in the past, some useful Western drugs have been derived from
these herbs. Nearly all serious poisonings are due to the few preparations
containing aconitine, podophyllin or anticholinergics or else proprietary
preparations containing dangerous Western drugs or heavy metals. Both medical
professionals and the general public should be alerted to the potential
toxicity of herbal remedies. There should be frequent monitoring of Chinese
herbal medicines or their derivatives, such as some Chinese proprietary
medicines, for undeclared Western drugs and heavy metals. Mothers should
be discouraged from treating their children with herbal or proprietary
medicines. There should be continuing efforts to collect safety information
on these widely used products.
Publication Types:
- Review
- Review, tutorial
Chan TY, Lee KK, Chan AY, Critchley JA. Poisoning due to
Chinese proprietary medicines. Hum Exp Toxicol 1995 May;14(5):434-436
Abstract: 1. To determine the toxic potentials
of those Chinese proprietary medicines (CPM) which are commonly used for
self-poisoning by adults in Hong Kong, all patients admitted to four of
the eight general medical wards at the Prince of Wales Hospital between
January 1988 and December 1993 were retrospectively studied. 2. There were
54 women and 17 men with their age ranging from 15 to 86 years. Twenty-three
subjects (32%) also took alcohol, chemicals or drugs. Of the 51 subjects
(72%) who had taken topical medicaments, 22 had no symptoms while 28 had
minor features of gastrointestinal irritation (n = 26), mild (n = 2) or
severe (n = 1) salicylate poisoning. Of the 17 subjects (24%) who had taken
CPM tablets/capsules, nine had mild symptoms including nausea/vomiting
and drowsiness. The three remaining patients (4%) who had ingested liquid
CPM preparations were asymptomatic. Elevated plasma salicylate or paracetamol
concentrations (> 0.1 mmol l-1) were found in some patients who had taken
topical medicaments and CPM tablets/capsules, respectively. All the 71
patients completely recovered. 3. Most of the CPM used for self-poisoning
in Hong Kong were of low to moderate toxicity except for those containing
wintergreen oil (methyl salicylate).
Chan TY, Tomlinson B, Tse LK, Chan JC, Chan WW, Critchley JA.
Aconitine poisoning due to Chinese herbal medicines: a review.
Vet Hum Toxicol 1994 Oct;36(5):452-455
Abstract: Both "chuanwu", the main root of Aconitum carmichaeli,
and "caowu", the root of A kusnezoffii, are believed to possess anti-inflammatory,
analgesic and cardiotonic effects and have been used in Chinese materia
medica mainly for the treatment of musculoskeletal disorders. They contain
the highly toxic C19 diterpenoid alkaloids of aconitine, mesaconitine and
hypaconitine. After ingestion, patients may present with signs and symptoms
that are typical of aconitine poisoning. Death may occur from ventricular
arrhythmias, which are most likely to occur within the first 24 h. Management
of aconitine poisoning is essentially supportive. There are no adequate
studies in humans to indicate the most effective treatment of the ventricular
arrhythmias. All clinicians should be alerted to the potential toxicity
of "chuanwu" and "caowu".
Publication Types:
- Review
- Review, tutorial
Chan TY. The prevalence use and harmful potential of
some Chinese herbal medicines in babies and children. Vet Hum
Toxicol 1994 Jun;36(3):238-240
Abstract: This article reviews the prevalence use of Chinese
herbal medicines (CHM) in Chinese pregnant women, babies and children living
in Hong Kong and the harmful potential of some CHM and Chinese proprietary
medicines (CPM) in babies and children. The use of CHM appears to be common
amongst Chinese pregnant women. The possible effects of these herbs on
the fetus and baby and their overall safety are not known. This practice
should be discouraged since there is suggestion that maternal consumption
of CHM might increase the risk of neonatal jaundice. Both "chuen-lin" and
"yin-chen" can displace bilirubin from their serum protein binding and
increase the risk of hyperbilirubinaemia. These herbs should not be given
to the neonates. The use of CPM-containing undeclared drugs of high toxicity
or lead, arsenic and mercurial compounds should be banned. The medical
profession and the general public should be alerted to the harmful potential
of some of the CHM and CPM. There should be continuing efforts to collect
information on the safety of these compounds.
Publication Types:
- Review
- Review, multicase
Chan TY, Tomlinson B, Critchley JA. Aconitine poisoning following
the ingestion of Chinese herbal medicines: a report of eight cases. Aust
N Z J Med 1993 Jun;23(3):268-271
Abstract: BACKGROUND: Traditional Chinese
medicines often contain 'chuanwu' and 'caowu', the roots of certain Aconitum
species which are thought to have an anti-inflammatory effect in many conditions.
Excessive amounts of these materials, which contain diterpene alkaloids
particularly aconitine, can produce toxic effects and occasional fatalities.
AIMS: This study was conducted to document the adverse effects related
to these herbal medicines which resulted in hospital admission and to determine
the outcome in these patients. METHODS: A retrospective survey was conducted
of patients admitted to the Prince of Wales Hospital, Hong Kong with suspected
adverse effects from Chinese herbal medicines containing chuanwu or caowu
over a two year period from 1989 to 1991. RESULTS: Eight patients were
identified with features of mild to moderate intoxication including nausea
and vomiting, paraesthesiae or numbness in the mouth and extremities, hypotension
and ventricular extrasystoles. The management of aconitine poisoning is
essentially supportive and in-hospital observation with ECG monitoring
should be continued for at least 24 hours because of the risk of cardiovascular
collapse and ventricular arrhythmias. The medical profession and general
public should be alerted to the potential toxicity of these herbs and their
usage should be controlled by legislation in Hong Kong as it is in some
other countries.
Chan TY, Chan JC, Tomlinson B, Critchley JA. Chinese
herbal medicines revisited: a Hong Kong perspective Lancet 1993
Dec 18-25;342(8886-8887):1532-1534
Abstract: Chinese herbal medicines (CHM) and Chinese proprietary
medicines (CPM) are widely used by people of Chinese origin throughout
the world. Although the use of these medicinal materials rarely causes
significant toxic effects, cases of severe and even fatal poisoning have
occurred after medication with herbs containing aconitine, podophyllin,
and anticholinergic substances. Furthermore, CHM and CPM are often adulterated
with substituted herbs, heavy metals, and western medicines; such contamination
can have important clinical consequences. In Hong Kong, surveillance and
legislation are required to control the use of some of these herbal preparations.
In other countries, medical practitioners should also be aware of the possibility
that these herbal-medicine-related remedies may cause significant clinical
problems in their Chinese patients.
Dharmananda, S. ITM START 1993 Nov, The Story of Jin Bu Huan;
Institute for Traditional Medicine, Portland, OR
Dharmananda, S. ITM START 1996Nov ,Drugs in Imported Chinese
Herb Products; Institute for Traditional Medicine, Portland, OR
Ferguson JE, Chalmers RJ, Rowlands DJ. Reversible dilated cardiomyopathy
following treatment of atopic eczema with Chinese herbal medicine.
Br J Dermatol 1997 Apr;136(4):592-593
Abstract: Chinese herbal medicines are increasingly being used
as an alternative treatment for chronic skin disease. Most patients and
many doctors remain insufficiently aware of their potential toxicity. We
report a patient with eczema who developed a severe cardiomyopathy following
a 2-week course of Chinese herbal medicine. The connection between the
two conditions was not made until 2 weeks after presentation when the patient
was specifically asked if she had ingested any unusual substances. The
belief that herbs, as natural products available without prescription,
are harmless, is commonplace and patients may not consider them worthy
of mention during a standard medical history.
Fratkin, Jake Paul, OMD. Oriental Medicine Journal. Vol. 6, No. 3-4,
Fall/Winter 1997
Horowitz RS, Feldhaus K, Dart RC, Stermitz FR, Beck JJ. The
clinical spectrum of Jin Bu Huan toxicity. Arch Intern Med
1996 Apr 22;156(8):899-903
Abstract: Herbal medications and other nontraditional medical
therapies are becoming increasingly popular in the United States. We describe
three children and three adults in whom severe toxic effects developed
after ingestion of a Chinese herbal medication, jin bu huan, which is sold
as Jin Bu Huan Anodyne Tablets. Jin bu huan produced distinct clinical
syndromes after acute ingestion in children and long-term use in adults.
A single, acute ingestion in children rapidly produced life-threatening
neurologic and cardiovascular manifestations, while long-term jin bu huan
use in adults was associated with hepatitis. Jin bu huan contains levo-tetrahydropalmatine,
a potent neuroactive substance. The constituents of jin bu huan are misidentified
on the package, resulting in significant delay in identifying the plant
alkaloid responsible for its toxicity. Although perceived as innocuous,
jin bu huan may produce major health effects. The highly concentrated formulation,
the lack of childproof packaging, and the product insert listing indications
for the treatment of serious medical conditions may all contribute to the
development of toxic reactions.
Huang WF, Wen KC, Hsiao ML.
Adulteration by synthetic therapeutic substances of traditional
Chinese medicines in Taiwan.
J Clin Pharmacol 1997 Apr;37(4):344-350
Abstract: The adulteration by synthetic therapeutic substances
of traditional Chinese medicines has been reported on various occasions
and has been a public health concern in Taiwan over the past several years.
A large-scale effort was initiated in 1992 to screen traditional Chinese
medicines that were suspected of adulteration with synthetic therapeutic
substances. The term "adulteration" refers to traditional Chinese medicines
that are tested and found to contain chemical substances not prescribed
or labeled as part of the intended use. A total of 2,609 samples were collected
by eight major general hospitals in Taiwan. Samples were collected through
physicians' referrals during patients visits. The samples were analyzed
by hospital pharmacists following the established standard procedures in
comparison to references by thin-layer chromatography. An average of 23.7%
(n = 618) of the samples collected from the eight hospitals were adulterated.
Four samples with either a rheumatoid or an antiinflammatory indication
contained six different kinds of adulterants. More than half (52.8%) of
the adulterated traditional Chinese medicines contained two or more adulterants.
The sources of adulterated samples and their claimed indications, as well
as the most frequently detected synthetic therapeutic substances, are presented
in this report. The controversies regarding the combination of synthetic
therapeutic substances and traditional Chinese medicines without adequate
labeling should be resolved through regulatory actions for better safety
of drug use.
Kang-Yum E, Oransky SH. Chinese patent medicine
as a potential source of mercury poisoning. Vet Hum Toxicol 1992
Jun;34(3):235-238
Abstract: This research is an effort to create an awareness.
of the potential hazards of some Chinese patent medicines which contain
mercurial ingredients. This should be of consideration when screening symptomatic
patients who are of Asian ethnic background or other users of these medicines.
This research discusses reported cases of mercury poisoning related to
the use of Chinese patent medicines and the potential toxicity of cinnabar
(red mercuric sulfide) and calomel (mercurous chloride), 2 mercurials commonly
used in these medicines. A list of mercurial-containing Chinese patent
medicines available on the open market in North America has been compiled,
together with their traditional uses and mercurial contents and is presented
as a quick reference for Specialists in Poison Information. This class
of medicine may not pose a problem when used appropriately; however, its
misuse, abuse, overdosage and improper storage can lead to serious mercury
poisoning.
Jin bu huan toxicity in adults--Los Angeles, 1993.MMWR
Morb Mortal Wkly Rep 1993 Dec 3;42(47):920-922
Abstract: Jin Bu Huan (JBH) is a traditional Chinese herbal product
used as a sedative and analgesic. During 1993, public health and health-care
providers in Colorado reported three children with unintentional overdoses
of JBH that caused central nervous system and respiratory depression with
rapid onset of life-threatening bradycardia. Subsequently, the first cases
of acute hepatitis attributed to use of JBH were diagnosed in three women
in Los Angeles during July and August 1993. Patients 1 and 2 were referred
to a Los Angeles hepatology clinic by their physicians; patient 3 was identified
by patient 2. All three patients had purchased JBH at the same health-food
store. This report summarizes the investigation of these cases.
Jin bu huan toxicity in children--Colorado, 1993.MMWR
Morb Mortal Wkly Rep 1993 Aug 27;42(33):633-636
Abstract: The consumption of traditional ethnic remedies can
have adverse health effects, especially among children. Life-threatening
bradycardia with rapid onset and central nervous system (CNS) and respiratory
depression developed in three unrelated children in Colorado during 1993
following ingestion of Jin Bu Huan tablets, a Chinese herbal medicine used
for relieving pain. This report summarizes the investigations of these
cases.
Picciotto A, Campo N, Brizzolara R, Giusto R, Guido G, Sinelli N, Lapertosa
G, Celle G.
Chronic hepatitis induced by Jin Bu Huan. J
Hepatol 1998 Jan;28(1):165-167
Abstract: BACKGROUND/AIMS: Jin Bu Huan and other Chinese herbal
products are widely taken remedies. They have been developed as a natural
alternative to traditional drugs in the treatment of various ailments.
Their ability to induce several side effects such as acute hepatitis has
already been described. We report a case of chronic hepatic damage following
administration of Jin Bu Huan Anodyne tablets. METHODS: The patient, a
49-year-old man, developed biochemical signs of liver damage 2 months after
beginning Jin Bu Huan intake (3 tablets/daily) including biopsy-proven
chronic hepatitis with moderate fibrosis. Virological, autoimmune, metabolic
or other hepatotoxic causes were excluded. Liver function impairment was
resolved by discontinuing Jin Bu Huan intake. CONCLUSIONS: This case reinforces
the already known hepatotoxicity of this product and should make us think
more about the uncontrolled use of alternative products.
Ries CA, Sahud MA.
Agranulocytosis caused by Chinese herbal medicines. Dangers
of medications containing aminopyrine and phenylbutazone. JAMA
1975 Jan 27;231(4):352-355
Abstract: Four non-Chinese patients, middle-aged or older, developed
agranuloctyosis while taking Chinese herbal medicines for relief of arthritis
and back pain. All four developed life-threatening infections with bacterial
sepsis; one died. The herbal medicines were shown to contain substantial
amounts of undeclared aminopyrine and phenylbutazone, drugs that are well-known
causes of agranulocytosis. These Chinese herbal medicines are widely available
over the counter throughout the United States.
Tie B, Qi W, Chen G. Determination of soluble mercury
contents in Chinese traditional patent medicines for children. Chung
Kuo Chung Yao Tsa Chih 1990 Oct;15(10):602-604, 639
Abstract: Soluble mercury contents in Baochi San, Xiaoer Zhibon
Ding and Xiaoer Baishou Dan have been determined using dithizone method.
This method has the advantages of short digestion time, clear digestion
end point, simple operation and reproducible results. The recovery rate
ranges from 98.4 to 103%. The data obtained can be used as a reference
for controlling soluble mercury contents in Chinese traditional patent
medicines containing cinnabar.
Woolf GM, Petrovic LM, Rojter SE, Wainwright S, Villamil FG, Katkov
WN, Michieletti P, Wanless IR, Stermitz FR, Beck JJ, et al. Acute
hepatitis associated with the Chinese herbal product jin bu huan.
Ann Intern Med 1994 Nov 15;121(10):729-735
Abstract: OBJECTIVE: To describe the hepatotoxicity associated
with ingestion of the Chinese herbal product Jin Bu Huan Anodyne Tablets
(Lycopodium, serratum) and to propose possible mechanisms of injury. DESIGN:
Retrospective analysis. SETTING: Academic hepatology units and private
practice facilities. PATIENTS: Seven previously healthy patients. MEASUREMENTS:
Clinical, laboratory, radiologic, and histologic studies. RESULTS: Acute
hepatitis occurred after a mean of 20 weeks (range, 7 to 52 weeks) of Jin
Bu Huan ingestion and resolved in six patients within a mean of 8 weeks
(range, 2 to 30 weeks); another patient is currently improving. Hepatitis
was associated with symptoms of fever, fatigue, nausea, pruritus, and abdominal
pain and with signs of jaundice and hepatomegaly. Biopsy specimens showed
that one patient had hepatitis with eosinophils (consistent with a drug
reaction) and the other had mild hepatitis, moderate fibrosis, and microvesicular
steatosis. Decreasing the Jin Bu Huan dose in one patient improved liver
test results. Reusing Jin Bu Huan in two other patients caused abrupt recrudescence
of hepatitis. CONCLUSION: Jin Bu Huan can cause liver injury. Although
the hepatotoxic mechanisms are not defined, they may include hypersensitive
or idiosyncratic reactions or direct toxicity to active metabolites. Hepatotoxicity
caused by herbal products underscores the toxicity caused by herbal products
underscores the importance of national surveillance programs and quality
control of the manufacture of these products.
Comments:
- Comment in: Ann Intern Med 1994 Nov 15;121(10):803-804
- Comment in: Ann Intern Med 1995 Apr 15;122(8):636
Zhang ZW, Watanabe T, Shimbo S, Higashikawa K, Ikeda M. Lead
and cadmium contents in cereals and pulses in north-eastern China
Sci Total Environ 1998 Sep 18;220(2-3):137-145
Abstract: It is known that, unlike Japanese, Koreans or southern
Chinese who depend on rice as a major source of energy for daily life,
people in north-eastern China rely not only on rice, but on wheat and other
cereals and to a lesser extent also on pulses. Cereal and pulse samples
were collected from open markets in north-eastern China, and analyzed by
inductively-coupled plasma spectrometry (ICP-MS) for two potentially hazardous
heavy metals--lead (Pb) and cadmium (Cd). The average Pb level in cereals
(31.3 ng Pb/g as a geometric mean) and that of pulses (25.7 ng Pb/g) were
similar to each other with no significant difference. Among the cereals,
Pb contents were higher in foxtail millet (54.3 ng/g) and lower in maize
(35.4 ng Pb/g; grain and flour in combination), wheat flour (28.8 ng Pb/g)
and rice flour (22.7 ng Pb/g). Lead levels in two important types of pulses,
kidney bean and soybean (24.6 and 30.8 ng Pb/g, respectively), were comparable
to the levels in rice and wheat. In contrast, Cd levels were substantially
higher in pulses (55.7 ng Cd/g) than in cereals (9.2 ng Cd/g), and among
the pulses, Cd in soybean (55.7 ng Cd/g) was significantly higher than
that in kidney bean (23.8 ng Cd/g). The possible public health implication
of the Pb and Cd levels, especially the high Pb level in foxtail millet
(54.3 ng Pb/g) and the high Cd level in soybean (73.5 ng Cd/g), is discussed.