Usage and adverse effects of Chinese herbal medicines

Ethnopharmacology of five flowers herbal tea, a popular traditional beverage in Hong Kong and South China

BACKGROUND

It has been a long-standing tradition of using herbal tea for preventive and therapeutic healthcare in Hong Kong and South China and Five Flowers Tea is one of the most popular herbal teas. Based on the principle of traditional Chinese medicine, the pharmacological functions are to clear heat and dispel dampness in the body. Heat and dampness are thought to contribute to a range of health problems, especially during the hot and humid season in South China and Hong Kong. The most prevalent herbs in the formula contain bioactive compounds including flavonoids, alkaloids and terpenoids, which have a wide range of pharmacological properties including anti-inflammation, antivirus, antidiarrhoea, antibacteria, and antioxidation. However, with the composition varies widely, the ethnopharmacological benefits described may not be delivered uniformly. This study is to provide a comprehensive analysis on the composition of the Five Flowers Tea sold in Hong Kong and investigate the rationale behind the selection of herbs used in the formula. This study also provides information on the variation and quality of the Five Flowers Tea in the market.

METHODS

Thirty-three Five Flowers Tea samples were collected from various locations in Hong Kong. The size, texture, colour and organoleptic properties were documented. Macroscopic and molecular authentication methods were employed to identify the individual components.

RESULTS

Macroscopic identification revealed there were 23 herbs belonging to 18 plant families. The most prevalent herb was Bombax ceiba L., followed by Chrysanthemum morifolium. Ten adulterants and the existence of insect Lasioderma serricorne were confirmed by DNA barcoding techniques.

CONCLUSION

This study employed a comprehensive approach to authenticate the herbs in Five Flowers Tea samples collected from various locations in Hong Kong. Macroscopic and molecular methods were used to identify the herbs and adulterants. The findings revealed the varied composition in Five Flowers Tea and the occurrence of adulterants in some samples. This shows that quality assurance of Five Flowers Tea is essential for the effective use of this popular folk medicine.

A comprehensive review on phytochemicals for fatty liver: are they potential adjuvants?

Non-alcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of metabolic syndrome and, as such, is associated with obesity. With the current and growing epidemic of obesity, NAFLD is already considered the most common liver disease in the world. Currently, there is no official treatment for the disease besides weight loss. Although there are a few synthetic drugs currently being studied, there is also an abundance of herbal products that could also be used for treatment. With the World Health Organization (WHO) traditional medicine strategy (2014-2023) in mind, this review aims to analyze the mechanisms of action of some of these herbal products, as well as evaluate toxicity and herb-drug interactions available in literature.

Reflections on the aconitine poisoning

Aconitine is a natural toxic substance belonging to the family of aconitum alkaloids, which is used in small doses by Traditional Chinese practitioners. We present a case of accidental death due to acute aconitine poisoning. A 65-year-old Chinese man presented to a medical clinic with fever and shoulder pain. Soon after administration of intravenous ceftriaxone, a bottle of Chinese medicinal wine was administered. The man rapidly experienced headache, hearing loss and tinnitus, nausea, diarrhea, numbness of the lips, tongue, face, and the upper and lower extremities, cold sweat, fall of blood pressure, and discomfort of the entire body, and he died on the same day. Postmortem examination showed cyanosis of the nail beds, severe congestion in lungs and other organs, bilateral pleural effusions, and infiltration of basophils in the intestinal submucosa. No significant increase of IgE was found in the blood. Toxicological analysis detected aconitine in the medicinal wine, blood, and stomach contents by liquid chromatography-tandem mass spectrometry (LC-MS⁄MS). Aconitine was quantified in cardiac blood as 16.4 ng/ml, and in stomach contents (63.8 ng/ml) and wine sample (10.1 ug/ml). The cause of death was aconitine poisoning. This case report highlights the danger of aconitine. LC-MS⁄MS has the advantages of high analytic speed, sensitivity, and accuracy. It would be desirable for the government to control the use of aconitine-containing herbal extracts.

Fraud Detection of Herbal Medicines Based on Modern Analytical Technologies Combine with Chemometrics Approach: A Review

Fraud in herbal medicines (HMs), commonplace throughout human history, is significantly related to medicinal effects with sometimes lethal consequences. Major HMs fraud events seem to occur with a certain regularity, such as substitution by counterfeits, adulteration by addition of inferior production-own materials, adulteration by chemical compounds, and adulteration by addition of foreign matter. The assessment of HMs fraud is in urgent demand to guarantee consumer protection against the four fraudulent activities. In this review, three analysis platforms (targeted, non-targeted, and the combination of non-targeted and targeted analysis) were introduced and summarized. Furthermore, the integration of analysis technology and chemometrics method (e.g., class-modeling, discrimination, and regression method) have also been discussed. Each integration shows different applicability depending on their advantages, drawbacks, and some factors, such as the explicit objective analysis or the nature of four types of HMs fraud. In an attempt to better solve four typical HMs fraud, appropriate analytical strategies are advised and illustrated with several typical studies. The article provides a general workflow of analysis methods that have been used for detection of HMs fraud. All analysis technologies and chemometrics methods applied can conduce to excellent reference value for further exploration of analysis methods in HMs fraud.

Herbal therapy as a promising approach for regulation on lipid profiles: A review of molecular aspects

Impaired lipid profile is defined as abnormal plasma levels of low-density lipoprotein, triglycerides, and total cholesterol. This disease state is associated with the development and progression of various disorders, such as diabetes mellitus, cardiovascular diseases, and acute myocardial infarction. Globally, all of these disorders are related to a significant rate of death. Therefore, finding a suitable approach for the prevention and treatment of lipid profile-related disorders is in the spotlight. Recently, herbal therapy has been considered a promising therapeutic approach for the treatment of hyperlipidemia or its related disorders due to its safety and efficacy. Hereby, we address the potential benefits of some of these herbal compounds on different aspects of lipid profile and its abnormalities with a special focus on their underlying mechanisms. Using herbal products, such as teas and mushrooms, or their derivatives, Rosmarinus officinalis Linn, Curcuma longa, Green tea, Lippia triphylla, Lippia citriodora, Plantago asiatica L, Vine tea, and Grifola frondosa have been proved to exert several therapeutic impacts on lipid profile and its related disorders, and we would provide a brief review on them in this literature.

An Intentional Aconite Overdose: A Case Report

BACKGROUND

Aconite is one of the most toxic known herbs, widely used for centuries as an essential Chinese medicine, but also for deliberate poisoning throughout history. Clinically indicated in herbal medicine for a range of ailments from headaches to muscle spasm, unfortunately the narrow therapeutic window may lead to a range of toxic presentations. The mechanism of action of the pharmacologically active compounds in Aconite relate to the activation of voltage gated sodium channels within a range of tissue including myocardial, neuronal and smooth muscle leading to persistent cellular activity.

CASE PRESENTATION

We report on a rare case of a fifty year old male with intentional aconite overdose presenting with refractory cardiovascular instability from persistent life threatening arrhythmias, respiratory failure and seizure activity.

CONCLUSION

An overview of Aconite, its history, pharmacological effects, treatment of overdose and outcomes is presented.

Metals and metalloids in traditional medicines (Ayurvedic medicines, nutraceuticals and traditional Chinese medicines)

Traditional medicine (TM) including Ayurvedic medicines, traditional Chinese medicines and nutraceuticals are popular across the globe as dietary supplements and traditional and alternative medicines. Health risks from these remedies continue to present serious concerns, with occurrences of poisoning by metals and metalloids present at concentrations above acceptable regulatory standards. This review overviews the prevalence of TM use, cases of metal and metalloid poisoning following TM consumption, and forms of TM contamination and adulteration. The review summarises regulations by the World Health Organization (WHO) and other relevant bodies. Finally, the review recommends how to protect consumers.

Current Status and Major Challenges to the Safety and Efficacy Presented by Chinese Herbal Medicine

Traditional Chinese medicine (TCM) is not only used prevalently in Asian countries but has also gained a stable market globally. As a principal form of TCM, Chinese herbal medicine (CHM) is comprised of treatments using multiple Chinese herbs which have complex chemical profiles. Due to a lack of understanding of its modality and a lack of standardization, there are significant challenges associated with regulating CHM’s safety for practice and understanding its mechanisms of efficacy. Currently, there are many issues that need to be overcome in regard to the safety and efficacy of CHM for the further development of evidence-based practices. There is a need to better understand the mechanisms behind the efficacy of CHM, and develop proper quality standards and regulations to ensure a similar safety standard as Western drugs. This paper outlines the status of CHM in terms of its safety and efficacy and attempts to provide approaches to address these issues.

Research progress of aconitine toxicity and forensic analysis of aconitine poisoning

Chinese herbal medicines have been extensively used in China and other countries for centuries. Aconitine, a diterpenoid alkaloid extracted from Aconitum plants, has anti-inflammatory and analgesic activities, but can also induce severe arrhythmia and neurotoxicity. Aconitine poisoning accidents caused by misuse, suicide, or homicide have been reported in recent years. In China, fatal aconitine poisoning can occasionally happen on account of accidental ingestion of some wild plants or consumption of herbal decoction made from the roots of Aconitum plants. However, it is rather difficult for forensic experts to find the specific results in present forensic autopsy of aconitine-induced death. To further clarify its potential risk following the widespread application of aconitine, toxicological characteristics and pharmacokinetics of aconitine are reviewed. Moreover, gastrointestinal, neurological, and cardiovascular symptoms were observed frequently in aconitine poisoning cases. In addition, the review also aims at providing some convincing evidences for forensic experts to identify unexplained death with postmortem examination.

Ontology-based systematic representation and analysis of traditional Chinese drugs against rheumatism

Background

Rheumatism represents any disease condition marked with inflammation and pain in the joints, muscles, or connective tissues. Many traditional Chinese drugs have been used for a long time to treat rheumatism. However, a comprehensive information source for these drugs is still missing, and their anti-rheumatism mechanisms remain unclear. An ontology for anti-rheumatism traditional Chinese drugs would strongly support the representation, analysis, and understanding of these drugs.

Results

In this study, we first systematically collected reported information about 26 traditional Chinese decoction pieces drugs, including their chemical ingredients and adverse events (AEs). By mostly reusing terms from existing ontologies (e.g., TCMDPO for traditional Chinese medicines, NCBITaxon for taxonomy, ChEBI for chemical elements, and OAE for adverse events) and making semantic axioms linking different entities, we developed the Ontology of Chinese Medicine for Rheumatism (OCMR) that includes over 3000 class terms. Our OCMR analysis found that these 26 traditional Chinese decoction pieces are made from anatomic entities (e.g., root and stem) from 3 Bilateria animals and 23 Mesangiospermae plants. Anti-inflammatory and antineoplastic roles are important for anti-rheumatism drugs. Using the total of 555 unique ChEBI chemical entities identified from these drugs, our ChEBI-based classification analysis identified 18 anti-inflammatory, 33 antineoplastic chemicals, and 9 chemicals (including 3 diterpenoids and 3 triterpenoids) having both anti-inflammatory and antineoplastic roles. Furthermore, our study detected 22 diterpenoids and 23 triterpenoids, including 16 pentacyclic triterpenoids that are likely bioactive against rheumatism. Six drugs were found to be associated with 184 unique AEs, including three AEs (i.e., dizziness, nausea and vomiting, and anorexia) each associated with 5 drugs. Several chemical entities are classified as neurotoxins (e.g., diethyl phthalate) and allergens (e.g., eugenol), which may explain the formation of some TCD AEs. The OCMR could be efficiently queried for useful information using SPARQL scripts.

Conclusions

The OCMR ontology was developed to systematically represent 26 traditional anti-rheumatism Chinese drugs and their related information. The OCMR analysis identified possible anti-rheumatism and AE mechanisms of these drugs. Our novel ontology-based approach can also be applied to systematic representation and analysis of other traditional Chinese drugs.

Electronic supplementary material

The online version of this article (10.1186/s12918-017-0510-5) contains supplementary material, which is available to authorized users.

Safety of chinese herbal medicine for chronic obstructive pulmonary disease

Chinese herbal medicine (CHM) is increasingly used by patients with chronic obstructive pulmonary disease (COPD); however, there has been no systematic evaluation of its safety. This review examined the adverse events (AEs) reported in clinical studies of CHM for COPD. Five English databases (PubMed, Embase, CINAHL, AMED, and CENTRAL) and four Chinese databases (CBM, CNKI, CQVIP, and Wanfang Data) were searched from inception to May 2013. Adverse event data, including nature, severity, author-assigned causality, management, and outcome, were extracted from included studies. Descriptive statistics were used for the rate of adverse events. Of the 152 included studies, AEs were reported in 47 studies. The rate of adverse events was slightly lower in the CHM groups compared with controls (84 events in 5,909 participants, 1.4% versus 102 events in 5,676 participants, 1.8%). The most frequently reported adverse event was nausea (28 cases in the CHM groups and 19 cases in the control groups), which was more common in studies where CHM was combined with pharmacotherapy to treat acute exacerbation of COPD. Other frequent adverse events were abdominal discomfort, dry mouth, and dizziness. Detailed information about the adverse events was scant. Overall, CHM appears to be well tolerated in people with COPD.

Chinese herbal medicines for hypothyroidism

BACKGROUND

The reduced production of thyroid hormones is the main feature of the clinical state termed hypothyroidism. In Chinese philosophical and medical theory, it results from Yang deficiency. Chinese herbal medicines (CHM) are thought to restore Yang and have been used in China to treat hypothyroidism for many years.

OBJECTIVES

To assess the effects of CHM for hypothyroidism.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, the Chinese Biomedical Literature Database on Disc, and the China National Knowledge Infrastructure for randomised clinical trials (RCTs). The date of the last search was September 2014 for all databases. We also searched for ongoing trials in trial registers.

SELECTION CRITERIA

We considered RCTs of CHM alone or combined with thyroid hormone therapy compared with no treatment, placebo or thyroid hormone therapy. We also planned to compare different formulae of CHM with each other, alone or combined with thyroid hormone therapy. Hypothyroid individuals had to be diagnosed by the standard criteria valid at the time of the beginning of the trial regardless of the cause of hypothyroidism.

DATA COLLECTION AND ANALYSIS

Data extraction and risk of bias assessment were not performed because no study could be included.

MAIN RESULTS

We found no RCTs and therefore could not establish the effects of CHM on hypothyroidism.

AUTHORS' CONCLUSIONS

Currently, there is no evidence available from RCTs on CHM for the treatment of hypothyroidism. We also did not find any ongoing registered trial.

Safety of Chinese herbal medicines during pregnancy

Miscarriage and infertility have long been public concerns due to the mental and physical suffering they bring to potential parents. There is a strong need for effective and affordable treatments. Chinese herbal medicines (CHMs) have been shown to be effective for preventing miscarriage and treating infertility; however, due to the limited knowledge of their pharmacological mechanisms and unknown potential toxicity, their use has been restricted. This paper reviews 24 clinical trials of CHMs to prevent miscarriage and treat infertility. Most of these studies did not meet the requirements of randomized controlled trials. Even when using quality assessments based on the Newcastle-Ottawa Scale to assess the quality of non-randomized studies, most studies did not meet the requirements. The reviewed papers were evaluated for maternal and embryonic adverse effects, including those in animal experiments. Slight maternal effects were noted, with some reports of severe toxic effects of CHMs for preventing miscarriage and severe adverse maternal effects of CHMs used for infertility. Owing to the poor quality of the randomized controlled clinical trials and the limited number of studies, it is not possible to draw a conclusion. From animal studies, for all three gestational periods, growth delay and congenital anomalies were the most commonly recorded adverse effects. However, baseline toxicological data and detailed mechanisms are still lacking. To gain a better understanding of the potential toxic effects of CHMs, additional high-quality randomized controlled trials should be conducted, and high-throughput in vitro screening method for baseline data should be considered.

Acute adverse events from over-the-counter Chinese herbal medicines: a population-based survey of Hong Kong Chinese

Background

Although over-the-counter traditional Chinese herbal medicine (COTC) is commonly used to treat everyday illness in many parts of the world, no population-based study has been done to examine the prevalence and factors associated with COTC-related adverse events.

Methods

A cross-sectional telephone survey was conducted among Hong Kong Chinese adults in 2011 (n = 1100) with informed verbal consent. Stepwise logistic regression of demographic, attitudinal and behavioral variables was used to determine factors associated with past-year adverse events.

Results

Of study respondents, 71.7% (789/1100) reported past-year COTC use and 2.3% (25/1100) reported at least one COTC-related adverse event in the past year. Of the 27 adverse events cases reported among COTC users, the most common were allergic reactions (n = 11) dizziness (n = 5), and gastro-intestinal problems (n = 4). Pills/capsules were the dosage form that caused the highest proportion of adverse events (n = 10), followed by plasters (n = 7), creams/ointments (n = 5), and ingestible powders (n = 2).

Although COTC users reporting adverse events were more likely to report greater practices to avoid adverse events (OR = 6.47; 95% CI: 1.38-30.3); they were also more likely to possess lower education levels (OR = 9.64, 95% CI: 2.20-42.3) and to have received COTC information from non-reliable, mass-media information sources such as magazines (OR = 3.32; 95% CI: 1.01-8.50) or television (OR = 2.93; 95% CI: 1.03-10.7). Package labels were also felt to be unclear by 42.9% of COTC users. A large proportion of COTC users demonstrated low levels of COTC-related knowledge, while the main impediment to greater information-seeking was the belief that reliable COTC information is not obtainable from Western health professionals.

Conclusions

Despite global movements toward more stringent complementary medicine regulation, the limited accessibility of reliable information and widespread misperceptions among consumers present major challenges for the safe use of complementary medicine.

Herbal Medicine in Healthcare-An Overview

It is generally accepted by all concerned that modern pharmaceuticals will remain out of reach of many people and ‘health for all’ may only be realized by the use of adequately assessed herbal products. Mankind has been using herbal medicine for healing right from the beginning of human civilization. With the advent of ‘modern medicine’ herbal products have been looked down upon, especially by western societies. Yet, in recent times, use of herbal medicine for heathcare has increased steadily all over the world. However, serious concerns are being realized regarding the safety, claimed efficacy and quality of herbal products used as herbal medicine, nutraceuticals, health food and cosmetics. Although herbal products are generally considered safe due to their age-old usage, significant side effects have been reported for many herbal products, including herbal medicine. Accidental contamination and intentional adulteration are considered as primary reasons for the side effects. The historical perspective and the philosophy of herbal medical practice along with its present status in the light of present day science have been reviewed and included in the present article. Assurance of safety by identification of contaminants and assessment of toxicity has been outlined. Assessment of claimed efficacy of herbal medicine is difficult due to its holistic approach. Practical ways of assessing efficacy of herbal medicine by adapting the methodologies used for modern pharmaceutical are described. The maintenance of standard of herbal medicine has been stressed and pragmatic approaches of assuring quality of herbal medicine by using modern tools of fingerprinting the chemical profile of herbal medicine are discussed. As much of the traditional herbal medical knowledge is scattered around the world at the family and community levels, and more so in the indigeneous people, the knowledge base is continuously being lost and so needs immediate documentation. Difficulties in documentation due to concerns of Intellectual Property Rights (IPR) have been highlighted.

Oral traditional Chinese medication for adhesive small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) is one of the most common emergent complications of general surgery. Intra-abdominal adhesions are the leading cause of SBO. Because surgery can induce new adhesions, non-operative management is preferred in the absence of signs of peritonitis or strangulation. Oral traditional Chinese herbal medicine has long been used as a non-operative therapy to treat adhesive SBO in China. Many controlled trials have been conducted to investigate its therapeutic value in resolving adhesive SBO.

OBJECTIVES

The aim of this review was to assess the efficacy and safety of oral traditional Chinese medicine (TCM) for adhesive small bowel obstruction.

SEARCH METHODS

We searched the following databases, without regard to language or publishing restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Chinese Biomedical Database (CBM), China National Knowledge Infrastructure/Chinese Academic Journals full-text Database (CNKI), and VIP (a full-text database of Chinese journals). The searches were conducted in November 2011.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials comparing Chinese medicines administered orally, via the gastric canal, or both with a placebo or conventional therapy in participants diagnosed with adhesive SBO were considered. We also considered trials of TCM (oral administration, gastric tube perfusion, or both) plus conventional therapy compared with conventional therapy alone for patients with adhesive SBO. Studies addressing the safety and efficacy of oral traditional Chinese medicinal agents in the treatment of adhesive SBO were also considered.

DATA COLLECTION AND ANALYSIS

Two authors collected the data independently. We assessed the risk of bias according to the following methodological criteria: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting and other sources of bias. Dichotomous data are presented as risk ratios (OR) and 95% confidence intervals (CI); continuous outcomes are presented as mean differences (MD) and 95% CIs. The data analyses were carried out using Review Manager 5.1. For cases in which necessary information was not reported in the paper, we contacted the primary authors for additional information.

MAIN RESULTS

Five randomised trials involving 664 participants were analysed. Five different herbal medicines were tested in these trials, including Huo-Xue-Tong-Fu decoction, Xiao-Cheng-Qi-Tang decoction, a combination of Xiao-Cheng-Qi-Tang and Si-Jun-Zi-Tang decoctions, Chang-Nian-Lian-Song-Jie-Tang decoction, and Fufang-Da-Cheng-Qi-Tang decoction. There were variations in the tested herbal compositions and methods of medicine administration. The main outcomes reported in the trials were effects on abdominal pain, abdominal distension, constipation defection, time of first defecation after treatment, and reoperation rate during the course of the disease. Secondary outcomes selected for this review were not available, including complications such as small bowel perfusion (bowel resection, system complications, and other possible complications), length of hospital stay, cost of hospitalisation, and time from admission to surgical intervention. The results of five trials showed that patients receiving TCM combined with conventional therapy seemed to have improved outcomes compared with patients receiving conventional treatment alone (OR 4.24, 95% CI 2.83 to 6.36).However, we cannot conclusively determine the efficacy of TCM in this review due to inadequate reporting, low methodological quality, and the prevalence of various biases in the reviewed studies. Furthermore, because none of the reviewed trials discussed adverse events, we could not evaluate the safety of TCM for adhesive SBO patients. All trials were conducted and published in China.

AUTHORS' CONCLUSIONS

Although many studies have assessed the use of TCM products for adhesive SBO, most were excluded from this review due to their methodological limitations. This systematic review did not find sufficient evidence to support the objective efficacy and safety of TCM for patients with adhesive SBO. The positive evidence should be interpreted with caution given the insufficient number of studies with large sample sizes, the absence of well-designed, high-quality trials, and the lack of safety information. Therefore, further studies with larger sample sizes and high-quality, randomised, and controlled trials are necessary to produce more accurate and meaningful data on the efficacy of Chinese herbal medicines for adhesive SBO.

Analytical methods for heavy metals in herbal medicines

INTRODUCTION

It is estimated that about 70-80% of the world's population relies on non-conventional medicine, mainly of herbal origin. However, owing to the nature and sources of herbal medicines, they are sometimes contaminated with toxic heavy metals such as lead, arsenic, mercury and cadmium, which impose serious health risks to consumers. It is critical to analyse source materials for heavy metals in order to ensure that their concentrations meet the related standards or regulations limiting their concentrations in herbal medicines. In this review, different analytical methods for analysis of heavy metals in herbal medicines are discussed.

OBJECTIVE

To provide a comprehensive review of the current state of the art in analytical methods used to detect heavy metals in herbal medicines.

METHODOLOGY

We systematically searched and reviewed the research articles regarding analytical methods for heavy metals in herbal medicine from various databases, such as Medline/PubMed, ScienceDirect, SciFinder, Google Scholar, EBSCO, Gale InfoTrac, Ingenta, Ovid, ProQuest and ISI Web of Knowledge.

RESULTS

In this review, we discuss in detail several commonly used and sensitive analytical techniques, including atomic absorption spectrometry, inductively coupled plasma optical emission spectrometry or mass spectrometry, X-ray fluorescence spectrometry, high-performance liquid chromatography, differential pulse polarography, neutron activation analysis and anodic stripping voltammetry. We also provide some application examples of these analytical techniques for heavy metals in herbal medicines.

Safety of botanical ingredients in personal care products/cosmetics

The key issue of the safety assessment of botanical ingredients in personal care products (PCP) is the phytochemical characterisation of the plant source, data on contamination, adulteration and hazardous residues. The comparative approach used in the safety assessment of GM-plants may be applied to novel botanical PCP ingredients. Comparator(s) are the parent plant or varieties of the same species. Chemical grouping includes definition of chemical groups suitable for a read-across approach; it allows the estimation of toxicological endpoints on the basis of data from related substances (congeneric groups) with physical/chemical properties producing similar toxicities. The Threshold of Toxicological Concern (TTC) and Dermal Sensitisation Threshold (DST) are tools for the assessment of trace substances or minor ingredients. The evaluation of skin penetration of substances present in human food is unnecessary, whereas mixtures may be assessed on the basis of physical/chemical properties of individual substances. Adverse dermal effects of botanicals include irritation, sensitisation, phototoxicity and immediate-type allergy. The experience from dietary supplements or herbal medicines showed that being natural is not equivalent to being safe. Pragmatic approaches for quality and safety standards of botanical ingredients are needed; consumer safety should be the first objective of conventional and botanical PCP ingredients.

Protocols on safety, efficacy, standardization, and documentation of herbal medicine (IUPAC Technical Report)

This Technical Report compiles and analyzes the current scientific knowledge on herbal medicine and highlights the practical ways for ensuring the safety of herbal preparations and evaluating their claimed efficacy. Emphasis has been given to the methods for standardization of herbal medicine and the ways and means for moving forward to achieve the difficult goal of preparing herbal medicines of consistent quality and effects. Pragmatic approaches have been recommended to overcome the difficulties in (i) protecting intellectual property rights (IPR); (ii) producing safe, potent, standardized, and affordable herbal medicine; and (iii) documenting the knowledge base on herbal medicine in an easily accessible format.

Public health risks from heavy metals and metalloids present in traditional Chinese medicines

Out of 247 traditional Chinese medicines (TCM) investigated, a proportion were contaminated with arsenic (5-15%), lead (approximately 5%), and mercury (approximately 65%). Some preparations exceeded the tolerable daily intake (TDI) for males and females for arsenic (4 and 5 products, respectively), lead (1 and 2 products), and mercury (5 and 7 products). These exceedances were as high as 2760-fold, which posed a potential danger to public health. As many users are known to self-prescribe, there is a substantial risk of poisoning from the consumption of these contaminated TCM.

A study of western pharmaceuticals contained within samples of Chinese herbal/patent medicines collected from New York City’s Chinatown

In America, recent growth in the popularity of Chinese herbal/patent medicines (CHM/CPM) has generated concerns as to the safety of these and other herbal remedies. Lack of strict federal regulations has lead to the possibility of improper labeling and even adulteration of these products with western drugs or other chemical contaminants. Our laboratory has conducted an analytical study to determine the presence of undeclared pharmaceuticals and therapeutic substances within CHM/CPM sold in New York City's Chinatown. Ninety representative samples randomly purchased in the form of pills, tablets, creams and teas were screened by appropriate analytical techniques including TLC, GC/MS and HPLC. Five samples contained nine different western pharmaceuticals. Two of these samples contained undeclared or mislabeled substances. One sample contained two pharmaceuticals contraindicated in people for whom the product was intended. Drugs identified include promethazine, chlormethiazole, chlorpheniramine, diclofenac, chlordiazepoxide, hydrochlorothiazide, triamterene, diphenhydramine and sildenafil citrate (Viagra).

Study of Aconitine toxicity in rat embryos in vitro

BACKGROUND

Aconitum is widely used in traditional medicine for its anti-inflammatory, analgesic, and cardiotonic properties. Knowledge is limited, however, on its effects on embryonic development.

METHODS

Whole embryo culture was applied to explore the effects of aconitine on rat embryos during their critical period of organogenesis. All embryos isolated on gestational day 9.5 were exposed to 0, 1, 2.5, 5, and 10 microg/ml of aconitine with and without S9 mix, and scored for their growth and differentiation at the end of the 48-hr culture period.

RESULTS

The embryonic growth and development were adversely affected at the concentration of 2.5 microg/ml aconitine without S9 mix, represented as reduced crown-rump length and head length, decreased number of somites, and lower morphologic score. When the concentration of aconitine was increased to 5 microg/ml, it induced severe dysmorphogenesis effects, including cardiac defect (undivided cardiac tube and inflated pericardial cavity), irregular somites, and brain malformation (e.g., narrow brain vesicles). In the presence of S9 mix, Aconitine toxicity to rat embryos was reduced to a certain extent.

CONCLUSIONS

Our study showed that Aconitine had direct embryotoxic effects during the rat organogenetic period. NOAEL was about 1 microg/ml and metabolism in S9 mix could induce the attenuation of Aconitine toxicity. Until more is known about the effects of Aconitine in pregnant women, we suggest its use should be treated with caution.

Aconitine involvement in an unusual homicide case

We describe a homicide complicated by an aconitine poisoning, which was initially thought to be a strangulation case. Routine toxicological analyses demonstrated only a small amount of alcohol in the blood and the urine. The case could not be clarified until 5 years after the event. A new element in the investigation made the wife the prime suspect, and finally, after thorough interrogation, she confessed her crime. She had mixed a decoction of three plants of Aconitum with red wine. Additional toxicological analyses, using the liquid chromatography-tandem mass spectrometry (LC-MS-MS) technique demonstrated 810 ng/ml of aconitine in urine, 6.5 ng/g in liver and 1.3 ng/g in the kidneys. Even though aconitine poisoning is still rare in Europe, it should be taken into account in suicides and homicides, particularly in unclarified cases.

Sensitive analysis of aconitine, hypaconitine, mesaconitine and jesaconitine in human body fluids and Aconitum tubers by LC/ESI-TOF-MS

The Aconitum species (Ranunculaceae) are widely distributed in northern Asia and North America. Their roots are popularly used in herbal medicines in China and Japan. Many cases of accidental, suicidal and homicidal intoxication with this plant have been reported; some of these were fatal because the toxicity of Aconitum is very high. It is thus important to detect and quantify Aconitum alkaloids in body fluids, with high sensitivity. We have developed a simple and sensitive method for measuring four kinds of Aconitum alkaloids (aconitine, hypaconitine, jesaconitine and mesaconitine) by LC/electrospray (ESI)-time-of-flight (TOF)-MS. For all of them, only molecular ions were observed at an orifice voltage of 75 V; at 135 V, base peaks corresponding to [M - 60 + H]+ ions were observed. These four compounds and methyllycaconitine (internal standard) in human plasma samples were purified by solid-phase extraction. The four extracted compounds were completely separated in mass chromatograms; the calibration curves showed good linearity in the range 10-300 ng/ml, and the detection limits were estimated to be 0.2-0.5 ng/ml. Using our method, we also determined the amounts of these compounds in tuber samples. The present method is applicable in clinical and forensic toxicology.

A survey of Chinese herbal medicine intake amongst preoperative patients in Hong Kong

We have surveyed, by means of a questionnaire, the preoperative use of traditional Chinese medicines in 259 adult Chinese patients admitted to a Hong Kong teaching hospital. The spectrum and use of herbal remedies differed from that reported by Western sources. Of those patients surveyed 90% used Chinese herbs on a regular daily basis in traditional soups and teas while 44% had consulted a traditional Chinese medicine practitioner in the last twelve months prior to admission, but mainly for health promotion (59%) and minor ailments (30%). Only 25% sought advice for their current illness and 13% were taking regular traditional Chinese medicines prior to admission. The ingredients were difficult to identify. Patients with cancer were more likely to use ling zhi (odds ratio 5.4). Female patients with reproductive problems were more likely to visit a traditional Chinese medical practitioner (odds ratio 2.6) and use ginseng (odds ratio 5.1). The anaesthetic implications of preoperative traditional Chinese medicine in keeping with Hong Kong practices need to be investigated, and appropriate anaesthetic guidelines should be developed.

Adulteration of South African traditional herbal remedies

Traditional herbal remedies are used as alternative medicine by a large proportion of people worldwide. Herbals are generally perceived as safe, harmless, and free from side effects, but there have been reports of adulteration of Asian herbal remedies with Western pharmaceuticals, a practice that has not hitherto been observed in Africa. The authors present 2 cases from South Africa in which herbal remedies, consumed by patients admitted to hospital, were found to be adulterated with commercially available Western medicines. The adulterants were identified using high-performance liquid chromatography with a photodiode array detector and gas chromatography-mass spectrometry. The authors alert clinicians to the fact that adulteration of herbal remedies may become more common and should be considered, especially in cases where the symptoms are confusing in light of the history.

Rapid and reliable determination of illegal adulterant in herbal medicines and dietary supplements by LC/MS/MS

In recent years, dietary supplements and herbal medicines are increasing in popularity all over the world. However, it is problematic that some manufacturers illegally included synthetic drugs in their products. Due to the extremely complex matrices of those products, most existing methods for screening illegal adulterations are time-consuming and liable to false positive. In this paper, a robust LC/MS/MS method for the high-throughput, sensitive and reliable determination of illegal adulterations from herbal medicines and dietary supplements was established. Minimal LC separation was employed and MRM was used to simultaneously monitor the three transitions under their respective optimal collision energy for each compound. Positive results were determined only if well-defined peaks appeared at all of the three transitions and the ratios among the peak areas were within given threshold. In this study, the method had been applied for the screening of nine most commonly adulterated therapeutic substances, such as sildenafil (Viagra) and famotidine, and the lower limits of detection of these compounds ranged from 0.05 to 1.5 ng/ml. Little sample preparation was needed for this method and the analysis time was less than 5 min/sample. The reliability has been demonstrated by the test with blank matrix. Over 200 products that were under suspicion by SDA of China had been assayed and till now no false negative or positive result was found. This method is rapid, simple, reliable and capable of screening multiple adulterants in one run.

Risks of herbal medicinal products

PURPOSE

Herbal medicinal products (HMPs) are again highly popular. Their current popularity renders the assessment of their safety an urgent necessity.

METHOD

Narrative review using examples only.

RESULTS

Constituents of HMPs can be toxic and numerous examples of liver, kidney or other organ damage are on record. All HMPs contain a range of pharmacologically active constituents, and users of HMPs often combine HMPs with prescribed drugs. Thus herb-drug interactions are a real possibility. In most countries, HMPs are not submitted to stringent regulation and control. Thus unreliable quality can be a problem. In particular, this poses a risk when HMPs are contaminated (e.g. with heavy metals) or adulterated (e.g. with prescription drugs). The medical literature holds numerous examples for all of these scenarios and some are used in this article to illustrate the above points. As this area is grossly under-researched, it is rarely possible to define the size of the problem.

CONCLUSIONS

It is concluded that the widespread notion of HMPs being inherently safe is naive at best and dangerous at worst. More research is required to minimise the risk HMPs may pose to consumers' health.

Regulatory control of Chinese Proprietary Medicines in Singapore

In Singapore, there has been a growing public interest in traditional Chinese medicine (TCM), which plays an important role in the healthcare system. With effect from 1 September 1999, the control on Chinese Proprietary Medicines (CPM) was implemented in three phases over a span of 3 years. Under the CPM regulatory framework, CPM importers, wholesalers, manufacturers and re-packers must be licensed and CPM products assessed and listed by the health authority before they are allowed for sale. Product assessment is based on the criteria of safety and quality which include limits of toxic heavy metals and microbial contents. During the 3-year CPM listing exercise, irregularities were detected, including intrinsic toxicity, adulteration, substitution, contamination, misidentification, non-traditional and/or inappropriate usage, incorrect preparation, inappropriate labelling, exaggerated claims and/or advertising. The full implementation of CPM control by September 2001 saw the listing of 7943 CPM products and brought about an improvement in the quality and safety of CPM in Singapore as well as the removal of sub-standard, fake/imitation and adulterated products. The standards of practices by local CPM dealers have also been raised. These improvements have, in turn, increased the level of public confidence in CPM products in Singapore.

Use of traditional drugs in a hospital of Chinese medicine in Germany

The frequency of use of traditional Chinese drugs was investigated in relation to Western and Chinese diagnostic classifications in a hospital for traditional Chinese medicine in Germany. All 1597 in-patients treated in the hospital between February 1992 and August 1993 entered a prospective observational study. About two thirds of the patients suffered from chronic pain syndromes, the most frequent single diagnosis being migraine (n=244). All patients were treated with at least one of four Chinese therapies (traditional Chinese drugs, acupuncture, Tuina-massage, Qi-gong). 95.1% of all patients received traditional Chinese drug treatment, prescribed in complex prescriptions including 3 to 12 single drugs from a total of 305. Drug patterns prescribed to patients with the same Western diagnosis tended to be similar, but could differ strongly for single drugs in subgroups with distinct Chinese diagnoses. Studies evaluating traditional Chinese treatment strategies in patients classified according to Western nosology should take into account possible diagnostic differences according to Chinese nosology. The development of a reliable coding system for Chinese diagnostic classifications is a precondition for further cross-cultural studies.

Looking under every rock: Duchenne muscular dystrophy and traditional Chinese medicine

Traditional Chinese medicine has been advocated to alleviate symptoms in Duchenne muscular dystrophy. To investigate this hypothesis, a pilot study was carried out in Beijing on 10 DMD boys treated with various regimens, including pills, decoctions, massages and acupuncture at various stages of their disease course. Despite the limited scientific impact of such a study, it seems as if the benefit, if any, is minimal. Moreover, some indirect clinical clues such as the cushingoid appearance found in a few patients suggest these drugs may also contain corticosteroids to some extent.

Developing a pharmacovigilance system in the Philippines, a country of diverse culture and strong traditional medicine background

Pharmacovigilance is the study of adverse drug reactions (ADR, events-AE). It affords a unique vantage point from which to detect problem drugs and drug use. The ADR reporting system in the Philippines was established in August 1994 and was recognized as a national centre member of the World Health Organization International Drug Monitoring (currently known as the Uppsala Monitoring Centre) by February 1995. The pharmacovigilance system in the Philippines developed a number of communication and training packages with the intention of advocating safer medicines and rational drug use. Although unpopular with western-trained medical doctors, people do utilize traditional folk medicines. There have been few ADR reports, perhaps in part because the AE are unrecognized; sometimes, the AE is misconstrued as part of the healing action; and practitioners of these remedies are unlikely to report them. People who resort to herbal medicines are usually from the poor segment of the population, and are likely to believe in unscientific claims and unlikely to report what they suffered. The promotion of herbal medicines as natural safe alternatives neglects the possibility of AE. Although unregulated, traditional Chinese medicines are allowed in the Philippines if used by ethnic Chinese. The regulation of health supplements has also been inefficient. Both of these factors have provided gaps for the entry of harmful products. Pharmacovigilance programmes are useful in the detection of false claims and substandard medicines. Examples of the Philippine ADR monitoring experience are cited.

HPLC and GC-MS screening of Chinese proprietary medicine for undeclared therapeutic substances

Traditional Chinese medicine includes raw medicinal materials and Chinese proprietary medicine (CPM). Despite being of natural origin, toxic effects, adulteration with synthetic therapeutic substances and even deaths had been associated with CPM. There is thus a need to develop analytical technique to rapidly screen for undeclared toxic and therapeutic substances in CPM. In this study, a high performance liquid chromatography-diode-array detection method was developed and used to screen for undeclared therapeutic substances in CPM. An ultraviolet (UV) library of 266 drugs had been compiled. Solute identification was performed by comparing the analytical data (UV spectra, retention time and relative retention time) with those of the 266 standards. Gas chromatography-mass spectrometry was used as a confirmation method. These chromatographic methods had been shown to be selective and reproducible in screening for undeclared drugs in CPM. Using the method developed, 41 CPM samples in seven categories were screened for undeclared therapeutic substances. One anti-asthmatic CPM was found to contain codeine.

Chinese proprietary medicine in Singapore: regulatory control of toxic heavy metals and undeclared drugs

Traditional Chinese medicine (TCM) is gaining popularity as a form of complementary and alternative medicine. Reports of efficacy of TCM are increasing in numbers. TCM includes both crude Chinese medicinal materials (plants, animal parts and minerals) and Chinese proprietary medicine (CPM) [final dosage forms]. Despite the belief that CPM and herbal remedies are of natural origin, unlike Western medicine, and are hence safe and without many adverse effects, there have been numerous reports of adverse effects associated with herbal remedies. Factors affecting the safety of herbal medicines include intrinsic toxicity, adulteration, substitution, contamination, misidentification, lack of standardisation, incorrect preparation and/or dosage and inappropriate labelling and/or advertising. Hence, new regulations on the control of CPM were enforced in Singapore with effect from 1 September 1999. These include licensing and labelling requirements, as well as control of microbial contamination. This article also reviews reports of excessive toxic heavy metals and undeclared drugs in CPM in Singapore between 1990 and 1997. The names, uses, toxic heavy metal or drug detected and the year of detection are tabulated. Information on the brand or manufacturer's name are provided whenever available. The public and healthcare professionals should be better informed of the basic concept of TCM and its usefulness, as well as the potential adverse effects associated with its use. Greater control over the safety and quality of CPM could be achieved through good manufacturing practice, regulatory control, research, education, reporting usage of Chinese medicine (as in drug history) as well as reporting of adverse events.

Successful treatment of aconitine induced life threatening ventricular tachyarrhythmia with amiodarone

With the increasing trend of cross mixing of populations, aconitine induced poisoning and its related arrhythmias may be more frequently encountered worldwide. However, the clinical experience is often too limited to draw any conclusion on the optimal treatment for tachycardia induced by aconitine intoxication. The clinical presentation, serial electrocardiographic changes, and responses to antiarrhythmic agents are reported in a patient with aconitine induced life threatening ventricular tachyarrhythmia. Amiodarone was effective in suppressing polymorphic ventricular tachycardia, which might provide an example of successful pharmacological intervention in aconitine induced ventricular tachyarrhythmia.

Toxicity of complementary therapies: an eastern perspective

Chinese traditional medicine is used extensively in Chinese populations, and other Asian countries employ similar therapies. Herbal treatments have a major role in these systems, and although most have a well-established safety record, occasional adverse effects are seen. Problems arise when toxic herbs are used in excessive doses, with improper preparation, or when they are substituted erroneously. There may also be adulteration with Western drugs or heavy metals, and interactions between herbs and Western drugs may also occur. It is always prudent to obtain a complete history of the use of herbal medications during any clinical assessment, particularly in Asian patients.

LC and LC-MS-MS analyses of undeclared codeine in antiasthmatic Chinese proprietary medicine

This paper describes an accurate and sensitive reversed phase high-performance liquid chromatographic (RP-HPLC) method for the detection and quantification of undeclared codeine in a Chinese Proprietary Medicine (CPM) for asthma. A rapid and specific liquid chromatography-mass spectrometry-mass spectrometry (LC-MS-MS) method was applied to confirm the presence of codeine by selected reaction monitoring (SRM). Codeine was extracted from the capsules by dissolving in sodium dihydrogen phosphate buffer (10 mM, pH = 2.2) and ethanol, then made alkaline (pH = 9) and extracted using chloroform. The amount of codeine in AsthmaWan was found to be 61.8 microg/capsule (R.S.D. = 7.9%, n = 9). Excellent resolution was obtained despite the complexity of the product which claimed to contain at least nine herbal ingredients, none of which will give rise to codeine. As a further confirmation method, LC-MS-MS is accurate and specific. The LC method has been validated for linearity, limit of detection, limit of quantification, accuracy and specificity. Greater awareness of and control over undeclared drugs in complementary medicine are necessary to ensure patients' safety.