Is mercury in Tibetan Medicine toxic? Clinical, neurocognitive and biochemical results of an initial cross-sectional study

Elemental and Chemical Phase Analyses of Ras-Family Ayurvedic Medicinal Products

Fifteen Ayurvedic medicines of Ras-family (herbo-mineral-metallic preparations) from three reputed manufactures were analysed for elemental quantification and their chemical phase identification using the energy-dispersive (ED) and wavelength-dispersive (WD) X-ray fluorescence (XRF) techniques, and powder X-ray diffraction (XRD) technique, respectively. The low-Z elements C, H, N, S and O constituting a major portion of these medicines were also determined by CHNSO analyser and further used as input for XRF analyses. The elements of concern, Hg, Pb and As, are identified in different medicine products with disquiet concentration values (maximum concentration values range ~ 4-10%) and that too with substantial variations in the products from different manufacturers. These elements are identified mainly in the cinnabar (α-HgS)/metacinnabar (β-HgS), litharge (PbO) and alacranite (As₄S₄) phases in different medicines. Keeping in view the high concentration of chemicals of the Hg, Pb and As elements in the Ras-family medicines, it is vitally required to investigate their bioaccessibility and surmise the associated toxicological aspects. It is suggested that the formation of the bioaccessible toxic chemical forms of the Hg, Pb and As elements be avoided during preparation of the mineral ingredients or these soluble chemical forms be removed at suitable stage of the preparation. In view of large variations observed for the Hg, Pb and As based ingredients in the Ras family Ayurvedic medicine products from different manufacturers, adequate quality control mechanisms and production regulations are recommended.

The need for "gentle medicine" in a post Covid-19 world

As it has historically been the case with many pandemics, the Covid-19 experience will induce many philosophers to reconsider the value of medical practice. This should be a good opportunity to critically scrutinize the way medical research and medical interventions are carried out. For much of its history, medicine has been very inefficient. But, even in its contemporary forms, a review of common protocols in medical research and medical interventions reveal many shortcomings, especially related to methodological flaws, and more importantly, conflicts of interests due to profit incentives. In the face of these problems, we propose a program of "gentle medicine". This term, originally formulated by philosopher Jacob Stegenga, describes a form of medicine in which physicians intervene less than they currently do. As part of this general program, we advance a series of reform recommendations that could be enacted both by medical staff in their everyday practice, but also by public health officials and policymakers.

Evaluation of the neuroprotective effect of rutin on Drosophila melanogaster about behavioral and biochemical aspects induced by mercury chloride (HgCl2)

Mercury chloride (HgCl₂) acts as a bioaccumulator capable of causing numerous neurological and physiological changes in organisms in a negative way. However, rutin has been considered a very effective antioxidant compound in the treatment of neurodegenerative diseases, as it can neutralize radicals capable of damaging neuronal cells. In this context, this study aimed to evaluate rutin as a neoprotective agent against the damage induced by HgCl₂ in Drosophila melanogaster. The exposure of the flies to the agents was carried out in triplicate, and about 150 adult flies were evaluated. To assess the antioxidant action of rutin, MTT, phenanthroline, nitric oxide, total thiols and NPSH tests were carried out in the following concentrations: Control (1500 μL of distilled water), 1 mg/g of HgCl₂, 0.5 mg/g of Rutin + HgCl₂, 1 mg/g of Rutin + HgCl₂, 2 mg/g of Rutin + HgCl₂. The locomotion test was verified by negative geotaxis, the result of which showed that flies exposed to HgCl₂ had difficulties in flight. The group treated with HgCl₂ alone had a high mortality rate, while in combination with different concentrations of rutin, it heard a moderate reduction in the number of deaths, as well as in the negative geotaxis data in which the rutin had a positive effect. An increase in iron (II) levels was observed at the highest concentrations of rutin, while at low concentrations, rutin significantly decreased nitric oxide levels. The HgCl₂ + R group (2 mg/g) showed a significant increase in the total thiols content, while for the NPSH all rutin concentrations showed a significant increase in the levels of non-protein thiols. Our results demonstrate that mercury chloride can cause oxidative stress in D. melanogaster. However, the results suggest that rutin has antioxidant and protective effects against the damage caused by HgCl₂.

The silver linings of mercury: Reconsideration of its impacts on living organisms from a multi-timescale perspective

Research on mercury (Hg), a naturally occurring element in Earth's lithosphere, has been extremely hot in the past few decades due to the outbreak of a series of disastrous poisoning incidents. However, such studies might provide us a biased view towards Hg if no thorough review about its long-term effects on living organisms from a multi-timescale perspective was performed. Hg might have played a mysterious role in critical intervals (e.g., mass extinction and oceanic anoxia events) in several geologic periods due to the elevated Hg levels induced by volcanism whereas it has long been used for various purposes in human history. Therefore, it is necessary to go through previous studies and historical records of different timescales (10⁰ to 10⁶ yr). In this work, we conducted a thorough review of Hg knowledge at three different timescales, i.e., geologic periods (10⁶ yr), human history (10³ yr), and contemporary history (10⁰ yr), summarizing recent advances and indicated potential research gaps. By doing so, we demonstrated that it is possible to achieve safe and sustainable Hg applications despite the current Hg crisis. However, such silver linings depend on a better understanding of ecosystem dynamics. Besides, considering the possible dire consequences of erupted Hg levels as suggested in geological periods, swift actions to mitigate the impacts of anthropogenic activities on the Hg cycle will be another key point. Overall, this review presented a unique perspective of Hg combining different timescales, shedding light on the importance of a better understanding of the global ecosystem as a whole and maintaining the sustainability of planet Earth in the future.

Human Methylmercury Exposure and Potential Impacts in Central Tibet: Food and Traditional Tibetan Medicine

Methylmercury presents potent neurotoxicity to humans. Fish consumption is the leading source of human exposure to methylmercury worldwide. However, the exposure source in Tibet remains poorly understood because of the scarcity of observational data on most Tibetan foods, although high mercury levels were recently detected in some traditional Tibetan medicines. Here, the results of field investigations show that the joint consumption of traditional Tibetan medicines (TTMs), fish, and rice constitutes a primary exposure pathway to methylmercury in Tibetans and that the probable daily intake of methylmercury is close to that for many coastal regions. People who are young and high-income may have higher methylmercury exposure levels mainly because of economic development and cultural exchanges among regions. Our analysis indicates that a large proportion of the Tibetan population are likely to face a high methylmercury exposure risk and that mercury-susceptible populations in Tibet should be attentive to consuming TTMs with fish.

Zuotai (β-HgS)-containing 70 Wei Zhen-Zhu-Wan differs from mercury chloride and methylmercury on hepatic cytochrome P450 in mice

Background: Zuotai (mainly β-HgS)-containing 70 Wei-Zhen-Zhu-Wan (70W, Rannasangpei) is a famous Tibetan medicine for treating cardiovascular and gastrointestinal diseases.  We have shown that 70W protected against CCl 4 hepatotoxicity.  CCl 4 is metabolized via cytochrome P450 (CYP) to produce reactive metabolites. Whether 70W has any effect on CYPs is unknown and such effects should be compared with mercury compounds for safety evaluation.   Methods: Mice were given clinical doses of 70W (0.15-1.5 g/kg, po), Zuotai (30 mg/kg, po), and compared to HgCl 2 (33.6 mg/kg, po) and MeHg (3.1 mg/kg, po) for seven days. Liver RNA and protein were isolated for qPCR and Western-blot analysis. Results: 70W and Zuotai had no effects on hepatic mRNA expression of Cyp1a2, Cyp2b10, Cyp3a11, Cyp4a10 and Cyp7a1, and corresponding nuclear receptors [aryl hydrocarbon receptor (AhR), constitutive androstane receptor (CAR), pregnane X receptor (PXR), peroxisome proliferator-activated receptor-α (PPARα); farnesoid X receptor (FXR)]. In comparison, HgCl 2 and MeHg increased mRNA expression of Cyp1a2, Cyp2b10, Cyp4a10 and Cyp7a1 except for Cyp3a11, and corresponding nuclear receptors except for PXR. Western-blot confirmed mRNA results, showing increases in CYP1A2, CYP2B1, CYP2E1, CYP4A and CYP7A1 by HgCl 2 and MeHg only, and all treatments had no effects on CYP3A. Conclusions: Zuotai and Zuotai-containing 70W at clinical doses had minimal influence on hepatic CYPs and corresponding nuclear receptors, while HgCl 2 and MeHg produced significant effects.  Thus, the use of total Hg content to evaluate the safety of HgS-containing 70W is inappropriate.

Zuotai (β-HgS)-containing 70 Wei Zhen-Zhu-Wan differs from mercury chloride and methylmercury on hepatic cytochrome P450 in mice

Background: Zuotai (mainly β-HgS)-containing 70 Wei-Zhen-Zhu-Wan (70W, Rannasangpei) is a famous Tibetan medicine for treating cardiovascular and gastrointestinal diseases.  We have shown that 70W protected against CCl 4 hepatotoxicity.  CCl 4 is metabolized via cytochrome P450 (CYP) to produce reactive metabolites. Whether 70W has any effect on CYPs is unknown and such effects should be compared with mercury compounds for safety evaluation.   Methods: Mice were given clinical doses of 70W (0.15-1.5 g/kg, po), Zuotai (30 mg/kg, po), and compared to HgCl 2 (33.6 mg/kg, po) and MeHg (3.1 mg/kg, po) for seven days. Liver RNA and protein were isolated for qPCR and Western-blot analysis. Results: 70W and Zuotai had no effects on hepatic mRNA expression of Cyp1a2, Cyp2b10, Cyp3a11, Cyp4a10 and Cyp7a1, and corresponding nuclear receptors [aryl hydrocarbon receptor (AhR), constitutive androstane receptor (CAR), pregnane X receptor (PXR), peroxisome proliferator-activated receptor-α (PPARα); farnesoid X receptor (FXR)]. In comparison, HgCl 2 and MeHg increased mRNA expression of Cyp1a2, Cyp2b10, Cyp4a10 and Cyp7a1 except for Cyp3a11, and corresponding nuclear receptors except for PXR. Western-blot confirmed mRNA results, showing increases in CYP1A2, CYP2B1, CYP2E1, CYP4A and CYP7A1 by HgCl 2 and MeHg only, and all treatments had no effects on CYP3A. Conclusions: Zuotai and Zuotai-containing 70W at clinical doses had minimal influence on hepatic CYPs and corresponding nuclear receptors, while HgCl 2 and MeHg produced significant effects.  Thus, the use of total Hg content to evaluate the safety of HgS-containing 70W is inappropriate.

Mercury sulfide-containing Hua-Feng-Dan and 70W (Rannasangpei) protect against LPS plus MPTP-induced neurotoxicity and disturbance of gut microbiota in mice

ETHNOPHARMACOLOGICAL RELEVANCE

Mercury sulfides (HgS) are frequently included in Ayurveda, Tibetan and Chinese medicines to assist the presumed therapeutic effects, but the ethnopharmacology remains elusive. The present study examined the protective effects of α-HgS-containing Hua-Feng-Dan and β-HgS-containing 70 Wei-Zhen-Zhu-Wan (70W, Rannasangpei) against Parkinson's disease mice induced by lipopolysaccharide (LPS) plus 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP).

METHOD

A single injection of LPS (5 mg/kg ip) was given to adult male C57BL/6 mice, and 150 days later, the low dose of MPTP (15 mg/kg, ip, for 4 days) was given to produce the "two-hit" Parkinson's disease model. Together with MPTP treatment, mice were fed with clinically-relevant doses of Hua-Feng-Dan (0.6 g/kg) and 70W (0.2 g/kg) for 35 days. Rotarod test was performed to examine muscle coordination capability. At the end of the experiment, brain was transcardially perfused with paraformaldehyde, the substantia nigra was sectioned for microglia (Iba1 staining) and dopaminergic neuron (THir staining) determination. Colon bacterial DNA was extracted and subjected to qPCR analysis with 16S rRNA probes.

RESULTS

The low-grade, chronic neuroinflammation produced by LPS aggravated MPTP neurotoxicity, as evidenced by decreased motor activity, intensified microglia activation and loss of dopaminergic neurons. Both Hua-Feng-Dan and 70W increased rotarod activity and ameliorated the pathological lesions in the brain. In gut microbiomes examined, LPS plus MPTP increased Verrucomicrobiaceae, Methanobacteriaceae, Pronicromonosporaceae, and Clostridaceae species were attenuated by Hua-Feng-Dan and 70W.

CONCLUSIONS

α-HgS-containing Hua-Feng-Dan and β-HgS-containing 70W at clinical doses protected against chronic LPS plus MPTP-induced toxicity to the brain and gut, suggesting HgS-containing traditional medicines could target gut microbiota as a mechanism of their therapeutic effects.

Toxicological Risks of Renqingchangjue in Rats Evaluated by 1H NMR-Based Serum and Urine Metabolomics Analysis

Renqingchangjue (RQCJ), a kind of Traditional Tibetan Medicine, has been widely utilized to treat various gastroenteritis diseases. However, the biosafety and toxicity of RQCJ was still indefinite because of toxic components in RQCJ, which included a variety of heavy metals. Thus, this study was aimed to evaluate the toxicity and expound the toxicological mechanism of RQCJ. In this study, rats were intragastrically administered with different doses of RQCJ for 15 days, and then, the restorative observation period lasted for 15 days. Liver and kidney tissues were collected for histopathological examination, and simultaneously serum and urine samples were collected for 1H nuclear magnetic resonance (1H NMR) spectroscopy analysis and biochemical analysis combined with inductively coupled plasma mass spectrometry (ICP-MS) measurement. The 1H NMR-based metabolomics analysis revealed that the administration of RQCJ significantly altered the concentrations of 14 serum metabolites and 14 urine metabolites, which implied disturbances in energy metabolism, amino acid metabolism, intestinal flora environment, and membrane damage. Besides, the biochemical analysis of serum samples was consistent with the histopathological results, which indicated slight hepatotoxicity and nephrotoxicity. The quantification of As and Hg in urine and serum samples by ICP-MS provided more evidence about the toxicity of RQCJ. This work provided an effective method to systematically and dynamically evaluate the toxicity of RQCJ and suggested that precautions should be taken in the clinic to monitor the potential toxicity of RQCJ.

Protective role of cinnabar and realgar in Hua-Feng-Dan against LPS plus rotenone-induced neurotoxicity and disturbance of gut microbiota in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Hua-Feng-Dan (HFD) is a traditional Chinese medicine used for neurological disorders. HFD contains cinnabar (HgS) and realgar (As₄S₄). The ethnopharmacological basis of cinnabar and realgar in HFD is not known.

AIM OF THE STUDY

To address the role of cinnabar and realgar in HFD-produced neuroprotection against neurodegenerative diseases and disturbance of gut microbiota.

MATERIALS AND METHODS

Lipopolysaccharide (LPS) plus rotenone (ROT)-elicited rat dopaminergic (DA) neuronal damage loss was performed as a Parkinson's disease animal model. Rats were given a single injection of LPS. Four months later, rats were challenged with the threshold dose of ROT. The clinical dose of HFD was administered via feed, starting from ROT administration for 46 days. Behavioral dysfunction was detected by rotarod and Y-maze tests. DA neuron loss and microglial activation were assessed via immunohistochemical staining and western bolt analysis. The colon content was collected to extract bacterial DNA followed by real-time PCR analysis with 16S rRNA primers.

RESULTS

LPS plus ROT induced neurotoxicity, as evidenced by DA neuron loss in substantia nigra, impaired behavioral functions and increased microglial activation. HFD-original (containing 10% cinnabar and 10% realgar) rescued loss of DA neurons, improved behavioral dysfunction and attenuated microglial activation. Compared with HFD-original, HFD-reduced (3% cinnabar and 3% realgar) was also effective, but to be a less extent, while HFD-removed (without cinnabar and realgar) was ineffective. In analysis of gut microbiome, the increased Verrucomicrobiaceae and Lactobacteriaceae, and the decreased Enterobacteeriaceae by LPS plus ROT were ameliorated by HFD-original, and to be the less extent by HFD-reduced.

CONCLUSION

Cinnabar and realgar are active ingredients in HFD to exert beneficial effects in a neurodegenerative model and gut microbiota.

Safety of traditional medicine and natural product supplements in psychiatry

Traditional medicines in the form of health food and supplements are highly popular nowadays. They are often aggressively promoted with unsubstantiated health benefit claims. Patients suffering from chronic illness, such as psychiatric disorders may be attracted to these products and use them concurrently with their prescribed drugs. The potential danger of these health supplements and traditional medicines containing products have prompted repeated warnings by the US Food and Drug Administration in recent years. A new initiative by the Food and Drug Administration in 2019 was also implemented to strengthen the oversight of these supplements. The WHO global compendium will include traditional medicines in 2019, which has generated much debate about their safety. Many practising psychiatrists are not familiar with traditional medicines, and clinically useful information is also not easily available. In this review, we examine the nature and safety of commonly encountered traditional medicine in these health food products and supplements.

Chemical Compositions of Metals in Bhasmas and Tibetan Zuotai Are a Major Determinant of Their Therapeutic Effects and Toxicity

Minerals are alchemically processed as Bhasmas in Ayurvedic medicines or as Zuotai in Tibetan medicines. Ayurveda is a knowledge system of longevity and considers the mineral elixir made from “nature” capable of giving humans perpetual life. Herbo-metallic preparations have a long history in the treatment of various diseases in India, China, and around the world. Their disposition, pharmacology, efficacy, and safety require scientific evaluation. This review discusses the Bhasmas in Ayurvedic medicines and Zuotai in Tibetan medicines for their occurrence, bioaccessibility, therapeutic use, pharmacology, toxicity, and research perspectives. A literature search on Mineral, Bhasma, Ayurvedic medicine, Zuotai, Tibetan medicine, and Metals/metalloids from PubMed, Google and other sources was carried out, and the relevant papers on their traditional use, pharmacology, and toxicity were selected and analyzed. Minerals are processed to form Bhasma or Zuotai to alter their physiochemical properties distinguishing them from environmental metals. The metals found in Ayurveda are mainly from the intentional addition in the form of Bhasma or Zuotai. Bhasma and Zuotai are often used in combination with other herbals and/or animal-based products as mixtures. The advanced technologies are now utilized to characterize herbo-metallic preparations as Quality Assurance/Quality Control. The bioaccessibility, absorption, distribution, metabolism, and elimination of herbo-metallic preparations are different from environmental metals. The pharmacological basis of Bhasma in Ayurveda and Zuotai in Tibetan medicines and their interactions with drugs require scientific research. Although the toxic potentials of Bhasma and Zuotai differ from environmental metals, the metal poisoning case reports, especially lead (Pb), mercury (Hg), and arsenic (As) from inappropriate use of traditional medicines, are increasing, and pharmacovigilance is desired. In risk assessment, chemical forms of metals in Bhasma and Zuotai should be considered for their disposition, efficacy, and toxicity.

Geopharmaceuticals of Himalayan Sowa Rigpa medicine: Ethnopharmacological uses, mineral diversity, chemical identification and current utilization in Bhutan

ETHNOPHARMACOLOGICAL RELEVANCE

Geological materials, such as minerals, have a long history of usage as ingredients in multicompound formulations of Himalayan Sowa Rigpa medicine - as well as in its localized form of Bhutanese traditional medicine (BTM) - for treating various disorders for over thousand years. Yet, hardly any scientific research has been done on their ethnopharmacological efficacy and chemistry.

AIM OF THE STUDY

This study documents and correlates the rarely explored ethnopharmacological and chemical identification of various minerals and their ethnomedicinal uses in BTM formulations for the first time.

MATERIAL AND METHODS

A five stage cross-disciplinary process was conducted as follows: (1) a review of classical literature of Sowa Rigpa texts (Tibetan medical texts, pharmacopoeias and formularies) that are still in use today; (2) listing of mineral ingredients according to Sowa Rigpa names, followed by identification with common English and chemical names, as well as re-translating their ethnomedical uses; (3) cross-checking the chemical names and chemical composition of identified Sowa Rigpa minerals with various geological mineral databases and mineral handbooks; (4) authentication and standardization of Sowa Rigpa names through open forum discussion with diverse BTM practitioners; (5) further confirmation of the chemical names of identified minerals by consulting different experts and pharmacognosists.

RESULTS

Our current study lists 120 minerals as described in Sowa Rigpa medical textbooks most of which we were able to chemically identify, and of which 28 are currently used in BTM herbo-mineral formulations. Out of these 28 mineral ingredients, 5 originate from precious metal and stone, 10 stem from earth, mud and rocks, 8 are salts, and 5 concern 'essences' and exudates.

CONCLUSIONS

Our study identified 120 mineral ingredients described in Sowa Rigpa medical textbooks, out of which 28 are currently used. They are crucial in formulating 108 multicompound prescription medicines in BTM presently in use for treating more than 135 biomedically defined ailments.

Traditional Tibetan Medicine Induced High Methylmercury Exposure Level and Environmental Mercury Burden in Tibet, China

Highly elevated concentrations of total mercury (THg) and methylmercury (MeHg) were found in the municipal sewage in Tibet. Material flow analysis supports the hypothesis that these elevated concentrations are related to regular ingestion of Hg-containing Traditional Tibetan Medicine (TTM). In Tibet in 2015, a total of 3600 kg of THg was released from human body into the terrestrial environment as a result of TTM ingestion, amounting to 45% of the total THg release into the terrestrial environment in Tibet, hence substantially enhancing the environmental Hg burden. Regular ingestion of TTM leads to chronic exposure of Tibetans to inorganic Hg (IHg) and MeHg, which is 34 to 3000-fold and 0-12-fold higher than from any other known dietary sources, respectively. Application of a human physiology model demonstrated that ingestion of TTM can induce high blood IHg and MeHg levels in the human body. Moreover, 180 days would be required for the MeHg to be cleared out of the human body and return to the initial concentration i.e. prior to the ingestion of 1 TTM pill. Our analysis suggests that high Hg level contained in TTM could be harmful to human health and elevate the environmental Hg burden in Tibet.

Increases of Total Mercury and Methylmercury Releases from Municipal Sewage into Environment in China and Implications

As a globally transported pollutant, mercury (Hg) released from human activity and methylmercury (MeHg) in the food web are global concerns due to their increasing presence in the environment. In this study, we found that Hg released from municipal sewage into the environment in China is a substantial anthropogenic source based on mass sampling throughout China. In total, 160 Mg (140-190 Mg, from the 20th percentile to the 80th percentile) of Hg (THg) and 280 kg (240-330 kg) of MeHg were released from municipal sewage in China in 2015. The quantities of released THg and MeHg were the most concentrated in the coastal regions, especially in the East, North and South China regions. However, the per capita release of THg and MeHg was the highest in the Tibetan region, which is recognized as the cleanest region in China. THg released into aquatic environments was mitigated from 2001 to 2015 in China, but the amounts released into other sinks increased. This study provides the first picture of the release of Hg from municipal sewage into various sinks in China, and policy makers should pay more attention to the diversity and complexity of the sources and transport of Hg, which can lead to Hg accumulation in the food web and can threaten human health.

1H NMR-Based Metabolomics Study of the Toxicological Effects in Rats Induced by "Renqing Mangjue" Pill, a Traditional Tibetan Medicine

“RenqingMangjue” pill (RMP), as an effective prescription of Traditional Tibetan Medicine (TTM), has been widely used in treating digestive diseases and ulcerative colitis for over a thousand years. In certain classical Tibetan Medicine, heavy metal may add as an active ingredient, but it may cause contamination unintentionally in some cases. Therefore, the toxicity and adverse effects of TTM became to draw public attention. In this study, 48 male Wistar rats were orally administrated with different dosages of RMP once a day for 15 consecutive days, then half of the rats were euthanized on the 15th day and the remaining were euthanized on the 30th day. Plasma, kidney and liver samples were acquired to ¹H NMR metabolomics analysis. Histopathology and ICP-MS were applied to support the metabolomics findings. The metabolic signature of plasma from RMP-administrated rats exhibited increasing levels of glucose, betaine, and creatine, together with decreasing levels of lipids, 3-hydroxybutate, pyruvate, citrate, valine, leucine, isoleucine, glutamate, and glutamine. The metabolomics analysis results of liver showed that after RMP administration, the concentrations of valine, leucine, proline, tyrosine, and tryptophan elevated, while glucose, sarcosine and 3-hydroxybutyrate decreased. The levels of metabolites in kidney, such as, leucine, valine, isoleucine and tyrosine, were increased, while taurine, glutamate, and glutamine decreased. The study provides several potential biomarkers for the toxicity mechanism research of RMP and shows that RMP may cause injury in kidney and liver and disturbance of several pathways, such as energy metabolism, oxidative stress, glucose and amino acids metabolism.