Safety issues with herbal medicine

A multi-center cross-sectional study of Chinese Herbal Medicine-Drug adverse reactions using active surveillance in Singapore's Traditional Chinese Medicine clinics

BACKGROUND

This study aimed to investigate the rates and causality of patient-reported adverse events (AEs) associated with concomitant Chinese Herbal Medicine (CHM) and Western Medicine prescription drug (WMPD) consumption through active surveillance in Singapore's Traditional Chinese Medicine (TCM) clinics.

METHODS

A cross-sectional study was conducted at five TCM clinics across Singapore from 8th May till 8th July 2023. Patients were screened to determine rates of CHM and WMPD consumption, and then interviewed if an AE was reported. An expert committee assessed the AE reports to determine causality. Along with descriptive statistics, odds ratios were calculated to determine AE occurrence likelihoods for patients who consumed both CHM and WMPD compared to CHM consumption alone.

RESULTS

1028 patients were screened and 62.65% of them reported concurrent CHM-WMPD consumption. Patients who consumed CHM and WMPD were 3.65 times more likely to experience an AE as compared to CHM consumption alone. 18 AE reports were adjudicated, with most AEs deemed unlikely due to CHM consumption.

CONCLUSIONS

A large proportion of patients consumed CHM and WMPD concurrently, thus increasing their risk of experiencing AEs compared to those consuming CHM only. Active surveillance is applicable for detecting AEs, collecting data for causality assessment, and analysis.

In Vivo Genotoxicity Evaluation of a No-Pain Pharmacopuncture Extract Using the Micronucleus Test

Objectives

We aimed to evaluate the genotoxicity of a recently developed no-pain pharmacopuncture (NPP) targeting muscle relaxation and analgesia using the micronucleus test.

Methods

To evaluate the potential of NPP extracts to induce micronuclei in rat bone marrow cells, a micronucleus test was performed using male Sprague-Dawley rats. The test substance NPP was administered intramuscularly at concentrations of 0.25, 0.5, and 1 mL/animal. Saline was used as the negative control and cyclophosphamide as the positive control.

Results

No NPP treatment-related deaths or abnormal changes in general appearance were observed at any dose level during the experimental period. No statistically significant differences in body weight were observed in any of the NPP dose groups compared to the saline negative control group. NPP did not cause a significant increase in the incidence of micronucleated polychromatic erythrocytes (PCEs) and PCEs or in the ratio of PCE-to-total erythrocytes.

Conclusion

The NPP extract did not exhibit genotoxic in Sprague-Dawley rat bone marrow cells under the conditions of this study. Further toxicity studies of the NPP extract are required.

Evaluation of Anti-Candida albicans Activities of Herbal Preparations Sold at the Kumasi Central Market in the Ashanti Region of Ghana

Candida albicans (C. albicans) is predominantly the leading cause of candidiasis among women with urogenital candidiasis. Since most people in resource-limited countries depend on herbal medicine for their primary care needs, many herbal drugs are sold to manage various infectious diseases. This study, therefore, evaluated the anti-C. albicans activities of five selected herbal preparations indicated for treating candidiasis sold at the Kumasi Central Market in the Ashanti Region of Ghana. The market was divided into five clusters, and one herbal preparation was randomly selected from each cluster. Using the Kirby Bauer disc diffusion antimicrobial susceptibility test, the herbal preparations were tested against clinically isolated C. albicans. Fluconazole, a standard antifungal drug, was included in the evaluation as a positive control. The experiments were performed on three different days and each in triplicates. Among the five selected herbal preparations, only one was effective against C. albicans with a mean inhibition zone of 19.1 mm. This effective herbal drug was prepared from Centella asiatica sap, Turnera microphylla leaves, and Vitex agnus-castus leaves. The results suggest that not all the herbal preparations selected were effective against C. albicans. Hence, we recommend that the authorities continually check the effectiveness of the herbal preparations on the market.

Anti-inflammatory Properties of the Genus Symphytum L.: A Review

: The Symphytum genus has been mainly used in traditional medicine, containing its anti-inflammatory activity. Symphytum spp.’s active components, such as allantoin, polyphenols, flavonoids, and alkaloids, can act on several intentions in the signaling pathway, constrain pro-inflammatory enzymes, reducing the construction of inflammatory chemokine’s and cytokines, and decreasing oxidative stress, which afterward suppresses inflammation procedures. Preclinical and clinical trials have reported the prevailing anti-inflammatory effect of several Symphytum species. This review presents an overview of the anti-inflammatory activities of different products and bioactive constituents in this genus. The papers with the English language were gathered from 2000 to 2021. This review may provide a scientific base for establishing innovative and alternative techniques for isolating a single individual from this genus to attenuate inflammatory disorders. The Symphytum genus is waiting for researchers to develop safe and effective anti-inflammatory agents for additional investigation of other different mechanisms of action.

Unpredictable adverse effects of herbal products

Herbal products are being increasingly used all over the world for preventive and therapeutic purposes because of the belief of their safety. They have become an important part of health care system in many countries since they can easily be purchased in the health food stores or online. However, the lack of sufficient study on their efficacy and toxicity, inadequate controls of their availability, reduce their safety. Unlike conventional drugs, herbal products are not regulated for purity and potency. Herbal products contain substances which can induce or inhibit enzymes that take part in drug metabolism. Therefore the concurrent use of drugs with some medicinal plants can cause serious adverse effects and can also decrease the efficacy of the therapy. Particularly, drugs with narrow therapeutic index and plants which can affect drug metabolizing enzymes when used together, may lead to unpredictable adverse reactions. Impurities, contaminants and adulterants found in the herbal products, are the most common malpractises in herbal raw-material trade. In this review the unpredictable adverse effects of herbal products due to their possible interactions with drugs and also due to the adulteration and contamination with prohibited chemicals will be discussed in detail.

In search of an ideal drug for safer treatment of obesity: The false promise of pseudoephedrine

Obesity is a major public health problem worldwide. Only relatively few treatment options are, at present, available for the management of obese patients. Furthermore, treatment of obesity is affected by the widespread misuse of drugs and food supplements. Ephedra sinica is an old medicinal herb, commonly used in the treatment of respiratory tract diseases. Ephedra species contain several alkaloids, including pseudoephedrine, notably endowed with indirect sympathomimetic pharmacodynamic properties. The anorexigenic effect of pseudoephedrine is attributable primarily to the inhibition of neurons located in the hypothalamic paraventricular nucleus (PVN), mediating satiety stimuli. Pseudoephedrine influences lipolysis and thermogenesis through interaction with β3 adrenergic receptors and reduces fat accumulation through down-regulation of transcription factors related to lipogenesis. However, its use is associated with adverse events that involve to a large extent the cardiovascular and the central nervous system. Adverse events of pseudoephedrine also affect the eye, the intestine, and the skin, and, of relevance, sudden cardiovascular death related to dietary supplements containing Ephedra alkaloids has also been reported. In light of the limited availability of clinical data on pseudoephedrine in obesity, along with its significantly unbalanced risk/benefit profile, as well as of the psychophysical susceptibility of obese patients, it appears reasonable to preclude the prescription of pseudoephedrine in obese patients of any order and degree.

Towards Advances in Medicinal Plant Antimicrobial Activity: A Review Study on Challenges and Future Perspectives

The increasing incidence of drug- resistant pathogens raises an urgent need to identify and isolate new bioactive compounds from medicinal plants using standardized modern analytical procedures. Medicinal plant-derived compounds could provide novel straightforward approaches against pathogenic bacteria. This review explores the antimicrobial activity of plant-derived components, their possible mechanisms of action, as well as their chemical potential. The focus is put on the current challenges and future perspectives surrounding medicinal plants antimicrobial activity. There are some inherent challenges regarding medicinal plant extracts and their antimicrobial efficacy. Appropriate and optimized extraction methodology plant species dependent leads to upgraded and selective extracted compounds. Antimicrobial susceptibility tests for the determination of the antimicrobial activity of plant extracts may show variations in obtained results. Moreover, there are several difficulties and problems that need to be overcome for the development of new antimicrobials from plant extracts, while efforts have been made to enhance the antimicrobial activity of chemical compounds. Research on the mechanisms of action, interplay with other substances, and the pharmacokinetic and/or pharmacodynamic profile of the medicinal plant extracts should be given high priority to characterize them as potential antimicrobial agents.

Phenolic Bioactives as Antiplatelet Aggregation Factors: The Pivotal Ingredients in Maintaining Cardiovascular Health

Cardiovascular diseases (CVD) are one of the main causes of mortality in the world. The development of these diseases has a specific factor-alteration in blood platelet activation. It has been shown that phenolic compounds have antiplatelet aggregation abilities and a positive impact in the management of CVD, exerting prominent antioxidant, anti-inflammatory, antitumor, cardioprotective, antihyperglycemic, and antimicrobial effects. Thus, this review is intended to address the antiplatelet activity of phenolic compounds with special emphasis in preventing CVD, along with the mechanisms of action through which they are able to prevent and treat CVD. In vitro and in vivo studies have shown beneficial effects of phenolic compound-rich plant extracts and isolated compounds against CVD, despite that the scientific literature available on the antiplatelet aggregation ability of phenolic compounds in vivo is scarce. Thus, despite the current advances, further studies are needed to confirm the cardioprotective potential of phenolic compounds towards their use alone or in combination with conventional drugs for effective therapeutic interventions.

Prevalence of using herbs and natural products as a protective measure during the COVID-19 pandemic among the Saudi population: an online cross-sectional survey

Considering that no food or supplement has been authorised to prevent COVID-19, individuals continue to search for and consume specific herbs, foods and commercial supplements for this purpose. This study aimed to estimate the prevalence of using such alternatives, determine their usage reasons and evaluate their potential side effects. An online cross-sectional survey of 1,054 participants was conducted from 1 May to 31 July 2020 and focused on respondents’ chronic disease histories, socio-demographic characteristics and frequency and trends of using these products. Descriptive and univariate analyses were performed to determine prevalence and associations between various products used and respondents’ socio-demographic data. Relationships were tested using Pearson’s chi-square test or an exact probability test. The use of herbs and natural products merely because of the COVID-19 pandemic was significantly increased (p=0.036) among Saudi populations. The products included honey (84%), black seeds (63%), lemon (54%) and ginger (41%). Furthermore, the distribution of using herbs and natural products was not linked with any socio-demographic factors other than age. Among the population, 69.30% were aware that herbs can improve their immunity but will not protect them from COVID-19. Finally, the current study highlights the undesirable side effects associated with using herbs and natural products in patients with chronic disease and recommends future research to assess the undesirable effects of using herbs in patients with diabetes with a control group.

The role of pharmacists in complementary and alternative medicine in Lebanon: users' perspectives

Background

Customers’ expectations and satisfaction are critical to ensure a more effective role of the community pharmacists in promoting the safe use of Complementary and Alternative Medicine (CAM). The aim of this study is to examine the perceptions and practices of customers buying their CAM products from pharmacies and explore their satisfaction with CAM-related services offered by the community pharmacists in Lebanon.

Methods

A national cross-sectional study was conducted among users of CAM (age > =18 years) who obtained their CAM from community pharmacies in Lebanon (n = 832). Within the proximity of the pharmacy, subjects were invited to complete a multi-component questionnaire. The latter consisted of four sections related to CAM: general beliefs, perception of pharmacists’ role, practices, satisfaction with services offered by the pharmacists. In addition, the questionnaire included questions about sociodemographic characteristics of participants.

Results

The majority of participants agreed to an active role of the pharmacists’ in guiding CAM use, however over half of the participants (61.3%) did not agree that the pharmacist is more knowledgeable in this field than other healthcare providers. As for practices, one in two surveyed customers (47%) did not always give feedback to their pharmacists about the outcomes after using CAM, 20% did not often ask the pharmacists about the safe and effective mode of use of the products and 28.1% did not discuss their medical history. For services offered by the pharmacist, the majority of participants reported receiving good education about the CAM product (87.1%), its side effects (87.1%) and mode of use (93.4%), while significant proportions of participants reported that pharmacists were not asking questions about their medical history before dispensing CAM products (22%) nor were they providing information on CAM-drug interactions (30%).

Conclusions

The results of this study highlighted important gaps between the perceptions of customers and the services they received from the pharmacists about CAM use. These findings could be used by concerned stakeholders, including public health authorities and educational bodies, to develop evidence-based interventions aimed at promoting the role of pharmacists in ensuring a safe and effective CAM use Lebanon.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03256-8.

Evaluation of the in vitro and in vivo genotoxicity of a Dioscorea Rhizome water extract

Dioscorea Rhizome is commonly used in traditional herbal medicines for the treatment of diabetes, hyperthyroidism, liver damage, neuropathy, and asthma. Here, we investigated the genotoxicity potential of D. Rhizome water extract (DRWE) using three standard battery systems in accordance with the test guidelines of the Organisation for Economic Cooperation and Development and Ministry of Food and Drug Safety as well as the principles of Good Laboratory Practice. A bacterial reverse mutation test (Ames test) was performed using the direct plate incorporation method in the presence or absence of a metabolic activation system (S9 mixture). The tester strains used included four histidine auxotrophic strains of Salmonella typhimurium, TA100, TA1535, TA98, and TA1537, along with a tryptophan auxotrophic strain of Escherichia coli, WP2 uvrA. An in vitro chromosome aberration test was performed using CHL/IU cells originally derived from the lung of a female Chinese hamster in the presence or absence of the S9 mixture. An in vivo mouse bone marrow micronucleus test was performed using male ICR mice. The micronucleus was confirmed after observation of the micro-nucleated polychromatic. The Ames test showed that DRWE did not induce gene mutations at any dose level in any of the tested strains. Additionally, DRWE did not result in any chromosomal aberrations specified in the in vitro chromosomal aberration and in vivo micronucleus tests. These results showed that DRWE exhibited neither mutagenic nor clastogenic potential in either the in vitro or in vivo test systems.

Regulatory landscape of dietary supplements and herbal medicines from a global perspective

The number of Individuals that use dietary supplements and herbal medicine products are continuous to increase in many countries. The context of usage of a dietary supplement varies widely from country-to-country; in some countries supplement use is just limited to general health and well-being while others permit use for medicinal purposes. To date, there is little consensus from country to country on the scope, requirements, definition, or even the terminology in which dietary supplement and herbal medicines categories could be classified. Transparent science-based quality standards for the ingredients across these regulatory frameworks/definitions becomes even more important given the international supply chain. Meanwhile, there has been a rapid advancement in emerging technologies and data science applied to the field. This review was conceived at the Global Summit on Regulatory Sciences that took place in Beijing on September 2018 (GSRS2018) which is organized by Global Coalition for Regulatory Science Research (GCRSR) that consists of the global regulatory agencies from over ten countries including the European Union. This review summarizes a significant portion of discussions relating to a longitudinal comparison of the status for dietary supplements and herbal medicines among the different national jurisdictions and to the extent of how new tools and methodologies can improve the regulatory application.

Genotoxic Assessment of the Dry Decoction of Myracrodruon urundeuva Allemão (Anacardiaceae) Leaves in Somatic Cells of Drosophila melanogaster by the Comet and SMART Assays

Medicinal plants are worldwide used as an efficient treatment of many diseases. Myracrodruon urundeuva Allemão (Anacardiaceae) is widely used Brazilian folk medicine to treat inflammations and infections of the female genital tract, conditions of the stomach and throat, and to heal wounds on the skin and mucous membranes. Several pharmacological properties of extracts and compounds isolated from M. urundeuva are found in the literature, corroborating its uses as antiulcer and gastroprotective, anti-inflammatory and analgesic, as well as antimicrobial. Despite these many uses in traditional herbal medicine, there are few reports of its toxic-genetic effect. This work aimed to investigate the genotoxic and mutagenic potential in vivo of the dry decoction of M. urundeuva leaves on somatic cells of Drosophila melanogaster, through the Comet assay and somatic mutation and recombination test (SMART). Six concentrations (0.5, 1.0, 2.0, 4.0, 8.0, and 16.0 mg/mL) were studied after feeding individuals for 24 hr in culture medium hydrated with extracts of M. urundeuva. In the Comet assay, all concentrations showed a genotoxic effect significantly higher than the negative control group, treated with distilled water. The two highest concentrations were also superior to the positive control group, treated with cyclophosphamide (1 mg/mL). In the SMART, there was a mutagenic effect at all concentrations tested, with a clear dose-dependent relationship. Both recombination and mutation account for these mutagenic effects. The set of results indicate that the dry decoction of M. urundeuva leaves is genotoxic and mutagenic for D. melanogaster under the experimental conditions of this study. Environ. Mol. Mutagen. 61:329-337, 2020. © 2019 Wiley Periodicals, Inc.

Acute and subacute toxicity of Ammi visnaga on rats

Ammi visnaga (Av) is a source of khellin where a tea made from the fruit of this plant was used as herbal medicine for kidney stones in Egypt. In the present research, the acute and subacute toxicity studies with oral intake of 150, 300 and 600 mg/kg of Av seed ethanolic extract in rats were done. In acute toxicity test, 4 groups of rats (n = 6/group: 3 males and 3 females) were chosen and the first control group received tap water, while the other three groups received Av seed ethanolic extract dissolved in tap water at doses of 150, 300, and 600 mg/kg, and general behavior, adverse effects, and mortality were recorded for up to 14 days. In subacute toxicity study, 72 rats (36 males and 36 females) were divided into 4 major groups; group I received tap water (control group), while animals in groups II, III, and IV (test groups) received oral intake of Av seed ethanolic extract dissolved in tap water at doses of 150, 300 and 600 mg/ kg bwt, respectively. Each of this major group was subdivided consequently into 3 subgroups (n = 6/group: 3 males and 3 females) where brain tissue, blood sample, body and organs weights were recorded at the beginning and then after two and four weeks of the experiment for the determination of hematological, biochemical and histopathological changes in tissues (liver, kidney, brain, spleen, heart, testis and ovary). With regard to acute toxicity, Av seed ethanolic extract did not induce any toxic effects or death or any organ toxicity. In subacute toxicity study; oral intake with Av seed ethanolic extract did not reveal any change in body and organs weights, hematological parameters, serum glucose and cholesterol, brain neurotransmitters, liver and kidney functions, male and female hormones. In conclusion, Av seed ethanolic extract is nontoxic to liver, kidney, brain, spleen, heart, testis and ovary.

Occurrence of pathogenic and endophytic fungi and their influence on quality of medicinal plants applied in management of neurological diseases and mental disorders

Due to increasing demand of medicinal plants (MPs), quality and safety more attention to the plant health should be paid. Among herb pathogens, especially fungi cause serious diseases in these plants decreasing yield and quality of herbal raw material. Some species, i.e. Fusarium sp., Alternaria sp., Penicillium sp. are known as mycotoxin producers. Paradoxically, self-treatment with herbal raw material can expose the patient to mycotoxin activity. In tissues of some MPs species, asymptomatically endophytic fungi residue. It is known that they are able to influence a biosynthesis of secondary metabolites in their host plant or produce biologically active compounds. Until recently these microorganisms have been neglected as a component of MPs, the reason why there have unexplored bioactivity and biodiversity. The paper presents an overview of herbal plants that are used in the treatment of nervous system diseases. Pathogenic fungi that infect these plants are described. It focused mainly on species producing harmful mycotoxins. The publication presents a list of these mycotoxins and a brief description of their effects on human health. The second part of this article provides information on the occurrence of endophytic fungi in herbal plants and their effects on human health. Coexistence of fungi and medicinal plants is not fully understood but can be crucial to ensure health and safety of patients with neurological diseases and mental disorders.

Survey of Preoperative Patients' Use of Herbal Products and Other Selected Dietary Supplements

Purpose

This study was designed to determine the prevalence of herbal and selected dietary product use among preoperative patients.

Methods

A questionnaire listing 26 herbal/dietary supplements was given to 979 preoperative patients in the anesthesia assessment unit. Subjects were asked to indicate the amounts and durations of products taken. Demographic data and proposed surgical procedures were noted.

Results

One hundred and seventy surgical patients (17.4%) reported taking herbal or dietary supplements. Neurosurgical, gynecological, and orthopedic surgical patients reported the highest incidences of use at 21%, 21%, and 20%, respectively. Of patients taking these agents, 34.7% took only one product, 23.5% took two products, 11.2% took three products, and 10.6% took four or more products. The most commonly used herbals, in descending order of frequency, were ginkgo, garlic, ginseng, St. John's wort, and echinacea. Glucosamine, chondroitin, and chromium were the surveyed dietary supplements most widely used. More than 40 herbs were taken occasionally. The median age of users and nonusers was 62 years. Orthopedic patients took glucosamine and chondroitin most commonly, ophthalmic patients took ginkgo most commonly, and urology patients took saw palmetto most commonly.

Conclusion

The adverse effects of herbals and dietary products during surgical procedures and the interactions between these products and anesthetic drugs warrant further research. The use of herbal or dietary supplements may indicate alteration of patients' perioperative regimens.

Loop-Mediated Isothermal Amplification (LAMP): Emergence As an Alternative Technology for Herbal Medicine Identification

Correct identification of medicinal plant ingredients is essential for their safe use and for the regulation of herbal drug supply chain. Loop-mediated isothermal amplification (LAMP) is a recently developed approach to identify herbal medicine species. This novel molecular biology technique enables timely and accurate testing, especially in settings where infrastructures to support polymerase chain reaction facilities are lacking. Studies that used this method have altered our view on the extent and complexity of herbal medicine identification. In this review, we give an introduction into LAMP analysis, covers the basic principles and important aspects in the development of LAMP analysis method. Then we presented a critical review of the application of LAMP-based methods in detecting and identifying raw medicinal plant materials and their processed products. We also provide a practical standard operating procedure (SOP) for the utilization of the LAMP protocol in herbal authentication, and consider the prospects of LAMP technology in the future developments of herbal medicine identification and the challenges associated with its application.

Development of standard operating procedure and standardization of Habb-e-Banafsha Qawi-A Unani polyherbal formulation

Introduction:

Herbals drugs became a boon for mankind since ancient times and still are used worldwide for the treatment of various human ailments. The safety of alternative medicinal preparations has been questioned due to reports of unwanted side effects. To maintain the quality and efficacy of these drugs, it is essential to standardize them in order to avoid the use of substandard or adulterated medicines in the market. Unani system of medicine mainly focuses on the treatment by natural drugs. Habb-e-Banafsha Qawi is useful in a cough, catarrah, and coryza.

Materials and Methods:

Physiochemical constants of Habb-e-Banafsha Qawi were determined through organoleptic characters, macro- and micro-scopic characters, ash value, solubility, pH values. Chromatographic fingerprints were developed using thin layer chromatography method. Aflatoxin (AF) contamination, heavy metal, and pesticide residues were also evaluated by standard methods.

Objectives:

In the present study, an attempt has been made to develop standard operating procedure and physiochemical parameters to monitor the quality of a Unani poly-herbal formulation, Habb-e-Banafsha Qawi.

Results:

The tablets tasted sweetish bitter with a pleasant odor, water soluble and acidic in nature. R_f values were almost same in all the extracts. No AF, heavy metal, and pesticide residues were observed.

Conclusions:

It may be concluded that the values and chromatographic fingerprints obtained can be used for quality evaluation and to set new pharmacopoeial standards for the preparation of Habb-e-Banafsha Qawi.

Commonly Used Dietary Supplements on Coagulation Function during Surgery

BACKGROUND

Patients who undergo surgery appear to use dietary supplements significantly more frequently than the general population. Because they contain pharmacologically active compounds, dietary supplements may affect coagulation and platelet function during the perioperative period through direct effects, pharmacodynamic interactions, and pharmacokinetic interactions. However, in this regard, limited studies have been conducted that address the pharmacological interactions of dietary supplements. To avoid possible bleeding risks during surgery, information of potential complications of dietary supplements during perioperative management is important for physicians.

METHODS

Through a systematic database search of all available years, articles were identified in this review if they included dietary supplements and coagulation/platelet function, while special attention was paid to studies published after 1990.

RESULTS

Safety concerns are reported in commercially available dietary supplements. Effects of the most commonly used natural products on blood coagulation and platelet function are systematically reviewed, including 11 herbal medicines (echinacea, ephedra, garlic, ginger, ginkgo, ginseng, green tea, kava, saw palmetto, St John's wort, and valerian) and 4 other dietary supplements (coenzyme Q₁₀, glucosamine and chondroitin sulfate, fish oil, and vitamins). Bleeding risks of garlic, ginkgo, ginseng, green tea, saw palmetto, St John's wort, and fish oil are reported. Cardiovascular instability was observed with ephedra, ginseng, and kava. Pharmacodynamic and pharmacokinetic interactions between dietary supplements and drugs used in the perioperative period are discussed.

CONCLUSIONS

To prevent potential problems associated with the use of dietary supplements, physicians should be familiar with the perioperative effects of commonly used dietary supplements. Since the effects of dietary supplements on coagulation and platelet function are difficult to predict, it is prudent to advise their discontinuation before surgery.

Popularity and customer preferences for over-the-counter Chinese medicines perceived by community pharmacists in Shanghai and Guangzhou: a questionnaire survey study

BACKGROUND

This study interviewed community pharmacists in Shanghai and Guangzhou for their perception of the popular categories of over-the-counter (OTC) Chinese medicines and the factors affecting customer preferences for OTC Chinese medicines.

METHODS

A cross-sectional survey was carried out in six main administrative districts in Guangzhou and eight main administrative districts in Shanghai, China. Descriptive statistical analysis was conducted in this study.

RESULTS

OTC Chinese medicines contributed 21-50% among all the pharmaceutical sales by the community pharmacies. The prevalent categories of OTC Chinese medicines were common cold medicines, respiratory system medicines, digestive system agents, gynecological medicines, health tonic medicines, and qing re (heat-clearing) and qu du (detoxifying) medicines. Customers were more concerned about medical factors of OTC Chinese medicines than business factors. Among the medical factors, the most important was drug safety, followed by efficacy, contraindications, indications, and side effects. Among the business factors, the most important were brand and price.

CONCLUSIONS

This study identified the top sales categories of OTC Chinese medicines in Shanghai and Guangzhou and the important factors such as drug safety, efficacy, period of validity, contraindications, and indications that are affecting the customer preferences for OTC Chinese medicines.

Safety Evaluation of Artocarpus altilis as Pharmaceutical Agent in Wistar Rats

This study was designed to elucidate the acute toxicity of Artocarpus altilis leaf and bark extracts. In acute toxicity study, no mortality or any toxic reaction was recorded in any group after 14 days of administering the extracts (2000 mg Kg⁻¹ BW). The extracts (ALA, ABA, ALM, and ABM) did not cause any behavioural or physical changes in experimental rats. There was no significant (P ≤ 0.05) difference in the biochemical parameters analysed between the groups. Slight elevation in activities of AST and ALT in extract treated groups was observed, but this did not exert any deleterious effect on the normal metabolism which was supported by the histopathology of liver. Histopathological studies showed no remarkable changes after 14 days of oral administration of ALA, ABA, ALM, and ABM extracts. The study contributes to establishing the nontoxic quality parameters of Artocarpus altilis leaf and bark parts and the results suggest the safety of the extracts in therapeutic uses.

The growing use of herbal medicines: issues relating to adverse reactions and challenges in monitoring safety

The use of herbal medicinal products and supplements has increased tremendously over the past three decades with not less than 80% of people worldwide relying on them for some part of primary healthcare. Although therapies involving these agents have shown promising potential with the efficacy of a good number of herbal products clearly established, many of them remain untested and their use are either poorly monitored or not even monitored at all. The consequence of this is an inadequate knowledge of their mode of action, potential adverse reactions, contraindications, and interactions with existing orthodox pharmaceuticals and functional foods to promote both safe and rational use of these agents. Since safety continues to be a major issue with the use of herbal remedies, it becomes imperative, therefore, that relevant regulatory authorities put in place appropriate measures to protect public health by ensuring that all herbal medicines are safe and of suitable quality. This review discusses toxicity-related issues and major safety concerns arising from the use of herbal medicinal products and also highlights some important challenges associated with effective monitoring of their safety.

Herbal products in pregnancy: experimental studies and clinical reports

The aim of this work is to provide an update from an overview of the literature of the most frequently consumed herbal remedies during pregnancy, both alone and concomitantly with prescribed medications and particularly on their side effects to the mother and fetus. We have also analyzed some of the adverse interactions that may occur due to concomitant use of herbal and pharmaceutical products during pregnancy. Herbal remedies are not evaluated according to the same standards as pharmaceuticals, and in the USA some of it are not licensed but sold as food supplements. There is a lack of basic knowledge on the part of both clinicians and patients as to the indications for use and safety of herbal medicines used in pregnancy and lactation. If 'traditional use' is the only available information, the pregnant woman should be made aware of this to enable her to make an informed decision concerning potential use.

Alternative medicine and anesthesia: Implications and considerations in daily practice

Nowadays, herbal medicines are widely used by most of the people, including the pre-surgical population. These medicines may pose numerous challenges during perioperative care. The objective of the current literature review is to dwell upon the impact of the use of herbal medicines during the perioperative period, and to review the strategies for managing their perioperative use. The data was generated from various articles of different journals, text books, web source, including, Entrez Pubmed, Medscape, WebMD, and so on. Selected only those herbal medicines for which information on, safety, usage, and precautions during the perioperative period was available. Thereafter, the information about safety, pharmacokinetics, and pharmacodynamics from selected literature was gathered and analyzed. The whole review focused on the fact that these commonly used alternative medicines could sometimes pose as a concern during the perioperative period, in various ways. These complications could be due to their direct action, pharmacodynamic effect, or pharmacokinetic effect. In view of the serious impacts of herbal medicine usage in perioperative care, the anesthesiologist should take a detailed history, especially stressing on the use of herbal medicine during the preoperative anesthetic assessment. The anesthesiologist should also be aware of the potential perioperative effects of those drugs. Accordingly, steps should to be taken to prevent, recognize, and treat the complications that may arise due to their use or discontinuation.

Euforia-induced acute hepatitis in a patient with scleroderma

Euforia, a supplement containing a variety of natural ingredients, is widely used as an antioxidant and anti-inflammatory formula. It is not approved by the US Food and Drug Administration and its side effects are unknown. We report a 45-year-old woman with limited systemic sclerosis who presented with jaundice and marked elevation of serum transaminases. One month before, she started taking Euforia juice. A liver biopsy disclosed submassive hepatocellular necrosis with histopathological changes consistent with toxic hepatitis. The patient's symptoms resolved with cessation of Euforia. Six months later, she persisted with abnormal liver function tests, but these resolved 18 months after discontinuation of Euforia. The mechanism by which Euforia causes liver injury is unknown. Some ingredients contained in this supplement (green tea, Aloe vera, noni and goji) are linked to hepatic injury. To our knowledge, this is the first report of hepatotoxicity associated with Euforia.

An overview of the evidence and mechanisms of herb-drug interactions

Despite the lack of sufficient information on the safety of herbal products, their use as alternative and/or complementary medicine is globally popular. There is also an increasing interest in medicinal herbs as precursor for pharmacological actives. Of serious concern is the concurrent consumption of herbal products and conventional drugs. Herb-drug interaction (HDI) is the single most important clinical consequence of this practice. Using a structured assessment procedure, the evidence of HDI presents with varying degree of clinical significance. While the potential for HDI for a number of herbal products is inferred from non-human studies, certain HDIs are well established through human studies and documented case reports. Various mechanisms of pharmacokinetic HDI have been identified and include the alteration in the gastrointestinal functions with consequent effects on drug absorption; induction and inhibition of metabolic enzymes and transport proteins; and alteration of renal excretion of drugs and their metabolites. Due to the intrinsic pharmacologic properties of phytochemicals, pharmacodynamic HDIs are also known to occur. The effects could be synergistic, additive, and/or antagonistic. Poor reporting on the part of patients and the inability to promptly identify HDI by health providers are identified as major factors limiting the extensive compilation of clinically relevant HDIs. A general overview and the significance of pharmacokinetic and pharmacodynamic HDI are provided, detailing basic mechanism, and nature of evidence available. An increased level of awareness of HDI is necessary among health professionals and drug discovery scientists. With the increasing number of plant-sourced pharmacological actives, the potential for HDI should always be assessed in the non-clinical safety assessment phase of drug development process. More clinically relevant research is also required in this area as current information on HDI is insufficient for clinical applications.

Relaxation drinks and their use in adolescents

OBJECTIVES

A new class of beverages called relaxation drinks advertises calming effects and an easy way to wind down when life gets stressful. This article examines these drinks in the context of their use in adolescents.

METHODS

A review of the literature relevant to relaxation drinks and their functional ingredients was conducted.

RESULTS

The beverages contain ingredients such as melatonin, valerian, kava, tryptophan, and other products traditionally thought to play a role in sleep, sedation, or neurocognitive function. Studies of the efficacy and safety of these supplements are limited and many have significant methodological limitations. Despite appropriate warnings placed on the labels of relaxation drinks, marketing is cleverly designed to appeal to young consumers and often evokes the experiences produced by alcohol and drug use.

CONCLUSION

Although moderate consumption of these beverages by healthy individuals is likely safe, an objective reduction in stress is improbable and associated adverse effects are possible.

Profiling the indole alkaloids in yohimbe bark with ultra-performance liquid chromatography coupled with ion mobility quadrupole time-of-flight mass spectrometry

An ultra-performance liquid chromatography/ion mobility quadrupole time-of-flight mass spectrometry (UPLC/IM-QTOF-MS) method was developed for profiling the indole alkaloids in yohimbe bark. Many indole alkaloids with the yohimbine or ajmalicine core structure, plus methylated, oxidized and reduced species, were characterized. Common fragments and mass differences are described. It was shown that the use of IMS could provide another molecular descriptor, i.e. molecular shape by rotationally averaged collision cross-section; this is of great value for identification of constituents when reference materials are usually not available. Using the combination of high resolution (~40000) accurate mass measurement with time-aligned parallel (TAP) fragmentation, MS(E) (where E represents collision energy), ion mobility mass spectrometry (IMS) and UPLC chromatography, a total 55 indole alkaloids were characterized and a few new indole alkaloids are reported for the first time.

Systematic review of herbals as potential anti-inflammatory agents: Recent advances, current clinical status and future perspectives

Many synthetic drugs reported to be used for the treatment of inflammatory disorders are of least interest now a days due to their potential side effects and serious adverse effects and as they are found to be highly unsafe for human assistance. Since the last few decades, herbal drugs have regained their popularity in treatment against several human ailments. Herbals containing anti-inflammatory activity (AIA) are topics of immense interest due to the absence of several problems in them, which are associated with synthetic preparations. The primary objective of this review is to provide a deep overview of the recently explored anti-inflammatory agents belonging to various classes of phytoconstituents like alkaloids, glycosides, terpenoids, steroids, polyphenolic compounds, and also the compounds isolated from plants of marine origin, algae and fungi. Also, it enlists a distended view on potential interactions between herbals and synthetic preparations, related adverse effects and clinical trials done on herbals for exploring their AIA. The basic aim of this review is to give updated knowledge regarding plants which will be valuable for the scientists working in the field of anti-inflammatory natural chemistry.

Detection and characterization of synthetic steroidal and non-steroidal anti-inflammatory drugs in Indian ayurvedic/herbal products using LC-MS/TOF

It is claimed that ayurvedic/herbal healthcare products (AHPs) are safe because of their natural origin. However, several reports exist of adulteration of AHPs with synthetic drugs. In this study, a generalized strategy was developed using LC-MS/TOF for the detection and verification of steroidal and anti-inflammatory drugs in 58 AHPs collected from various parts of India. The strategy involved recording of mass spectral information for standard drugs-including ionization mode (ESI/APCI - ve or + ve), mass spectrum, accurate mass, identification of qualifier fragments (two), extracted ion chromatograms (EICs), isotopic pattern and determination of UV max (nm)-through UV-PDA studies. Adulteration was then detected in AHPs primarily through comparison of EICs at accurate m/z for molecular ion peaks and R(T) matching with the standard. It was confirmed by spiking with the standards, and matching mass spectrum, accurate mass, R(T) of qualifier fragments, isotopic pattern and UV spectrum of the standards with the adulterant peaks in AHPs. Dexamethasone and diclofenac were detected as adulterants in ten AHPs whereas one AHP tested positive for piroxicam and another for dexamethasone. All the adulterated products were sold by the healthcare practitioners, while no product marketed by manufacturers or chemist shops had this problem. The study showed that LC-MS/TOF-based screening could be used as a rapid approach to monitor adulteration of steroids and anti-inflammatory drugs in AHPs.

A possible case of saw palmetto-induced pancreatitis

A 65-year-old male with a history of diabetes, hypertension, hyperlipidemia, gout, Barrett esophagitis, and chronic gastritis developed acute pancreatitis after taking one week of the herbal medicine, saw palmetto, for symptoms related to benign prostatic hyperplasia (BPH). Ultrasound and computed tomography ruled out cholelithiasis and obstruction, triglycerides were normal, and he had no recent infection or trauma. He had a history of occasional alcohol consumption, though there was no recent increased intake. The most likely cause of pancreatitis in this case was saw palmetto. Saw palmetto (Serenoa repens) is an herbal medication used primarily in the treatment of symptoms related to BPH. It has a high content of fatty acids and phytosterols which are thought to exert their effects by inhibiting the enzyme 5-alpha-reductase, thereby preventing the conversion of testosterone into dihydrotestosterone (DHT). It has been postulated that saw palmetto directly stimulates estrogenic receptors and inhibits progesterone receptors in the prostate tissue. A previous report implicated the estrogen/antiandrogen properties of saw palmetto as inducing hepatotoxicity in a patient. Additionally, it has also been postulated that stimulation of the estrogenic receptors may lead to increased triglyceride levels or induction of a hypercoagulable state that leads to pancreatic necrosis. Finally, inhibition of cyclooxygenase, a property of saw palmetto, may be linked to acute pancreatitis. Acute pancreatitis, a serious and sometimes fatal disorder may occur secondary to medications. Although the mechanism is not fully known, this is the second case of acute pancreatitis that has been documented secondary to the herbal medication saw palmetto. It is important for clinicians to obtain detailed medication histories, including over-the-counter and herbal medications, in order to prevent further complications from occurring.

The use of complementary and alternative medicine by patients attending a general otolaryngology clinic: can we afford to ignore it?

BACKGROUND

There is growing interest in use of complementary and alternative medicine (CAM) among the general population. Little information is available, however, on CAM use in adults attending an otolaryngology outpatient clinic in the UK.

OBJECTIVE

The purpose of this article is to study the prevalence and pattern of CAM use among adult patients attending the ear, nose, and throat (ENT) clinic in a UK teaching hospital.

STUDY DESIGN

A cross-sectional study was used.

SUBJECTS AND METHODS

All patients on their primary visit to an ENT clinic were asked to complete an anonymous questionnaire for a 14-week period from October 2005 to January 2006.

RESULTS

Based on 1366 completed questionnaires, 53% (728/1366) were female and 47% (638/1366) were male. Twenty-nine percent (395/1366) were older than 60 years, and 56% (763/1366) were married. Twenty percent (275/1366) had a university education. Sixty-one percent (833/1366) had used CAM, almost 36% in the preceding 12 months. The popular remedies were cod liver oil (368/833), garlic (197/833), cranberry (181/833), aloe vera (176/833), primrose oil (174/833), and Echinacea (163/833). Nonherbal therapies included massage (230/833), acupuncture (186/833), aromatherapy (135/833), chiropractic (121/833), reflexology (119/833), and homeopathy (110/833). Seventeen percent (143/833) used CAM for their current illness. Only 8% (64/833) found CAM ineffective; yet, 57% (473/833) would recommend CAM to others. Fifty-one percent (421/833) failed to inform their primary physician of their CAM use.

CONCLUSION

Despite concerns over CAM efficacy, safety, and cost effectiveness, use of CAM is popular among patients attending an ENT clinic. Their use is not generally related to their presenting illness. Otolaryngologists should be aware of current trends in CAM use when managing patients, including possible interactions with other medication.

[Knowledge of perioperative risk associated with use of medicinal plants]

OBJECTIVES

To assess physicians' knowledge of perioperative risk for patients who consume medicinal plants. To review interactions between drugs and the main medicinal plants with a view to justifying a plan for preoperative intervention.

MATERIAL AND METHODS

Surgeons and anesthesiologists were sent an e-mail survey with questions on knowledge of and attitudes toward surgical patients' consumption of medicinal plants. At the same time, we performed a literature search on the species of plants that can interact with anesthetic and surgical processes. The species included were Allium sativum, Ephedra sinica, Echinacea purpurea, Ginkgo biloba, Panax ginseng, Hypericum perforatum, Piper methysticum, Glycyrrhiza glabra and Valeriana officinalis. The focus of the search was on indications for the use of these plants and their interactions with drugs.

RESULTS

The questionnaire was sent to 131 physicians. The response rate was 80.5%. Twenty-two physicians had trained in Spanish hospitals and 3 in hospitals abroad. Medicinal plants were believed to be effective by 55%, but 78% did not ask patients about their use. Only 3% knew the interactions of some of the plants mentioned in the survey and only 7% knew that the use of some should be suspended before surgery.

CONCLUSIONS

Medicinal plants are currently being used in our culture. In spite of appropriate warnings from such scientific bodies as the American Society of Anesthesiologists on timing the withdrawal of medicinal plants before surgery, our results indicate that the advice is not followed. We also found that physicians lacked knowledge of the indications for using these plants and their interactions, a situation which is alarming.

Complementary and alternative medicine use by otolaryngology patients: a paradigm for practitioners in all surgical specialties

There is growing interest in complementary and alternative medicine (CAM) amongst the general population. Little information is available on CAM use in otolaryngology patients in the UK. Despite concerns over safety, efficacy and cost-effectiveness, CAM use is common amongst ENT patients. Patients perceive these medications as possible boosters to their immune system. It is becoming increasingly important that health care providers in all specialties ask their patients about CAM use and are aware of the implications it carries. The objective is to study the prevalence and pattern of CAM use among adult and paediatric ENT patients in a UK teaching hospital. A cross-sectional study was done by sending anonymous questionnaire to all outpatient and elective inpatients over a 3-month period. Response rate was 73% (1,789/2,440). Prominent demographics: female, married, over-50 s. Sixty percent had used CAM, 35% in last year. Most common herbs: cod liver oil (n = 481), garlic (n = 255), cranberry (n = 224); non-herbal: massage (n = 287), acupuncture (n = 233), aromatherapy (n = 170). Most commonly cited reasons for using CAM: general health, enhanced immunity and prevention/treatment of common illnesses like the common cold, asthma and bodily aches and pains.

Roles and responsibilities of pharmacists with respect to natural health products: key informant interviews

BACKGROUND

Although many pharmacies sell natural health products (NHPs), there is no clear definition as to the roles and responsibilities (if any) of pharmacists with respect to these products.

OBJECTIVE

The purpose of this study was to explore pharmacy and stakeholder leaders' perceptions of pharmacists' professional NHP roles and responsibilities.

METHODS

Semi-structured key informant interviews were conducted with pharmacy leaders (n=17) and stakeholder (n=18) leaders representing consumers, complementary and alternative medicine practitioners, conventional health care practitioners, and industry across Canada.

RESULTS

All participants believed a main NHP responsibility for pharmacists was in safety monitoring, although a one challenge identified in the interviews was pharmacists' general lack of NHP knowledge; however, stakeholder leaders did not expect pharmacists to be experts, but should have a basic level of knowledge about NHPs.

CONCLUSION

Participants described pharmacists' professional roles and responsibilities for NHPs as similar to those for over-the-counter drugs; more awareness of existing NHP-related pharmacy policies is needed, and pharmacy owners/managers should provide additional training to ensure front-line pharmacists have appropriate knowledge of NHPs sold in the pharmacy.

Conjugated linoleic acid-induced toxic hepatitis: first case report

A 46-year-old female patient was referred to our department with presenting symptoms of asthenia, jaundice, and pruritus. There was no medical history or clinical evidence of viral hepatitis, autoimmune hepatitis, hemochromatosis, or Wilson's disease. The patient revealed that 14 days prior to admission she had begun self-medicating with conjugated linoleic acid (CLA) to reduce body fat, leading to the suspicion of CLA hepatotoxicity, which was subsequently confirmed by a liver biopsy. After the patient ceased to ingest CLA, liver enzymes levels normalized. To the best of our knowledge, this is the first report of hepatotoxicity due to CLA ingestion.

Prevalence of use and the risk of adverse effects associated with complementary and alternative medicine in a cohort of patients receiving warfarin

BACKGROUND

The use of complementary and alternative medicine (CAM), including orally administered herbals, botanicals, vitamins, and supplements, may pose a risk to patients on warfarin therapy.

OBJECTIVE

To estimate the prevalence of CAM use among patients taking warfarin and evaluate the impact of CAM exposure on the risk of warfarin-related adverse effects.

METHODS

A survey was administered to hospital inpatients and clinic outpatients on drug exposure (including CAM) over the previous month, self-reported bleeding events, use of alcohol and vitamin K-rich foods, and medical conditions. Prescription medication use was verified, and laboratory records were checked for out-of-range international normalized ratios (INRs) (defined as INR >4 or <2). The use of CAM, including products with reported or theoretical interactions with warfarin, was compared between patients with and without self-reported bleeding or out-of-range INR.

RESULTS

Among the 314 patients who completed the survey, 44.3% reported using CAM at least weekly. Potentially interacting CAM was used by 34.1% of all patients, or 18.2% if vitamin E was excluded as an interacting CAM. Vitamin E was used by 24.2% of all patients and 71.0% of those who used potentially interacting CAM. There was no significant difference in CAM use or consumption of vitamin K-rich foods between patients with and without INRs greater than 4 or for patients with and without INRs less than 2.

CONCLUSIONS

The use of potentially interacting CAM in this cohort was higher than the use previously reported among patients on warfarin therapy. However, exposure to CAM was not associated with an increase in the risk of self-reported bleeding or out-of-range INR.

Do Supplements Benefit Exercise?

It is a known fact that exercise will have beneficial effects on one's health. Nutritional supplementation is on the rise, resulting in a billion-dollar industry. However, because these medications are not regulated by the Food and Drug Administration, it is difficult for the public to determine what is safe and effective. Health care providers have to be aware of this lack of knowledge and educate their patients on which supplements are beneficial and which may be harmful to their health.

State of the Art Review: Pharmacists' Approach to Selecting Dietary/Nutritional Supplements for Patients

Consumers' accessibility to over-the-counter dietary supplements is unlimited. Alarmingly, although dietary supplement use is on the rise, national surveys have shown a gross underreporting to health care practitioners. This has resulted in a growing concern in the concomitant use of dietary supplements with prescription medications and certain disease states; therefore, it is essential for health care providers to aid in the decision-making process to assess safety and efficacy of dietary supplement use. Although all health care practitioners can aid consumers in making informed decisions, pharmacists are in a key role due to their accessibility, knowledge of alternative medicines, and training in pathophysiology and pharmacology. In addition to assessing the safety and efficacy of dietary supplements when determining the appropriateness of use in consumers, pharmacists should also consider various patient characteristics, including the presence of disease states, concomitant use of other medications/ supplements, and cost. Thoroughly evaluating all of these factors should aid pharmacists in helping consumers make informed decisions prior to purchasing supplements. This article discusses an evidence-based approach to selecting dietary supplements, including the laws surrounding these products, professional organizations' position statements, con- cerns with use, special populations, quality control programs, and reliable databases/information resources to aid in selection.

Risk of warfarin-related bleeding events and supratherapeutic international normalized ratios associated with complementary and alternative medicine: a longitudinal analysis

STUDY OBJECTIVE

To determine the risk of bleeding and supratherapeutic international normalized ratios (INRs) associated with use of complementary and alternative medicine (CAM) in patients receiving warfarin.

DESIGN

Prospective, longitudinal study.

SETTING

An acute care, academic and research hospital in Canada.

PATIENTS

A total of 171 adults who were prescribed warfarin anticoagulation therapy for an expected duration of at least 4 months after enrollment.

INTERVENTION

Patients were asked to complete a 16-week diary by recording bleeding events and exposure to factors previously reported to increase the risk of bleeding and supratherapeutic INRs, including CAM consumption.

MEASUREMENTS AND MAIN RESULTS

Prescription, medical, and laboratory records were reviewed. Risk factors for bleeding events and supratherapeutic INR (at least 0.5 units above the target range) were evaluated longitudinally by using generalized estimating equation (GEE) modeling. Of the 171 patients completing a diary, 87 (51%) reported at least one bleeding event and 36 (21%) had a supratherapeutic INR. Seventy-three patients (43%) indicated they had used at least one CAM product previously reported to interact with warfarin. Warfarin use of less than 3 months' duration was the only statistically significant risk factor identified for supratherapeutic INR. The CAM therapies associated with an increased risk of self-reported bleeding included cayenne, ginger, willow bark, St. John's wort, and coenzyme Q(10). Use of more than one CAM while receiving warfarin was also a significant risk factor. Two CAMs were independently associated with an increased risk of self-reported bleeding: coenzyme Q(10) (odds ratio [OR] 3.69, 95% confidence interval [CI] 1.88-7.24) and ginger (OR 3.20, 95% CI 2.42-4.24). Other risk factors significantly associated with increased bleeding included high target INR (2.5-3.5), diarrhea, acetaminophen use, increased alcohol consumption, and increased age.

CONCLUSIONS

The use of CAM by patients receiving warfarin is common, and consumption of coenzyme Q(10) or ginger appears to increase the risk of bleeding in this population.