Adverse events associated with metal contamination of traditional chinese medicines in Korea: a clinical review

Lead in traditional and complementary medicine: a systematic review

Lead in the environment remains a matter of grave concern for public health. Lead has been associated with some traditional medicines and has been linked to cases of lead poisoning. A comprehensive compilation of these reports has not previously been conducted. The objective of this review is to explore how common is lead exposure after traditional medicine use, and which countries, systems and/or products are of most concern when it comes to lead contamination. A systematic search was conducted on PubMed, Ovid and EMBASE for studies published between 2005 and 2020. A grey literature search was conducted. Search terms related to lead and traditional medicine were developed for each database, and there were no limitations on language. Studies were included if they examined elevated lead in humans resulting from the use of traditional medicines reported in case reports, case-series, or observational studies. Of the papers discussing lead exposure, 85 case reports were identified and synthesized for the current review. Several themes were identified in the included studies. Traditional medicine has been used in the many parts of the world, however use is more common in South and Southeast Asian countries. The level of detectable lead in products varied widely by region and product types. Consumers of traditional medicines sought products for a wide variety of symptoms and ailments. The symptoms of lead poisoning from traditional medicine use reflected the typical symptom profile of lead poisoning, highlighting the need for awareness of traditional medicine products as a source of lead exposure. Traditional medicine usage remains an important part of health care in many regions, however there is a risk of lead exposure from several products. Health care practitioners in all regions of the world should be aware of the risk and explore the potential for traditional medicine use for patients presenting with elevated blood lead levels. Countries with a strong traditional medicine culture should explore policies for reducing lead exposure from traditional medicine products. JG, LO and MNBD are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of the World Health Organization.

Non-occupational lead poisoning associated with traditional Chinese medicine: A case report

Introduction

Traditional Chinese medicine has a long history and is widely popular in China because of its safety and small side effects. In Chinese families, people believe that the combination of traditional Chinese and Western medicine is more effective, and in terms of conditioning and health care, they tend to rely on traditional Chinese medicine. However, the toxic and side effects of traditional Chinese medicine, especially heavy metal poisoning, should not be ignored.

Patient concerns

A case of non-occupational lead poisoning caused by long-term use of traditional Chinese medicine.

Diagnosis

A 21-year-old man with severe colic periumbilical pain was referred to our hospital. Through careful inquiry of his medical history, we found that he had been taking traditional Chinese medicine to treat facial acne in the past year. His test results showed anemia, liver damage, blood lead concentration of 1,268.4 μg/L, and bone marrow smear showed basophilic stippling erythrocyte. The patient was diagnosed with "lead poisoning."

Interventions

The patient was given treatment with lead driving.

Outcomes

The patient recovered after treatment.

Conclusion

We found that lead poisoning in patients taking traditional Chinese medicine has been reported from time to time. Through consulting the data, we summarized the most common drugs leading to lead poisoning, and reviewed the pathogenesis and common clinical manifestations of lead poisoning. Because lead poisoning is easy to be misdiagnosed, we should ask more carefully about the past history and drug history of patients in order to make timely diagnosis and treatment.

Monitoring of Heavy Metals and Pesticide Residues of Herbal Decoctions in Traditional Korean Medicine Clinics in Korea

In this study, we investigated whether the levels of heavy metal and pesticide residues in herbal decoctions in Korea in 2019 were within normal limits. In total, 30 decoctions composed of multi-ingredient traditional herbs were sampled from traditional Korean medicine (TKM) clinics, TKM hospitals, and external herbal dispensaries in 2019. The decoctions were analyzed for heavy metal content such as lead, arsenic, and cadmium using inductively coupled plasma optical emission spectrometry. For mercury, an automatic mercury analyzer based on the gold amalgamation process was used. For pesticide residues, gas chromatography with electron capture detection and gas chromatography with mass selective detection were used for the analyses. Based on the testing, heavy metals were identified in most of the decoctions (Cd: 0.000–0.003 ppm, Pb: 0.003–0.023 ppm, As: 0.000−0.016 ppm, Hg: 0.000–0.002 ppm). Pesticide residues (e.g., total DDT, total BHC, aldrin, endrin, dieldrin) were not detected at all. All of these were no more than the limit values in preceding studies. Therefore, this study confirms that the contents of heavy metals and pesticides in herbal decoctions are within safe levels based on a previous study and provides evidence for establishing safety management standards for herbal decoctions in Korea.

Interspecific and intraspecific analysis of Selinum spp. collected from Indian Himalayas using DNA barcoding

BACKGROUND

DNA barcoding is a powerful method for phylogenetic mapping and species identification. However, recent research has come to a consistent conclusion about the universality of DNA barcoding. We used matK and rbcL markers to test the universality of twelve accessions from different locations belonging to two Selinum species, Selinum tenuifolium Wall. C. B. Clarke and Selinum vaginatum C. B. Clarke, keeping in mind their ability to identify species and establish phylogenetic relationships within and between the accessions.

RESULTS

The success rates of PCR amplification using matK and rbcL were 75.26% ± 3.65% and 57.24% ± 4.42%, and the rate of DNA sequencing was 63.84% ± 4.32% and 50.82% ± 4.36%, respectively, suggesting that success rates of species identification of the two fragments were higher than 41.00% (matK, 41.50% ± 2.81%; rbcL, 42.88% ± 2.59%), proving that these fragments might be used to identify species. The best evolutionary tree with good supporting values was produced utilizing combinations of matK + rbcL markers when phylogenetic relationships were built with random fragment combinations. The twelve accessions of Selinum collected from different locations and their molecular sequences of matK and rbcL markers were blasted with other genera of Apiaceae family, and it was found that Selinum is most closely related to Angelica species of Apiaceae family.

CONCLUSION

The present study has grouped twelve accessions of Selinum species using molecular markers into phylogenies, which is first-of-its-kind report that established interrelationships within different species of Apiaceae with respect to Selinum.

An Insight into Pathway and Health Risk Assessment of Toxic Metals in Herbal Medicine

Introduction. Along with and in competition with orthodox medicines, herbal medicines have converted into a popular form of cure. While cumulative investigation reports on adverse effects by herbal drug uptake are few, systematic review along with deep insight into other relevant topics (carcinogenic and noncarcinogenic risk assessment, mechanism of toxicity, and entering toxic metal from source to herbal drug) is sporadic. Methods. Therefore, existing research and their published outputs pointing safety assessment of herbal medicines in terms of toxic metals have been reviewed systematically and information synthesized thematically while suggesting mechanism of toxicity, consequence of prolong exposure, and pathway of toxic metal from source to herbal drugs. Result and Discussion. Our study suggests that most of the herbal medicines were unsafe to consume although claimed harmless. Possible pathways regarding migration of toxic metals into herbal medicine are discussed. Conclusion. There should have appropriate screening from herb collection, and manufacturing to selling of finished herbal medicine by authority concerned is backed.

Carbon monoxide: An emerging therapy for acute kidney injury

Treating acute kidney injury (AKI) represents an important unmet medical need both in terms of the seriousness of this medical problem and the number of patients. There is also a large untapped market opportunity in treating AKI. Over the years, there has been much effort in search of therapeutics with minimal success. However, over the same time period, new understanding of the underlying pathobiology and molecular mechanisms of kidney injury have undoubtedly helped the search for new therapeutics. Along this line, carbon monoxide (CO) has emerged as a promising therapeutic agent because of its demonstrated cytoprotective, and immunomodulatory effects. CO has also been shown to sensitize cancer, but not normal cells, to chemotherapy. This is particularly important in treating cisplatin-induced AKI, a common clinical problem that develops in patients receiving cisplatin therapies for a number of different solid organ malignancies. This review will examine and make the case that CO be developed into a therapeutic agent against AKI.

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.

Carbon monoxide: An emerging therapy for acute kidney injury

Treating acute kidney injury (AKI) represents an important unmet medical need both in terms of the seriousness of this medical problem and the number of patients. There is also a large untapped market opportunity in treating AKI. Over the years, there has been much effort in search of therapeutics with minimal success. However, over the same time period, new understanding of the underlying pathobiology and molecular mechanisms of kidney injury have undoubtedly helped the search for new therapeutics. Along this line, carbon monoxide (CO) has emerged as a promising therapeutic agent because of its demonstrated cytoprotective, and immunomodulatory effects. CO has also been shown to sensitize cancer, but not normal cells, to chemotherapy. This is particularly important in treating cisplatin-induced AKI, a common clinical problem that develops in patients receiving cisplatin therapies for a number of different solid organ malignancies. This review will examine and make the case that CO be developed into a therapeutic agent against AKI.

Blood lead concentration and exposure related factors in Korea from the National Environmental Health Survey (KoNEHS) II (2012-2014)

This study evaluated lead concentrations in blood and related factors among the South Korean population based on data from the Korea National Environmental Health Survey (KoNEHS) II (2012-2014) conducted by the National Institute of Environmental Research and the Ministry of Environment. Personal data were obtained from non-institutionalized civilian Korean individuals in an interview with trained community surveyors using a structured questionnaire (n = 6,455, aged 19 or older, mean age 49.7 years). The lead concentrations in whole blood were analyzed by atomic absorption spectrophotometry (AAS) with a Zeeman-effect-based background corrector. The precision and accuracy of the analytical methods were verified by internal and external quality controls (G-EQUAS, Germany). Statistical analysis was performed using weighted KoNEHS II data separated by sex, and the lead concentration was expressed as a geometric mean (GM). Multiple linear regression was performed using the SPSS 23.0 software package (SPSS Inc., Chicago, IL, USA). The total GM of lead concentrations was 19.5 µg/L. Lead concentrations increased with age and were higher in males (22.8 µg/L) than in females (16.6 µg/L). Smokers and drinkers had higher concentrations than non-smokers and non-drinkers of both sexes. People who used herbal medications had higher concentrations than those who did not among females. People of both sexes living in rural areas had higher lead concentrations than those in urban areas. Lead concentrations also varied with educational level, total family income, the type of water regularly consumed, and occupation. The average lead concentration of the general adult population in Korea has rapidly decreased over time from 45.8 µg/L (1999) to 19.45 µg/L (2012-2014); however, it remains higher than that of the United States, Germany, and Canada. The factors significantly related to lead concentration in South Korea were age, sex, smoking and alcohol drinking status, herbal medication usage by females, residential area, drinking water at home, and occupation. These factors could be used to improve occupational and environmental hygiene among the Korean population.

Heavy metal content of herbal health supplement products in Dubai - UAE: a cross-sectional study

BACKGROUND

Lead, mercury, cadmium, chromium, and arsenic intoxication have been associated with the use of health supplement (HS) products. The aim of this study is to estimate the concentration of heavy metals in HS products that are on sale in Dubai, United Arab Emirates, premises and to compare estimated daily metal intake with regulatory standards.

METHODS

Dubai-area premises selling HS products were identified by searching the Dubai Municipality database to identify all pharmacies, para-pharmacies and nutrition and healthcare shops. A total of 859 premises were identified in the Deira and Bur-Dubai areas. Data collection was performed between September 1 and December 12, 2016. During that period, all premises that had been identified within Dubai were visited and samples for laboratory testing were collected.

RESULTS

A total of 200 HS products were tested for lead, mercury, cadmium, chromium and arsenic. High proportion of samples were found to contain metals less than the limits of the detection (LOD) of the method. It was found that 93% of products contained Arsenic (As) < LOD, 94.5% of lead (Pb) < LOD, 100% of Cadmium (Cd) < LOD, 99% of Mercury (Hg) < LOD and 23.5% of Chromium (Cr) < LOD. Using the single imputation method to account for LOD, estimates for the average daily intake of lead was 0.88 μg compared to the tolerable daily intake (TDI) of 20 μg, daily intake of mercury was 0.09 μg (TDI = 20 μg), daily intake of cadmium was 0.83 μg (TDI = 6 μg) while for arsenic it was 0.92 μg compared to the tolerable daily intake of 10 μg. The average daily intake of chromium was 7.57 μg with no internationally established TDI. Assuming users followed the manufacturers' instructions, daily intake of arsenic, lead and mercury would not exceed TDI for any of the 200 products. However, the daily intake of cadmium exceeded or approximated the TDI for three products.

CONCLUSIONS

In this study we found low levels of metals in the products that were available for sale in Dubai. With few exceptions, if the products were used according to the suppliers' instructions, average daily intake of heavy metals will be well below the recommended tolerable daily intakes.

Collective exposure to lead from an approved natural product-derived drug in Korea

Background

In Asian countries, including Korea, lead poisoning caused by traditional herbal medicines is often observed in the clinic. However, there have been no reports thus far of lead poisoning caused by drugs that were approved by the Korea Food and Drug Administration (KFDA). Here, we describe seven patients who ingested a problematic natural product-derived drug (NPD).

Case presentation

In July 2018, seven patients visited a university hospital after ingesting an NPD, S. capsules. These patients complained of various symptoms, and their blood lead levels (BLLs) were elevated relative to those of the general population (arithmetic mean: 19.5 ± 11.6 µg/dL, range: 6.28–35.25 µg/dL). The total doses and BLLs were directly proportional to each other among the patients (r = 0.943, p = 0.001). After the patients discontinued drug intake, their BLLs decreased gradually. The capsule was confirmed to contain lead above the standard value (arithmetic mean: 2,547 ± 1,821.9 ppm).

Conclusion

This incident highlights the need to strengthen standards for the management of NPD ingredients in Korea. NPDs are more likely to be contaminated than other drugs. Thorough management by the KFDA is essential to prevent a recurrence. Moreover, systematic health care is needed for many patients who have taken problematic NPDs.

Association between levels of urinary heavy metals and increased risk of urothelial carcinoma

OBJECTIVES

To evaluate possible sources of exposure to heavy metals in the general population, and to determine the association between urinary heavy metals and urothelial carcinoma risk.

METHODS

We recruited 205 patients with urothelial carcinoma and 406 control participants for a case-control study between June 2011 and December 2013. The control participants were frequency-matched with cases according to sex and age. We measured the urinary levels of arsenic, cadmium, chromium, nickel and lead by using inductively coupled plasma mass spectrometry. We collected environmental exposure-related information through questionnaires. Multivariate logistic regression and 95% confidence intervals were applied to estimate the urothelial carcinoma risk and potential effects of urothelial carcinoma-related risk factors on the levels of urinary heavy metals.

RESULTS

Patients with urothelial carcinoma showed higher urinary levels of arsenic, cadmium, chromium, nickel and lead than the controls. After considering other potential risk factors, a significantly increased risk for urothelial carcinoma was observed in patients with increased urinary levels of cadmium, chromium, nickel and lead. Smokers showed a high urinary cadmium level. In addition to cadmium, a high urinary lead level was associated with cumulative cigarette smoking and herbal medicine use.

CONCLUSION

Environmental factors might contribute to higher urinary levels of heavy metals and ultimately result in urothelial carcinoma carcinogenesis. These findings can promote proper environmental surveillance of exposure to heavy metals in the general population.