Herbal remedies: effects on clinical laboratory tests

What risks do herbal products pose to the Australian community?

Traditional herbal products are widely used in Australia to treat a broad range of conditions and diseases. It is popularly believed that these products are safer than prescribed drugs. While many may be safe, it is worrying that the specific effects and harmful interactions of a number of their components with prescription medications is not well understood. Some traditional herbal preparations contain heavy metals and toxic chemicals, as well as naturally occurring organic toxins. The effects of these substances can be dire, including acute hepatic and renal failure, exacerbation of pre-existing conditions and diseases, and even death. The content and quality of herbal preparations are not tightly controlled, with some ingredients either not listed or their concentrations recorded inaccurately on websites or labels. Herbal products may also include illegal ingredients, such as ephedra, Asarum europaeum (European wild ginger) and endangered animal species (eg, snow leopard). An additional problem is augmentation with prescription medications to enhance the apparent effectiveness of a preparation. Toxic substances may also be deliberately or inadvertently added: less expensive, more harmful plants may be substituted for more expensive ingredients, and processing may not be adequate. The lack of regulation and monitoring of traditional herbal preparations in Australia and other Western countries means that their contribution to illness and death is unknown. We need to raise awareness of these problems with health care practitioners and with the general public.

Heart Toxicity Related to Herbs and Dietary Supplements: Online Table of Case Reports. Part 4 of 5

BACKGROUND

The purpose of this review was to create an online research summary table of heart toxicity case reports related to dietary supplements (DS; includes herbs).

METHODS

Documented PubMed case reports of DS appearing to contribute to heart-related problems were used to create a "Toxic Table" that summarized the research (1966 to April, 2016, and cross-referencing). Keywords included "herb," "dietary supplement," and cardiac terms. Case reports were excluded if they were herb combinations (some exceptions), Chinese herb mixtures, teas of mixed herb contents, mushrooms, poisonous plants, self-harm (e.g. suicide), excess dose (except vitamins/minerals), drugs or illegal drugs, drug-herbal interactions, and confounders of drugs or diseases. The spectrum of heart toxicities included hypertension, hypotension, hypokalemia, bradycardia, tachycardia, arrhythmia, ventricular fibrillation, heart attack, cardiac arrest, heart failure, and death.

RESULTS

Heart related problems were associated with approximately seven herbs: Four traditional Chinese medicine herbs - Don quai (Angelica sinensis), Jin bu huan (Lycopodium serratum), Thundergod vine or lei gong teng (Tripterygium wilfordii Hook F), and Ting kung teng (Erycibe henryi prain); one an Ayruvedic herb - Aswagandha, (Withania somnifera); and two North American herbs - blue cohosh (Caulophyllum thalictroides), and Yohimbe (Pausinystalia johimbe). Aconitum and Ephedra species are no longer sold in the United States. The DS included, but are not limited to five DS - bitter orange, caffeine, certain energy drinks, nitric oxide products, and a calming product. Six additional DS are no longer sold. Licorice was the food related to heart problems.

CONCLUSION

The online "Toxic Table" forewarns clinicians, consumers and the DS industry by listing DS with case reports related to heart toxicity. It may also contribute to Phase IV post marketing surveillance to diminish adverse events that Government officials use to regulate DS.

Lesson From Comparison of CAM Use by Women With Female-Specific Cancers to Others: It's Time to Focus on Interaction Risks With CAM Therapies

There has been no examination as to whether the prevalence of complementary and alternative medicine (CAM) use, as well as personal factors associated with CAM use and predictive of CAM use for women with female-specific cancers, is similar to those in other diagnostic groups. The purpose of this review is to compare CAM use and personal factors associated with and predictive of CAM use by women with female-specific cancers to samples of other diagnostic groups. If it is the case that CAM use is similar across various types of samples, then it may be unnecessary to continue to study detailed CAM use by those in separate diagnostic groups and instead focus energies on the examination of CAM therapies that may have risks for interaction with conventional therapies, such as biologically based therapies. The researcher concludes that we are now in an era in which we need to use our restricted time, human resources, and finances to examine biologically based CAM use that may carry high risks for interactions or toxicities for specific groups under examination, rather than examine global CAM use, unless the situation warrants such all-inclusive study.

Liver toxicity related to herbs and dietary supplements: Online table of case reports. Part 2 of 5 series

BACKGROUND

No online current list of potentially life-threatening, hepatotoxic herbs and dietary supplements based on PubMed case reports exists in a summarized tabular form.

METHODS

Documented case reports of herbs or dietary supplements (DS; includes herbs) appearing to contribute to liver injury were used to create an online "DS Toxic Table" of potentially hepatotoxic herbs and dietary supplements (PubMed, 1966 to June, 2016, and cross-referencing). The spectrum of DS induced liver injuries (DSILI) included elevated liver enzymes, hepatitis, steatosis, cholestasis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, veno-occlusive disease, acute liver failure requiring a liver transplant, and death.

RESULTS

Over the past 50 years, approximately 21 herbs (minus germander and usnic acid that are no longer sold) and 12 dietary supplements (minus the nine no longer sold and vitamin A & niacin due to excess intake) posed a possible risk for liver injures in certain individuals. The herbs with the most number of reported publications (but not cases studies) in descending order, were germander, black cohosh, kava extract, and green tea extract.

CONCLUSION

These online DS Toxic Tables will contribute to continued Phase IV post marketing surveillance to detect possible liver toxicity cases and serve to forewarn consumers, clinicians, and corporations.

FDA-approved drugs that interfere with laboratory tests: A systematic search of US drug labels

Drug-related laboratory test interference or drug/laboratory test interactions (DLTI) are a major source of laboratory errors. DLTI is of concern with regard to both the clinical diagnosis and the monitoring of patients. Although there have been numerous reports about specific drugs that interfere with laboratory tests, there has not been a recent review on the topic. We herein provide a review of the known DLTI of US FDA-approved drugs based on a systematic search of DailyMed, a website containing the labels of US FDA-approved drugs. The labels for all human single-ingredient prescription drugs included in the database (1368) were searched using stemmed keywords and were manually reviewed for their relevance to DLTI. A total of 134 labels were positive, which indicated that the drug interferes with at least one clinical laboratory test. Antibacterial agents, psychotropic drugs and contrast media are the classes of drugs most likely to lead to DLTI. Urine was the clinical sample most frequently affected by DLTI. The FDA drug label is a source of information for studies of DLTI, although information is still lacking for most drugs, and additional improvements are needed for many of the existing records. Medical professionals, clinicians and laboratory staff should keep these possible interactions in mind when interpreting the results of laboratory tests, and should ensure that they obtain a complete and accurate record of all drugs being used by patients in order to anticipate potential DLTI. The development of a reporting system to address potential DLTI is warranted.

Hyperglycemia in poor controlled diabetes from crude tamarind herbal pill: a case study

Hyperglycemia is an important finding in the diabetic patient with poor glycemic control. There are several possible causes of hyperglycemic. Here, the author presents an interesting case study on a female diabetic patient presenting with hyperglycemic due to intake of crude tamarind herbal pill. General practitioner should realize that the use of alternative medicine can be a cause of unexplained hyperglycemic episode in diabetic patient.

Medicinal herbs and therapeutic drugs interactions

People mistakenly think that all herbs are safe, because of the fact that they are natural, and the use of herbal medication is growing. Aspects of the efficacy, safety, and quality of herbal or natural products are the subjects of on-going debates. Concurrent administration of herbs may interfere with the effect of drugs. Lack of knowledge of the interaction potential together with an underreporting of herbal use poses a challenge for health care providers and a safety concern for patients. A good understanding of the mechanisms of herb-drug interactions is also essential for assessing and minimizing clinical risks. Examples of herbal medicine-pharmaceutical drug interactions of commonly used herbs are presented. The potential pharmacokinetic and pharmacodynamic basis of such interactions is discussed, as well as the challenges associated with the identification and prediction of herb-drug interactions.

Forensic problems with the composition and content of herbal medicines

A survey of herbal medicines available for internet and over-the-counter purchase in South Australia, Australia, was conducted looking specifically at those used for 'arthritis', 'cold and flu', 'gastrointestinal', 'stress' and 'premenstrual syndrome'. 121 products consisted of 29 in the 'arthritis' category, 33 in 'cold and flu', 19 in 'gastrointestinal' 30 in 'stress' and 10 in 'premenstrual syndrome'. Twenty two (18%) of 121 products were not registered with the Australian Register of Therapeutic Goods (ARTG), despite this being a legal requirement for their sale. Of the registered products 59 (60%) of 99 had differing ingredient concentrations on the website compared to their ARTG listing. Only three of the 15 purchased products had ingredient concentrations which were consistent between the website, ARTG listing and product packaging. These findings demonstrate that it may not be possible to determine what herbal substance an individual has been exposed to prior to death and in what concentration, based on packaging from medications seized at the scene, or from examination of website data and the ARTG listing. These discrepancies may increase the problems that exist in attempting to determine what role herbal medicines may play in the mechanism of death in certain forensic cases.

Induction of apoptosis by cinobufacini preparation through mitochondria- and Fas-mediated caspase-dependent pathways in human hepatocellular carcinoma cells

Cinobufacini (Huachansu), an aqueous extract from the skins of Bufo bufo gargarizans Cantor, is a well-known traditional Chinese medicine widely used in clinical cancer therapy in China. However, the precise mechanisms induced by cinobufacini in human hepatocellular carcinoma (HCC) cells are still not very clear. The aim of present study was to investigate possible apoptotic mechanisms induced by cinobufacini in HCC cell lines HepG(2) and Bel-7402. We found that cinobufacini treatment resulted in a significant decrease in cell proliferation and induced apoptotic cell death with the increase of treatment time. It indicated that cinobufacini-induced apoptosis was associated with mitochondria-mediated pathway including the loss of mitochondrial membrane potential (Δψm), the increase of Bax/Bcl-2 ratio, cytochrome c release, caspase-9 and caspase-3 activation, and poly(ADP-ribose) polymerase (PARP) degradation. Additionally, cinobufacini also activated Fas-mediated apoptosis pathway obviously as evident by an increase in Fas expression, and caspase-8 and caspase-10 activation. Moreover, the BH3-only protein Bid was cleaved into a truncated Bid (tBid) after cinobufacini treatment. Taken together, these data suggested cinobufacini could induce apoptosis of HCC cells through mitochondria- and Fas-mediated caspase-dependent pathways with the increase of treatment time, which might provide an experimental evidence for cinobufacini treatment of HCC.

A review of the potential forensic significance of traditional herbal medicines

Traditional herbal substances may contain highly toxic chemicals and heavy metals, in addition to naturally occurring organic toxins. These substances may cause illness, exacerbate pre-existing ill health or result in death, particularly if taken in excess or in an unusual manner (e.g., injected rather than ingested). Lack of regulation of the content and quality of herbal medicines may result in contamination and adulteration with prescription medications. As there may be no history of the specific use of these products their contribution to death may not be fully appreciated during a standard autopsy. Even when their existence is known or suspected, it may be difficult to identify these substances on standard toxicologic screening. Herbal medicines may also be responsible for a range of symptoms and signs that may confuse the clinical presentation of cases. Given these issues the role of herbal medicines in forensic practice needs to be more clearly defined as deaths may be occurring where herbal medicines have made a significant, but as-yet unrecognized, contribution.

Safety of the traditional Korean herbal medicine CGX: a 6-month repeated-dose study in rats

ETHNOPHARMACOLOGICAL RELEVANCE

CGX is a traditional Korean herbal medicine used to treat chronic liver diseases.

AIM OF STUDY

The purpose of this study was to evaluate the pharmaceutical safety of hepatoprotective herbal medicine, CGX via systemic 6-month repeated dose toxicity study in SD rats.

MATERIALS AND METHODS

Male and female SD rats were administered CGX for 6 months (0, 100, 200, or 400 mg kg(-1), respectively). The rats were visually inspected for changes in behavior, body weight, food and water consumption, and appearance during the experiment period. At the end of the experiment, urine, hematological, biochemical analysis, and histopathological examination were carried out.

RESULTS

No drug-induced abnormalities were found as clinical signs or in the histopathology, hematology, blood biochemistry, and urinalysis results for any administered doses of CGX.

CONCLUSION

The results suggest that CGX is safe and could be considered as an effective and prospective herbal formulation in clinical applications with a wide therapeutic index.

Structural basis of human pregnane X receptor activation by the hops constituent colupulone

Hops extracts are used to alleviate menopausal symptoms and as an alternative to hormone replacement therapy, but they can produce potentially harmful drug-drug interactions. The nuclear xenobiotic receptor pregnane X receptor (PXR) is promiscuously activated by a range of structurally distinct chemicals. It has a key role in the transcriptional regulation of genes that encode xenobiotic metabolism enzymes. In this study, hops extracts are shown to induce the expression of numerous drug metabolism and excretion proteins. The beta-bitter acid colupulone is demonstrated to be a bioactive component and direct activator of human PXR. The 2.8-A resolution crystal structure of the ligand binding domain of human PXR in complex with colupulone was elucidated, and colupulone was observed to bind in a single orientation stabilized by both van der Waals and hydrogen bonding contacts. The crystal structure also indicates that related alpha- and beta-bitter acids have the capacity to serve as PXR agonists as well. Taken together, these results reveal the structural basis for drug-drug interactions mediated by colupulone and related constituents of hops extracts.

American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics

The American Academy of Pediatrics is dedicated to optimizing the well-being of children and advancing family-centered health care. Related to these goals, the American Academy of Pediatrics recognizes the increasing use of complementary and alternative medicine in children and, as a result, the need to provide information and support for pediatricians. From 2000 to 2002, the American Academy of Pediatrics convened and charged the Task Force on Complementary and Alternative Medicine to address issues related to the use of complementary and alternative medicine in children and to develop resources to educate physicians, patients, and families. One of these resources is this report describing complementary and alternative medicine services, current levels of utilization and financial expenditures, and associated legal and ethical considerations. The subject of complementary and alternative medicine is large and diverse, and consequently, an in-depth discussion of each method of complementary and alternative medicine is beyond the scope of this report. Instead, this report will define terms; describe epidemiology; outline common types of complementary and alternative medicine therapies; review medicolegal, ethical, and research implications; review education and training for complementary and alternative medicine providers; provide resources for learning more about complementary and alternative medicine; and suggest communication strategies to use when discussing complementary and alternative medicine with patients and families.

Effect of Asian ginseng, Siberian ginseng, and Indian ayurvedic medicine Ashwagandha on serum digoxin measurement by Digoxin III, a new digoxin immunoassay

Asian ginseng, Siberian ginseng, and Indian Ayurvedic medicine Ashwagandha demonstrated modest interference with serum digoxin measurements by the fluorescent polarization immunoassay (FPIA). Recently, Abbott Laboratories marketed a new digoxin immunoassay, Digoxin III for application on the AxSYM analyzer. We studied potential interference of these herbal supplements on serum digoxin measurement by Digoxin III assay in vitro and compared our results with the values obtained by Tina-quant assay. Aliquots of drug-free serum pool were supplemented with various amounts of Asian ginseng, Siberian ginseng, or Ashwagandha approximating expected concentrations after recommended doses and overdoses of these herbal supplements in serum. Then digoxin concentrations were measured by the Digoxin III and Tina-quant (Roche Diagnostics) assay. We also supplemented aliquots of a digoxin pool prepared from patients receiving digoxin with various amounts of these herbal supplements and then measured digoxin concentrations again using both digoxin immunoassays. We observed modest apparent digoxin concentrations when aliquots of drug-free serum pool were supplemented with all three herbal supplements using Digoxin III assay (apparent digoxin in the range of 0.31-0.57 ng/ml), but no apparent digoxin concentration (except with the highest concentration of Ashwagandha supplement for both brands) was observed using the Tina-quant assay. When aliquots of digoxin pool were further supplemented with these herbal supplements, digoxin concentrations were falsely elevated when measured by the new Digoxin III assay. For example, we observed 48.2% (1.63 ng/ml digoxin) increase in digoxin concentration when an aliquot of Digoxin pool 1 (1.10 ng/ml digoxin) was supplemented with 50 microl of Asian ginseng extract (Brand 2). Measuring free digoxin does not eliminate the modest interferences of these herbal supplements in serum digoxin measurement by the Digoxin III assay.

An evidence-based systematic review of herb and supplement interactions by the Natural Standard Research Collaboration

Reported utilisation of prescription drug use concurrently with herbal or vitamin products have increased, placing an estimated 15 million patients at risk of potential drug-supplement interactions. This systematic review aims to consolidate relevant herb and supplement interactions data available for some of the more common classes of interactions experienced by clinicians. These classes include: hypoglycaemic/hyperglycaemics; hypotensive/hypertensives, diuretics, sedatives, cardiac glycosides, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, laxatives, immunomodulators, agents that may increase the risk of bleeding or clotting, agents that may be hepatotoxic, agents that may have hormonal properties, and agents with cytochrome P450 enzyme activity. The format is designed to promote use as a decision support tool for healthcare providers.