Psychosomatics 39:3-13, February 1998
© 1998 The Academy of Psychosomatic Medine
Use of Herbal Medicines Among Consultation-Liaison Populations
A Review of Current Information Regarding Risks, Interactions, and Efficacy
Catherine C. Crone, M.D., and
Thomas N. Wise, M.D.
Received December 18, 1996; revised March 12, 1997; accepted April 16, 1997. From the Transplant Center of Fairfax Hospital, INOVA Health System, Falls Church, Virginia. Address reprint requests to Dr. Crone at Fairfax Hospital, 3300 Gallows Rd., Falls Church, VA 22046.
|
ABSTRACT
|
Consultation-liaison psychiatrists evaluate a wide variety of patients who are often disillusioned with conventional medical care and are seeking to gain some measure of control over their illness. With the growing popularity of alternative health care practices, consultation-liaison psychiatrists must learn more about the implications of herbal medicine usage. This review provides an overview of herbal medicines, a vital component of the alternative medicine movement.
Key Words: Alternative Medicine • Herbal Medicine • Drug Interactions
|
INTRODUCTION
|
Herbal medicines make up an important component of the trend toward alternative medicine. A Harvard study recently found that one in three respondents acknowledged use of at least one alternative therapy within the past year.1 Extrapolated, these findings suggest that up to $13.7 billion were spent in 1990 alone for these treatments.1 Tyler defines herbal medicines as "crude drugs of vegetable origin utilized for the treatment of disease states, often of a chronic nature, or to attain or maintain a condition of improved health."2 Current demands for herbal medicines have resulted in an annual market of $1.5 billion and increasingly widespread availability.3
Manufacturers and supporters of herbal drugs offer a broad range of therapeutic claims. As a result, the attraction of herbal medicines is not surprising, especially for patients faced with chronic conditions or life-threatening prognoses. Purported benefits range from enhancement of the immune system to cancer cures and "natural" treatments for depression. These claims are powerful temptations for consumers who perceive herbal drugs to be a better and safer alternative to the pharmaceutical agents prescribed by their physicians. Moreover, patients are often all too familiar with the unwanted side effects and adverse reactions from prescription medicines. Patients may also be frustrated by the limitations of conventional medications to provide relief from or control of illnesses such as cancer, human immunodeficiency virus (HIV) disease, Alzheimer's disease, and chronic fatigue syndrome.
Consultation-liaison psychiatrists are frequently asked to see patients who are struggling with the physical and emotional effects of acute or chronic disease. Oftentimes, they have become disillusioned with conventional medical treatments and their health care providers. This patient population may be prone to use alternative approaches, including herbal medicines, to regain a sense of control or hope regarding their illness. Despite the potential risks, patients are often unaware of the potential problems caused by herbal medicines. In addition, their physicians commonly lack knowledge about these compounds. This factor results in the perception by physicians that herbal drugs are ineffective placebos that can simply be ignored. Some physicians view use of these products as a threat to their paternalistic role and sternly admonish their patients or angrily label them as being crazy. However, numerous studies and case reports demonstrate that herbal medicines are neither inactive, benign, or without any therapeutic worth. Because of the potential for side effects, toxic reactions, and unwanted drug-drug interactions, physicians especially need to learn about the herbal medicines selected by their patients.
|
WHO USES HERBAL MEDICINES?
|
Individuals who use alternative medicine are often Caucasian, well educated, and employed, not New Age devotees or members of ethnic populations tied to native practices.1, 4, 5 A higher proportion are female, young to middle aged, and aware of the importance of healthy lifestyle practices (i.e., exercise, diet, stress reduction).4–7 While Furnham and Sutherland report that alternative health care users are more skeptical of conventional medicine and more dissatisfied with physicians,7–9 other studies demonstrate that these individuals are satisfied with conventional medical care.10, 11 Nearly all patient groups studied have chosen to combine alternative therapies along with their conventional medical care, rather than simply abandoning the latter.1, 12–17
Among the general population, alternative therapies are often used for common conditions such as headaches, back problems, insomnia, and anxiety.1 Studies that have focused on patient populations with chronic illness also point to frequent use of alternative practices that include herbal medicines. Such patients may be seeking added relief with these treatments when conventional medical approaches fail to produce desired results. Studies have shown that from 9% to 16% of patients with gastrointestinal disorders use alternative remedies, with the highest rates in patients with irritable bowel syndrome, often considered to have a component of functional etiology.9, 12, 13 Both rheumatology and hemodialysis patients use these treatments even more frequently than those with gastrointestinal disorders.14, 18–20 In a recent study focused on patients with Alzheimer's disease, over half of the caregivers acknowledged trying at least one alternative therapy to help the patient's memory. Vitamins, health foods, home remedies, and herbal medicines were the most popular choices cited by caregivers.21
A large percentage of patients with life-threatening disorders turn to alternative medical therapies.15, 16, 22–27 This may be because of the poor prognosis that many of these patients face despite the use of a full spectrum of conventional medical approaches. Worsening physical symptoms, troubling side effects from prescription drugs, and diminishing hope may further add to the allure of less orthodox approaches. Studies of patients with cancer and HIV disease find that many have tried at least one alternative treatment. Furthermore, patients sometimes acknowledge concurrent use of several different alternative approaches. Among the cancer patients surveyed, up to three quarters have used these therapies to help them manage their disease.15, 22–23 The HIV patient populations studied also acknowledge frequent use of alternative health care practices.11, 16, 24–27 One study found over 20% of HIV-positive patients had used herbal medicines within the past 3 months.16 Participation in clinical drug trials did not prevent patients from taking herbal medicines despite potential interactions. Another group that has recently been studied is organ transplant patients. Of 300 patients who either have undergone or are awaiting transplantation at 1 center, 20% reported current or prior use of alternative therapies.17
|
SOURCES, AVAILABILITY, AND PREPARATION
|
Although some of the plants that make up herbal medicines are cultivated and processed within the United States, most are imported from around the world. Many of these are grown and processed in European countries such as Germany and Switzerland, where there is a large market for herbal products. Other areas of origin include India, China, and South America, where use of herbal medicines is also widely accepted because of cultural belief systems on health and disease. Raw materials for herbal drugs may be derived from carefully cultivated plants or collected in the wild. A final source of medicinal plants is from the home garden of the alternative therapy user who is seeking to make his/her own herbal remedies.
The increasing demand for herbal medicines in the United States has led to their widespread availability in neighborhood grocery stores and local pharmacies, where sales of herbal drugs totaled over $100 million in 1994.28 Despite this, health food stores and mail order companies remain the primary sources for herbal medicines, although patients may also seek them out by visiting alternative therapy practitioners. Herbalists, acupuncturists, homeopaths, and chiropractors sometimes prescribe these preparations alone or in combination with other treatments. Disciplines such as naturopathy and Ayurveda commonly recommend use of herbal medicines along with other practices including meditation.29
Herbal medicines are available in several forms and often require preparation before their use. They can frequently be purchased in bulk form as dried plants or plant parts, or loosely packaged for herbal teas and decoctions. Brewing of the teas involves steeping a specified amount of herb in either cold or hot water for a given amount of time. Decoctions are made by boiling the herb in water, then straining out the plant material. More concentrated forms of herbal medicines are available in the form of hydroalcoholic tinctures and fluid extracts.28 Methods of preparation may differ because of the nature of the plant's active chemical constituents. Volatile oils, resins, alkaloids, glycosides, and fixed oils may be present in varying degrees and possess disparate characteristics in terms of their solubility and heat tolerance.30
|
POTENTIAL BENEFITS
|
Historically, herbal medicines have played a significant role in the management of both minor and major medical illnesses. One example is foxglove, which contains cardiac glycosides, and serves as a classic treatment for congestive heart failure. Even now, physicians still use many drugs that possess botanical origins. Huxtable notes that one-quarter of the prescriptions currently written in the United States are for plant products, while one quarter are for agents based on botanical compounds.31 The therapeutic potential of herbal medicines cannot be ignored and is highlighted in the three examples provided next.
Feverfew
Feverfew has been used since ancient times for fever, headache, menstrual irregularities, and stomach discomfort. Research reveals feverfew to offer therapeutic benefits by reducing the frequency and severity of migraine headaches. Small amounts of either fresh or dried leaves contain an active component, parthenolide, a sesquiterpene lactone. This compound has activity as a serotonin antagonist, which inhibits release of serotonin from platelets, and prevents or reduces blood vessel spasm. The action of feverfew is believed to be similar to migraine agents such as methysergide.2, 32
Ginger
The use of ginger as an effective antiemetic for motion sickness-induced nausea is supported by European and American studies. The therapeutic action of ginger may be in the gastrointestinal tract, as research indicates that ginger has no effect on the central nervous system. Active components are contained in the volatile oil or oleoresin, which can be extracted by brewing an herbal tea from pieces of ginger root.2 Interestingly, patients at our cancer center have been using ginger to help manage the nausea they experience from chemotherapy. Dubovsky has mentioned the successful use of powdered ginger capsules or ginger tea in reducing the nausea brought on by medications such as selective serotonin reuptake inhibitor agents (Wise TN, personal communication, 1997).
Milk Thistle
Milk thistle is used by cirrhotic patients because of its putative ability to slow liver damage.33 Ripe fruit from the milk thistle plant is used to derive a concentrated extract known as silymarin. In vitro as well as animal and human studies suggest that silymarin protects hepatocytes from the toxic effects of substances such as carbon tetrachloride and phalloidin (amanita mushroom).2, 34–38 In humans exposed to hepatotoxins, silymarin was able to reduce the likelihood of developing more extensive liver failure.2, 36, 37 Silymarin is thought to act by the presence of a large number of flavonolignans, which work on the cell membrane to prevent the entry of toxic substances into the hepatocyte. Protein synthesis is also stimulated, accelerating the regeneration and production of new hepatocytes.2
|
SAFETY LIMITATIONS
|
Regulation
Despite pharmacologically active components in many herbal medicines, these products are not well regulated. The 1994 Dietary Supplement Health and Education Act permitted herbal drugs to be placed in the same category as food supplements such as vitamins and minerals.3, 28, 39 This legislation allows manufacturers to market herbal drugs without prior proof of their safety or therapeutic efficacy. Companies are only asked to maintain some proof of their drug's safety, though there are no specifications as to what type of documentation is required. Although therapeutic claims are not allowed on the package label, they may be implied by the inclusion of statements that detail their effects on the body's structure or function.3, 39 Manufacturers may strengthen their suggestions of therapeutic benefit by providing separate literature about their product. Patients may also turn to one of the many popular publications on alternative medicine to obtain detailed but often unsubstantiated information about the use of herbs in the treatment of their illness.
Terminology
The existence of regulatory loopholes certainly raises concerns about the safety of herbal medicines. Added to this are difficulties caused by the complicated naming process for medicinal plants. Depending on which naming system is used, a plant may be known under several different titles. Ginseng may be listed as ren-shen, radix ginseng, or Panax ginseng, depending on whether English common names, transliteration of herbal names, Latinized pharmaceutical names, or botanical names are used.40 In contrast, several different plants are sometimes known by the same common name. Ginseng may refer to Panax ginseng, Panax quinquefolius, or Eleuthrococcus senticosus, also known as Siberian ginseng, which does not contain the same active chemical components.2, 32 This naming confusion can prove problematic, as in the case of a Chinese herb referred to as fang-ji. While this usually refers to either Stephania tetrandra or Cocculus trilobus, which are benign, Hong Kong exporters may use Aristolochia fangchi, which contains a nephrotoxic compound.40 Unfortunately, this substitution would not be evident, as the product label would simply list fang-ji as an ingredient.
Cultivation and Handling
The strength of a plant's pharmacologic activity may vary according to where it was raised, when it was harvested, and how it was stored. Long periods of storage can result in the loss of any chemical activity in an herbal medicine. If plants are stored in hot and humid conditions, contamination with molds such as Aspergillus may occur and pose problems for an immunocompromised individual. Bacterial contamination has also been noted in some herbal preparations and in 1 case led to listeriosis in a 55-year-old man who was using alfalfa tablets.41 Gram-negative bacteria present in parenteral herbal compounds have also led to the finding of significant levels of pyrogenic endotoxins.41 Furthermore, allowing brewed herbal teas to be stored out in the open for prolonged periods can increase the opportunity for bacterial contaminants to flourish.41 Lastly, individuals who choose to harvest their own herbs have been harmed because of misidentification of plants and subsequent ingestion of toxic materials.42–45
Adulteration
Adulteration of herbal medicines with unlisted chemical substances may create health hazards for unsuspecting users of these products (Table 1). Patients have used herbal remedies with good results only to discover that the benefit was actually derived from the presence of undisclosed medicines. These have included a wide variety of steroids, anti-inflammatory agents, benzodiazepines, and hormones.46–58 Unfortunately, patients have also developed renal failure and Cushing's syndrome from their use of these adulterated products.46, 47, 51–53, 58 Heavy metals and other toxic substances have also been discovered, often after a patient develops symptoms of poisoning. Cadmium, lead, mercury, and arsenic have all been uncovered, and their presence is sometimes intentional.58–66 Herbal medicines imported from countries such as China and India appear to have a higher incidence of adulteration. Some Asian forms of alternative medicine actually incorporate these substances into their remedies for purported therapeutic benefits.64, 66
|
RISKS
|
Herbal drugs can produce unwanted side effects and adverse reactions caused by their pharmacologic properties (Table 2). Nausea, diarrhea, and skin reactions are common side effects of a wide variety of herbal medicines, and are usually considered relatively benign.3, 32, 67 More serious side effects may include hypertension from use of ginseng or licorice, anaphylaxis from chamomile teas, and reactivation of systemic lupus erythematosus or new-onset lupus-like symptoms caused by alfalfa tablets.41, 68–70 Ventricular arrhythmias, intravascular hemolysis, hemorrhage, renal failure, and pulmonary hypertension have all been linked to the active chemical components found in herbal remedies.70–86 Pyrrolizidine-containing plants, such as comfrey, chaparral, and groundsel, have been documented as causing liver changes that mimic the Budd-Chiari syndrome.75, 85–97 These disturbances in hepatic function can be irreversible, as noted in the case of a 60-year-old woman who used chaparral capsules for their purported antioxidant properties, only to develop severe hepatitis and ultimately require combined renal and liver transplantation.98 Sassafras and comfrey are known to contain carcinogenic compounds, which add to their risk of toxicity.87, 90, 99 Psychoactive effects in several herbal medicines have produced behavioral, cognitive, and emotional disturbances. Mania developed in a 45-year-old man was attributed to use of an herbal weight-loss remedy, which was later noted to contain ma huang, an ephedrine-rich plant substance.100 Repeated cases of anticholinergic delirium have also been reported from the intentional use of products marketed as "legal highs."101–108 That the addictive potential of herbal preparations is poorly understood is illustrated by the Australian attempt to encourage use of kava kava as a preferable alternative to alcohol use among Aboriginal communities.109–112 Kava kava was eventually abandoned when problems arose from the heavy consumption of this sedating brew.
Potential drug interactions between herbal medicines and standard pharmaceutical preparations are still poorly understood (Table 3). Hepatic microsomal enzymes, which help determine the half-lifes of many commonly prescribed medications, can be affected by herbal medicines. For example, eucalyptus oil is known to induce hepatic enzymes, whereas sassafras has been found to inhibit these same enzymes.77, 87, 113 In turn, drugs that induce microsomal enzymes, such as several of the antiepileptic agents, can increase the hepatotoxicity of various herbs, including comfrey and gordolobo, by promoting the transformation of their pyrrolizidine compounds into harmful metabolites.31, 113 Cardiac glycosides can be enhanced or made toxic by the potassium-losing diuretic effect of uva ursi and buchu.113 Use of these same herbs would need to be considered for their potential synergistic action in a patient already taking prescribed furosemide or hydrochlorothiazide. Excessive sedation can result from the combined use of sedatives or hypnotic agents with either valerian, hops, or passion flower.114 Finally, some herbal drugs contain woodruff, mellilot, or bromelain, which possess natural coumarins or have the ability to enhance the effects of coumarin compounds. These interactions could pose problems for patient populations already on anticoagulant therapy.71, 75, 114
|
DISCUSSION
|
Because of the potential for adverse reactions and drug-drug interactions, it is essential for physicians to ascertain if their patients are taking herbal medications. Patients who do acknowledge use of herbal drugs must also be understood in terms of their illness beliefs, their attitudes toward conventional treatment, and their rationale for taking alternative therapies. Healthy young adults often possess the physiologic capacity to properly metabolize herbal medicines with only limited reactions.31, 115 However, chronic users of herbs, whether physically healthy or not, are especially susceptible to complications linked to these treatments. Patients also at risk from herbal drugs are those who are already prone to difficulties from regularly prescribed medications. Infants, children, and the elderly are vulnerable to adverse reactions because of their tendency to build up higher drug levels and concomitant reduced ability to metabolize active agents. Pregnant women can be harmed by premature uterine contractions caused by ingestion of substances such as cohosh, yarrow, and pulsatilla.69, 116–118 Some herbal substances may also cross the placental barrier and lead to problems. The etiology of hepatic veno-occlusive disease in an infant was linked to the mother's use of a pyrrolizidine-containing herbal tea during pregnancy.91 Last, patients with chronic disease states are especially prone to adverse effects from herbal treatments, partially attributable to their poor physiologic reserve. These patients commonly take multiple medications, heightening the potential for unwanted drug-drug interactions with herbal treatments.31, 115
Although the use of alternative medicine is widespread among the public at large, patient populations seen by consultation-liaison psychiatrists may be especially susceptible to the therapeutic claims offered by these treatments. Patients coping with poor-prognosis illnesses or those with limited responses to conventional medical therapies, such as cancer, renal failure, HIV disease, or fibromyalgia and irritable bowel syndrome, are all potential subjects. Herbal medicines play an important role among alternative therapies because of their popularity and availability. As the evidence presented earlier highlights herbals' potential for reactions beyond a simple placebo response, we may benefit from understanding more about their benefits and risks. Knowledge about the use of herbal medicines may also strengthen our relationships with patients who have already become wary of the medical establishment. Furthermore, this data can be shared with colleagues from other specialties who will benefit from a more informed and measured viewpoint toward patients interested in alternative therapies.
Building alliances with patients often requires a willingness to listen to them and an ability to communicate an understanding of their concerns, skills inherent to the practice of consultation-liaison psychiatry. In the case of herbal medicines and other alternative health care practices, this may not equal unwavering acceptance of their choices. Instead, providing unbiased information about these therapies may still serve to express concern for their difficult situations. Patients may not realize that their use of herbal medicines is a potentially dangerous alternative to their prescribed medications. Makers of these products usually emphasize their therapeutic benefits while underplaying their potential for harm. Additional information about drug interactions, adulteration, and poor quality control should also be discussed. For patients who persist in their desire to try herbal medicines, they can be provided with suggestions that will reduce their chances of developing adverse reactions. This information includes recommendations to look for standardized formulas, use of single agent preparations, use of moderate doses, and warnings to those patients who belong to high-risk groups.31, 39 It is hoped that such patients will continue to inform their physicians about what they are taking. Ultimately, though, whether the medical community accepts alternative medicine as a viable therapeutic option, patients will continue to use herbal medicines despite our arguments and hesitations.
|
REFERENCES
|
-
Eisenberg DM, Kessler RC, Foster C, et al: Unconventional Medicine in the United States. N Engl J Med 1993; 328:246–252[Abstract/Free Full Text]
-
Tyler VE: Herbs of Choice: The Therapeutic Use of Phytomedicinals. Binghampton, NY, Pharmaceutical Products Press, 1994
-
Marwick C: Growing use of medicinal botanicals forces assessment by drug regulators. JAMA 1995; 273:607–609[Medline]
-
MacLennan A, Wilson DH, Taylor AW: Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347:569–573[Medline]
-
Fulder SJ, Munro RE: Complementary medicine in the United Kingdom: patients, practitioners, and consultations. Lancet 1985; 2:542–545[Medline]
-
Thomas KJ, Carr J, Westlake L, et al: Use of nonorthodox and conventional health care in Great Britain. BMJ 1991; 302:207–210
-
Furnham A, Bhagrath R: A comparison of health beliefs and behaviors of clients of orthodox and complementary medicine. Br J Clin Psychol 1993; 32:237–246
-
Furnham A, Forey J: Attitudes, behaviors and beliefs of patients of conventional vs. complementary (alternative) medicine. J Clin Psychol 1994; 50:458–469[Medline]
-
Sutherland LR, Verhoef MJ: Why do patients seek a second opinion or alternative medicine? Clinical Gastroenterology 1994; 19:194–197
-
Donnelly WJ, Spykerboer JE, Thong YH: Are patients who use alternative medicine dissatisfied with orthodox medicine? Med J Aust 1985; 142:539–541
-
Langewitz W, Ruttimann S: The integration of alternative treatment modalities in HIV infection—the patient's perspective. J Psychosom Res 1994; 38:687–693[Medline]
-
Verhoef MJ, Sutherland LR: Use of alternative medicine by patients attending a gastroenterology clinic. Can Med Assoc J 1990; 142:121–125[Abstract]
-
Smart HL, Mayberry JF: Alternative medicine consultations and remedies in patients with the irritable bowel syndrome. Gut 1986; 27:826–828[Abstract/Free Full Text]
-
Snyder P: The use of nonprescribed treatments by hemodialysis patients. Culture, Medicine, and Psychiatry 1983; 7:57–76
-
Cassileth BR, Lusk EJ, Strouse TB, et al: Contemporary unorthodox treatments in cancer medicine: a study of patients, treatments, and practitioners. Arch Intern Med 1984; 101:105–112
-
Kassler WJ, Blanc P: The use of medicinal herbs for human immunodeficiency virus-infected patients. Arch Intern Med 1991; 151:2281–2288[Abstract]
-
Crone C, Wise TN: Use of alternative medicine among transplant patients: for better or worse? Journal of Transplant Coordination 1997; 7:123–130
-
Vecchio PC: Attitudes to alternative medicine by rheumatology outpatient attenders. J Rheumatol 1994; 21:145–147[Medline]
-
Kronenfeld JJ, Wasner C: The use of unorthodox therapies and marginal practitioners. Soc Sci Med 1982; 16:1119–1125
-
Cronan TA, Kaplan RM, Posner L, et al: Prevalence of the use of unconventional remedies for arthritis in a metropolitan community. Arthritis Rheum 1989; 32:1604–1607[Medline]
-
Coleman LM, Fowler LL, Williams ME: Use of unproven therapies by people with Alzheimer's disease. J Am Geriatr Soc 1995; 43:747–750[Medline]
-
Montbriand MJ: An overview of alternative therapies chosen by patients with cancer. Oncol Nurse Forum 1994; 21:1547–1554[Medline]
-
Downer SM, Cody MM, McCluskey P, et al: Pursuit and practice of complementary therapies by cancer patients receiving conventional treatment. BMJ 1994; 309:86–89[Abstract/Free Full Text]
-
Anderson W, O'Connor BB, MacGregor RR, et al: Patient use and assessment of conventional and alternative therapies for HIV infection and AIDS. AIDS 1993; 7:561–566[Medline]
-
Singh N, Squier C, Sivek C, et al: Determinants of nontraditional therapy use in patients with HIV infection. Arch Intern Med 1996; 156:197–201[Abstract]
-
Hand R: Alternative therapies used by patients with AIDS. N Engl J Med 1989; 320:672–673[Medline]
-
Barton SE, Hawkins DA, Jadresic DM, et al: Alternative treatments for HIV infection. BMJ 1989; 298:1519–1520
-
Gillespie SG: Herbal drugs. Drug Store News For The Pharmacist, Sept 1995, 5, pp. 63–69
-
Zwicky JF, Hafner AW, Barrett S, et al: Reader's Guide to Alternative Health Methods. Chicago, IL, American Medical Association, 1993
-
Spoerke D: Herbal medication: use and misuse. Hospital Formulary, Dec 1980, 15, pp. 941–951
-
Huxtable RJ: The harmful potential of herbal and other plant products. Drug Safety 1990; 5 (suppl 1): 126–136
-
Tyler VE: The Honest Herbal. Binghampton, NY, Pharmaceutical Products Press, 1993
-
Ferenci P, Dragosics B, Dittrich H, et al: Randomized controlled trial of silymarin treatment in patients with cirrhosis of the liver. J Hepatol 1989; 9:105–113[Medline]
-
Vogel G, Tuchweber B, Trost W, et al: Protection against Amanita phalloides intoxication in beagles. Toxicol Appl Pharm 1975; 73:355–362
-
Desplaces A, Choppin J: The effects of silymarin on experimental phalloidin poisoning. Arzeneimittel-Forsch 1975; 25:89–96
-
Murray MT: The Healing Power of Herbs. United States, Prima Publishing, 1995
-
Awang D: Milk thistle. Canadian Pharmaceutical Journal 1993; 422:403–404
-
Hikino H, Kiso Y, Wagner H, et al: Antihepatotoxic actions of flavonolignans from Silybum marianum fruits. Planta Medica 1984; 50:248–250[Medline]
-
Anonymous: Herbal roulette. Consumer Reports, Nov 1995, 60, pp. 698–705
-
But PP: Need for correct identification of herbs in herbal poisoning. Lancet 1993; 341:637–638
-
De Smet PAGM, Keller K, Hansel R, et al: Adverse effects of herbal drugs 1. Berlin Heidelberg, Germany, Springer-Verlag, 1992
-
Cetaruk EW, Aaron CK: Hazards of nonprescription drugs. Emerg Med Clin North Am 1994; 12:483–510[Medline]
-
Anonymous: poisoning associated with herbal teas–Arizona, Washington. MMWR Morb Mortal Wkly Rep 1977; 126:257–259
-
Bain RJI: Accidental digitalis poisoning due to drinking herbal tea. BMJ 1985; 290;1624
-
Haynes BE, Bessen HA, Wightman WD, et al: Oleander tea: herbal draught of death. Ann Emerg Med 1985; 14:350–353[Medline]
-
Abt AB, Oh JY, Huntington RA, et al: Chinese herbal medicine induced acute renal failure. Arch Intern Med 1995; 155:211–212[Abstract]
-
Segasothy M, Samad S. Illicit herbal preparation containing phenylbutazone causing analgesic nephropathy. Nephron 1991; 59:166–167[Medline]
-
Gertner E, Marshall PS, Filandrinos D, et al: Complications resulting from the use of chinese herbal medications containing undeclared prescription drugs. Arthritis Rheum 1995; 38:614–617[Medline]
-
Karunanithy R, Sumita KP: Undeclared drugs in traditional Chinese antirheumatoid medicine. Int J Pharm Prac 1991; 1:117–119
-
Chan TYK, Lee KKC, Chan AYW, et al: Poisoning due to Chinese proprietary medicines. Hum Exp Toxiciol 1995; 14:434–436
-
Joseph AM, Biggs T, Garr M, et al: Stealth steroids. N Engl J Med 1991; 324:62[Medline]
-
Goldman JA: Chinese herbal medicine: camouflaged prescription antiinflammatory drugs, corticosteroids, and lead. Arthritis Rheum 1991; 34:207
-
Forster PJG, Calverly M, Hubball S, et al: Chuei-Fong-Tou-Geu-Wan in rheumatoid arthritis. BMJ 1979; 2:308
-
Rubin BK, LeGatt DF, Audette RJ: The Mexican asthma cure: systemic steroids for gullible gringos. Chest 1990; 97:959–961[Abstract/Free Full Text]
-
Anonymous: Herb Pills Pose Danger. FDA Consumer, 1984, 17 pp. 3–4
-
Bury RW, Fullinfaw RO: Problems with herbal medicines. Med J Aust 1987; 146:324–325[Medline]
-
Ries CA, Sahud MA: Agranulocytosis caused by Chinese herbal medicines. JAMA 1975; 231:352–355[Abstract]
-
Chan TYK, Chan JCN, Tomlinson B, et al: Chinese herbal medicines revisited: a Hong Kong perspective. Lancet 1993; 342:1532–1534[Medline]
-
Markowitz SB, Nunez CM, Klitzman S, et al: Lead poisoning due to Hai Ge Fen. JAMA 1994; 271:932–934[Abstract]
-
Keen RW, Deacon AC, Delves HT, et al: Indian herbal remedies for diabetes as a cause of lead poisoning. Postgrad Med J 1994; 70:113–114[Abstract]
-
Olujohungbe A, Fields PA, Sandford AF, et al: Heavy metal intoxication from homeopathic and herbal remedies. Postgrad Med J 1994; 70:764
-
Broen S, Ede R: Occult lead poisoning. BMJ 1995; 53:469
-
Dulon G. Jones AP: Lead poisoning due to Asian ethnic treatment for impotence. J Royal Soc Med 1991; 84:630–631[Medline]
-
Haq. I, Asghar M: Lead content of some traditional preparations—"Kushtas." J Ethnopharmacol 1989; 26:287–291[Medline]
-
Kew J, Morris C, Aihie A, et al: Arsenic and mercury intoxication due to Indian ethnic remedies. BMJ 1993; 306:506–507
-
Bhopal R: Use of Indian ethnic remedies. BMJ 1993; 306:1003–1004
-
Kunkel DB, Spoerke DG: Evaluating Exposures to Plants. Emerg Med Clin North Am 1984; 2:133–144[Medline]
-
Siegel RK: Ginseng abuse syndrome. JAMA 1979; 241:1614–1615[Medline]
-
Anonymous: Toxic reaction to plant products sold in health food stores. The Medical Letter 1979; 21:29–31
-
D'Arcy PF: Adverse reactions and interactions with herbal medicines, part 1: adverse reactions. Adverse Drug React Toxicol Rev 1991; 10:189–208[Medline]
-
Ridker PM: Toxic effects of herbal teas. Arch Environ Health 1987; 42:133–136[Medline]
-
Goldfrank L, Lewin N, Flomanbaum N, et al: The pernicious panacea. Hospital Physician, Oct 1982, 18, pp. 64–86
-
Arena JM: Plants that poison. Emerg Med Clin North Am 1989; 21:20–64
-
Larkin T: Herbs are often more toxic than magical. FDA Consumer, Oct 1983, 18, pp. 3–4
-
Ridker PM: Health hazards of unusual herbal teas. Am Fam Physician 1989; 39:153–156[Medline]
-
Cook C, Baisden D: Ancillary use of folk medicine by patients in primary care clinics in southwestern West Virginia. South Med J 1986; 79:1098–1101[Medline]
-
Saxe TG: Toxicity of medicinal herbal preparations. Am Fam Physician 1987; 35:135–142
-
Miskelly FG, Goodyer LI: Hepatic and pulmonary complications of herbal medicines. Postgrad Med J 1992; 68:935
-
Depierreuz M, Van Damme B, Vanden Houte K, et al: Pathologic aspects of a newly described nephropathy related to the prolonged use of Chinese herbs. Am J Kidney Dis 1994; 24:172–180[Medline]
-
Vanherwegem JL: Rapidly progressive interstitial renal fibrosis in young women: association with slimming regimen including Chinese herbs. Lancet 1993; 341:387–391[Medline]
-
van Ypersele de Strihou, C, Vanherwegem JL: The tragic paradigm of Chinese herbs nephropathy. Nephrol Dial Transplant 1995, 341:157–160
-
Koff RS: Herbal hepatotoxicity: revisiting a dangerous alternative. JAMA 1995; 273–502
-
Katz M, Saibil F: Herbal hepatitis: subacute hepatic necrosis secondary to chaparral leaf. J Clin Gastroenterol 1990; 12:203–206[Medline]
-
MacGregor FB, Abernathy VE, Dahabra S, et al: Hepatotoxicity of herbal remedies. BMJ 1989; 299:1156–1557
-
Woolf GM: Acute Hepatitis associated with the Chinese herbal product Jin Bu Huan. Ann Intern Med 1994; 121:729–735[Abstract/Free Full Text]
-
Larrey D, Vial T, Pauwels A, et al: Hepatitis after Germander administration: another instance of herbal medicine hepatotoxicity. Ann Intern Med 1992; 117:129–132
-
Segelman AB, Segelam FP, Karliner J, et al: Sassafras and herb tea. JAMA 1976; 236:477[Medline]
-
Winship KA: Toxicity of comfrey. Adverse Drug React Toxicol Rev 1991; 10:47–59[Medline]
-
Awang DVC: Comfrey. Can Pharm J 1987; 120:101–104
-
Bach N, Thung SN, Schaffner F: Comfrey herb tea-induced veno-occlusive disease. Am J Med 1989; 87:97–99[Medline]
-
Roulet M, Laurini R, Rivier L, et al: Hepatic veno-occlusive disease in newborn infant of a woman drinking herbal tea. J Pediat 1988; 112:433–436[Medline]
-
Ridker PM, Ohkuma S, McDermott WV, et al: Hepatic venocclusive disease associated with the consumption of pyrrolizidine-containing dietary supplements. Gastroenterology 1985; 88:1050–1054[Medline]
-
Kumana CR, Ng M, Lin HG, et al: Herbal tea induced hepatic veno-occlusive disease: quantification of toxic alkaloid exposure in adults. Gut 1985; 26:101–104[Abstract/Free Full Text]
-
Huxtable RJ: New aspects of the toxicology and pharmacology of pyrrolizidine alkaloids. Gen Pharmacol 1979; 10:159–167[Medline]
-
Smith LK, Culvenor CCJ: Plant sources of hepatotoxic pyrrolizidine alkaloids. J Nat Prod 1981; 44:129–152[Medline]
-
McGee J, Patrick RS, Wood CB, et al: A case of veno-occlusive disease of the liver in Britain associated with herbal tea consumption. J Clin Pathol 1976; 29:788–794[Abstract/Free Full Text]
-
Kumana CR, Ng M, Lin HJ, et al: Hepatic veno-occlusive disease due to toxic alkaloid in herbal tea. Lancet 1983; 2:1360–1361
-
Gordon DW, Rosenthal G, Hart J, et al. Chaparral ingestion: the broadening spectrum of liver injury caused by herbal medications. JAMA 1995; 273:489–490[Abstract]
-
Huxtable RJ, Luthy J, Zweifel U: Toxicity of Comfrey-Pepsin Preparations. N Engl J Med 1986; 315:1095[Medline]
-
Capwell RR: Ephedrine-induced mania from an herbal diet supplement. Am J Psychiatry 1995; 152:647
-
Brown JK, Malone MH: "Legal highs"—constituents, activity, toxicology, and herbal folklore. Clin Toxicol 1978; 12:1–31[Medline]
-
Siegel RK: Herbal intoxication: psychoactive effects from herbal cigarettes, tea, and capsules. JAMA 1976; 236:473–476[Abstract]
-
Centers for Disease Control: Anticholinergic poisoning associated with an herbal tea-New York City, 1994. JAMA 1995; 273:1166–1167[Medline]
-
Lamens D, DeHert S, Vermeyen K: Tea of thorn apple leaves: a rare cause of atropine intoxication. Acta Anesthesiol Belg 1994; 45:55–57
-
Hanna JP, Schmidley JW, Braselton WE: Datura delirium. Clin Neuropharmcol 1992; 15:109–113
-
Guharoy SR, Barajas M: Atropine intoxication from the ingestion and smoking of jimson weed (Datura Stramonium). Vet Hum Toxicol 1991; 33:588–589[Medline]
-
Anonymous: Jimson weed poisoning–Texas, New York, and California–1994. MMWR Morb Mortal Wkly Rep 1994; 44:41–45
-
Rhoads PM, Tong TG, Banner W: Anticholinergic poisonings associated with commercial burdock root tea. Clin Toxicol 1984–1985; 22:581–584
-
Cawte J: Psychoactive substances of the South Seas: Betel, kava, and pituri. Aust N Z J Psychiatry 1985; 19:83–87[Medline]
-
Cawte J: Parameters of kava used as a challenge to alcohol. Aust N Z J Psychiatry 1986; 20:70–76[Medline]
-
Mathews JD, Riley MD, Fejo L, et al: Effects of the heavy usage of kava on physical health: summary of a pilot survey in an Aboriginal community. Med J Aust 1988; 148:548–555[Medline]
-
Cawte J: Macabre effects of a ;qocult;qc for kava. Med J Aust 1988; 148:545;en546[Medline]
-
D'Arcy PF: Adverse reactions and interactions with herbal medicines. Part 2—Drug interactions. Adverse Drug React Toxicol Rev 1993; 12:147–162[Medline]
-
Hogan RP: Hemorrhagic diathesis caused by drinking an herbal tea. JAMA 1983; 249:2679–2680[Medline]
-
Huxtable RJ: The myth of beneficient nature: the risks of herbal preparations. Ann Intern Med 1992; 117:165–166
-
Philipson JD, Anderson LA: Herbal remedies used in sedative and antirheumatic preparations: Part 1. The Pharmaceutical Journal, July 1984, 233, pp. 80–82
-
Philipson JD, Anderson LA: Herbal remedies used in sedative and antirheumatic preparations: part 2. The Pharmaceutical Journal. July 1984, 233, pp. 111–115
-
Gold J, Cates W: Herbal abortifacients. JAMA 1980; 243:1365–1366
This article has been cited by other articles:
|
|
|
|
 
A. S. TRABOULSI, R. VISWANATHAN, and J. COPLAN
Suicide Attempt After Use of Herbal Diet Pill
Am J Psychiatry,
February 1, 2002;
159(2):
318 - 319.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Loera, S. A. Black, K. S. Markides, D. V. Espino, and J. S. Goodwin
The Use of Herbal Medicine by Older Mexican Americans
J. Gerontol. A Biol. Sci. Med. Sci.,
November 1, 2001;
56(11):
M714 - 718.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. M. Jacobs and K. A. Hirsch
Psychiatric Complications of Ma-Huang
Psychosomatics,
February 1, 2000;
41(1):
58 - 62.
[Full Text]
|
|
|
|
|
|
|
M. Cirigliano and A. Sun
Advising Patients About Herbal Therapies
JAMA,
November 11, 1998;
280(18):
1565 - 1566.
[Full Text]
[PDF]
|
|
|
|
TOP
ABSTRACT
INTRODUCTION