* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Herbal Medication Pitfalls Question “Natural Product” or Drug
Survey
Document related concepts
Pharmacogenomics wikipedia , lookup
Prescription costs wikipedia , lookup
Drug interaction wikipedia , lookup
Neuropharmacology wikipedia , lookup
Environmental impact of pharmaceuticals and personal care products wikipedia , lookup
Environmental persistent pharmaceutical pollutant wikipedia , lookup
Patent medicine wikipedia , lookup
Toxicodynamics wikipedia , lookup
Non-specific effect of vaccines wikipedia , lookup
Psychopharmacology wikipedia , lookup
Transcript
Question “Natural Product” or Drug? What do you get when you combine: Acetyl chloride Spiraea ulminia extract with acetyl chloride? Spiraea ulminia Herbal Supplements Herbal Supplements Introduction Introduction Why Might Herbal Products Be Dangerous? Herbal Medication Pitfalls Supplements, Natural Remedies, & Human Guinea Pigs Cyrus Rangan MD Assistant Medical Director California Poison Control System Los Angeles, California • Earliest use documented in 1500 B.C. in India and Egypt • First century A.D. publications – Divine Husbandman’s Classic (China) – De Materia Medica (Greece) • Shamans and folk healers began to promote herbals for spiritual and medicinal purposes • Scientific Revolution: first controlled purification of morphine extracts • Edward Stone (mid 18th c.) wrote to Royal Society of Medicine regarding the curative powers of willow tree bark in cases of “agues” (fever). Active ingredient was purified and synthesized widely in 1899. Vitamin-Mineral Amendments of 1976 • Prohibited FDA from establishing maximal safe doses of vitamins and minerals to be contained in dietary supplements • Prohibited FDA from classifying a product as a drug just because a certain level was exceeded Why Might Herbal Products Be Dangerous? Anti-science Attitude of “Herbalist Experts" 1994 Dietary Supplement and Health Education Act (DSHEA) • Herbal products could be marketed with no efficacy or safety testing. • FDA powerless to regulate dietary supplements in most instances • Shifted the burden of proof: "When properly used, herbs are the safest and surest medicines available. However, one must be aware of the power of herbs to heal and, if misused, to cause imbalance. Herbs produce no side effects when used in the amounts required to effect a cure. Negative effects occur only when one fails to observe the cautions that herbalists have recognized after many years of experience.“ – Manufacturers no longer had to demonstrate safety – FDA now had to demonstrate a lack of safety, to take an action Herbal Supplements Acceptable Marketing “..this product is not designed or sold to diagnose, cure, treat, or prevent any disease…” • Claims regarding how a supplement affects “body structure or function” are acceptable • No FDA input is solicited regarding packaging or advertisement The Way of Herbs, Michael Tierra, Pocketbooks, 1998: Sidenote • The herbal industry in the US was a $1.5 billion annual industry by 1994. By 1998 the alternative medicines industry in the United States accounted for $8.1 billion. US political donations by "nutrition companies" in the 1999-2000 political were $5.6 million, and included:* R Sen. Orrin Hatch: D Rep. Robert Wexler: R Rep. Dan Burton: D Sen. Tom Harkin: R Gov. George Bush: $107,100 $82,512 $79,249 $58,250 $52,750 *US News and World Report, February 12, 2001. Herbal Supplements Toxicity factors • • • • • Squill Oleander Seasons Plant parts Geographic regions Conditions/length of storage Misrepresentation, contamination, misidentification, unlisted ingredients, unknown interactions Foxglove Lily of the Valley Herbal Supplements Other Cardiac Glycosides Aconite “Oleander, Squill, Foxglove, Lily of the Valley” Herbal Supplements Aconite “Caowu, chuanwu, monkshood, wolfbane” • Source: dried plant root/tubers • Desired effects: topical analgesic • Toxic Effects: • Source: ubiquitous plants • Desired effects: treatment of asthma, cancer, epilepsy • Toxic Effects: – GI: nausea, vomiting, diarrhea – Neuromuscular: weakness – CVS: delayed repolarization (holds fast cardiac sodium channels open), resulting in ventricular dysrhythmias – Death may occur from dysrhthmias – CVS: digitalis effects, from multiple compounds – Death may occur from dysrhythmias • Treatment: ?sodium bicarbonate, ?lidocaine, ?procainamide, ?atropine, ?overdrive pacing • Treatment: serum digoxin level, Digibind® (Digoxin-specific Fab fragments) Bufo spp. Toads Bufotenin Herbal Supplements Bufo spp. toads “Ch’an su, Stone, Love Stone, Rock Hard” • Source: parotid and sebaceous secretions • Desired effects: topical anesthetic, “heart medicine”, aphrodisiac • Toxic Effects: – CNS: LSD-like effects (bufotenin) – CVS: digitalis effects (bufadienolides) Absinthe Vermouth Herbal Supplements Absinthe “Vermouth, Oil of Wormwood” • Source: volatile oil extracts (thujones), likely used by Van Gogh • Desired effects: hallucinations, euphoria • Toxic Effects: – CNS: psychosis, seizures, visual distortions (acute), intellectual deterioration (chronic) – Death may occur from seizures “Starry Night” Vincent van Gogh Belladonna Henbane Jimson Weed Herbal Supplements Belladonna alkaloids “Jimson Weed, henbane, mandrake” • Source: numerous plants containing atropine/scopolamine analogs • Desired effects: asthma/GI upset remedies, aphrodisiacs • Toxic Effects: – CNS: hallucinations, seizures, anticholinergic effects – Deaths may occur from ALOC-associated trauma • Treatment: supportive care, benzodiazepines, physostigmine (for diagnostic purposes) Jimson Weed Jimson Weed Ephedra Ephedra Metabolife®, Xenadrine® Herbal Supplements Nutmeg Ephedra “Ma-huang, Mormon tea, herbal ecstacy, Metabolife®” • Source: evergreen plants resembling small shrubs, contain ephedrine analogs • Desired effects: bronchial remedies, CNS stimulant effects Toxic Effects: – CNS: adrenergic hyperstimulation, hyperthermia – CVS: dysrhythmias, MI, hemorrhagic strokes – Causes of death may be multifactorial • Treatment: supportive care Herbal Supplements Myristica fragrans “Nutmeg, mace” • Source: evergreen tree (Spice Islands) • Desired effects: euphoria, Tx dyspepsia, arthritis, depression; abortifacient • Toxic Effects: – CNS/CVS: amphetamine-like reactions (myristicin is converted to several amphetamine-like compounds) – Hypothermia after large amounts (unknown mechanism) – Death occurs from amphetamine-like effects • Treatment: supportive Herbal Supplements Pennyroyal Pennyroyal • Source: volatile oil • Desired effects: antispasmodic, insect repellant, antiseptic, fragrance, abortifacient • Toxic Effects: – – – – Liver: fulminant hepatic failure (centrilobular necrosis) CNS: seizures Renal: ATN Pulm: bronchial epithelium toxicity • Treatment: N-acetylcysteine Herbal Supplements Comfrey Pyrrolizidine alkaloids Ginseng “Comfrey, Bush Tea, coltsfoot, gordolobo, T’u-san-chi’i” • Source: multiple plant families in Afghanistan, India, Jamaica • Desired effects: Tx respiratory ailments, tumors, topical treatment of bruises • Toxic Effects: – Liver: hepatic veno-occlusive disease, cirrhosis – Pulm: pulmonary hypertension – Death unlikely in the absence of other liver disease • Treatment: supportive Herbal Supplements Ginseng Ginseng • Source: deciduous, perennial Panax plants • Desired effects: Tx respiratory, GI illnesses, “whatever ails you…” • Toxic Effects: – – – – – – Metabolic: hypoglycemia Heme: increased erythropoiesis CVS: hypertension CNS: sympathetic stimulation G.A.S (HTN, sleeplessness, morning diarrhea) Death is unlikely • Treatment: supportive Echinacea Herbal Supplements Herbal Supplements Herbal Supplements Echinacea Chinese Patent Medications Chinese Patent Medications • Source: plant native to Nebraska, Kansas, Missouri; (Compositae family) • Desired effects: wound healing, immune system stimulation • Toxic Effects: – Immune: immune system suppression after chronic use – Death unlikely • Treatment: supportive • Leng Pui Kee Cough Pills • Jin Bu Huan – morphine analogs, pyrrolizidines • Nan Lien Chiu Fong Toukuwan – aminopyrine, phenacetin, phenylbutazone, indomethacin, mefenamic acid, diazepam, hydrochlorothiazide, dexamethasone, mercuric sulfide, lead, cadmium • Dr. Tong Shap Yee’s Asthma Pills Chinese Patent Medications • Kwei Ling Chi, Tse Koo Choy & Qing Fen – Mercuric sulfide and mercuric chloride • White Flower Medicine Oil, Red Flower Oil, Kwan Loong Medicated Oil – Wintergreen (methylsalicylate) – Camphor – Turpentine – diazepam, mefenamic acid • Gan Mao Ton Pian – phenylbutazone • Chui Feng Su Ho Wan – licorice – theophylline Herbal Supplements – bromhexine • Tung Shieh Licorice Herbal Supplements Licorice • Source: Glycyrrhiza glabra • Desired effects: Tx gastric irritation • Toxic Effects: – Neuro: weakness, hyporeflexia, lethargy – Renal: myoglobinuria, ATN, hypernatremia, hypokalemia (aldosterone-like effects), HTN – Death may occur from dysrhythmias or renal failure in severe cases • Treatment: supportive Herbal Supplements Kava Kava Herbal Supplements Kava kava “Awa, kew, tonga” • Source: Piper methysticum plant • Desired effects: relaxation, tx headaches, PMS, aphrodisiac • Toxic Effects: – CNS: euphoria, muscle weakness (lactoneinduced) – Death unlikely to occur • Treatment: supportive Herbal Supplements Garlic Garlic “Stinking rose, nectar of the gods, da suan” • Source: perennial bulb • Desired effects: Tx DM, cholesterol, bacterial infections • Toxic Effects: – – – – Heme: antiplatelet effects from ajoene Derm: contact dermatitis GI: nausea/vomiting Death may occur from bleeding secondary to drug interaction • Treatment: supportive Ginkgo biloba “Maidenhair tree, tebonin, rokan, kaveri” • Source: trees that live up to 1000 years • Desired effects: Tx Raynaud’s, asthma, improve memory • Toxic Effects: – – – – – CNS: headache, dizziness CVS: palpitations GI: Nausea/vomiting Immune: allergic reactions similar to poison ivy Death unlikely to occur • Treatment: supportive Elder Herbal Supplements Cyanogenic agents Morning Glory Morning Glory “apricot pits, apple seeds, elder” • Source: multiple fruit pits/seeds • Desired effects: diuretic, laxative, cancer remedies • Toxic Effects: cyanide toxicity • Treatment: amyl/sodium nitrite, sodium thiosulfate Morning Glory Herbal Supplements Morning Glory “Heavenly blue, blue star, flying saucers” • Source: ubiquitous flower, often found “choking” other flora • Desired effects: hallucinogenic • Toxic Effects: – LSD/LSA and other analogs produce hallucinations, adrenergic stimulation, and flashbacks – Death may occur from ALOC-associated trauma • Treatment: supportive Autumn crocus Herbal Supplements Autumn crocus Herbal Supplements Periwinkle “Fall crocus, meadow saffron, mysteria, vellorita” • Source: seasonal plant • Desired effects: Tx gout, rheumatism, prostate hypertrophy, hepatic disease, cancer, gonorrhea • Toxic Effects: • Source: ornamental plant native to Madagascar (also called Vinca) • Desired effects: Tx DM, hemorrhage, insect bites, cancer • Toxic Effects: same as vincristine, vinblastine • Death may occur from drug interaction, sepsis • Treatment: supportive – colchicine toxicity (GI upset, renal failure, agranulocytosis) – Death may occur from renal failure, sepsis • Treatment: supportive, ?GCSF St. John’s Wort Periwinkle “Old Maid, church-flower, ram-goat rose, myrtle, magdalena” Herbal Supplements St. John’s Wort “Klamath weed, goatweed, sho-ren-gyo” • Source: perennial flower in US, Canada, and Europe • Desired effects: Tx anxiety, depression, gastritis, AIDS • Toxic Effects: – Derm: photosensitization – Neuro: MAOI reactions, serotonin syndrome, NMS – Death may occur from hyperthermic syndromes from drug interactions • Treatment: supportive Tonka Bean Herbal Supplements Tonka Bean Extra Credit “Tonquin bean, cumaru” • Source: large trees in Venezuela, Guyana, and Brazil • Desired effects: flavoring agent, fragrance • Toxic Effects: Herbal Supplements Summary • Hundreds of agents, little regulation • Uses are increasing dramatically – anticoagulant effects from coumadin-like compounds – Death may occur from bleeding secondary to drug interaction • Herbal or natural medications are: – neither inherently efficacious nor inherently inefficacious – neither inherently safe nor inherently unsafe • Treatment: vitamin K, plasma, supportive care Herbal Supplements Herbal Supplements Herbal Supplements Summary Summary Summary • Use of herbal medicines is generally safe, so long as one is well informed with respect to the dangers associated with lack of regulation • Because herbal medicines can come on the market as “food supplements” not regulated by the FDA, there is bound to be poor science in some herbal use • Occasional poor science on the part of “experts” leads to product misuse: misidentification; contamination; lack of dose standardization; variability of plant constituents; misrepresentation; product adulteration; and herb-drug and herb-herb interactions… all contribute to safety concerns • Good scientific information is gradually growing – describes the content, potential efficacy, and toxicity of herbal medicines • Paucity of data on effects in children • Public perception of “natural” products warps reality • What can we do…?