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Toxicology Meeting
Dr. V. Ng
UCH
Chinese Herbs
雷公滕
Case
 M/56
 PH : HT / gout / psoriasis
 Took 雷公滕片 1-10 /Dec/04
 Presented on 17 / Dec/ 04 for facial rash &
epigastric pain & frequency of urine
 P/E showed pigmentation and telegectasia
over face, also oral mucositis was noted
 Other vitals : Normal
 ECG : SR
 CBP, APTT/PT/INR , L/RFT – Normal
Management
 Symptomatic treatment
 Look for / Warn for other adverse effect
 Advice to stop the herbs
 Follow up
雷公滕 ( Lei Gong Teng)
 Comes from the roots, leaves & flowers of
Tripterygium Wilfordii Hook
 Literal Name : thunder vine
 English Name : Tripterygium, common
broad lily root
 Folk Name : ‘walk seven steps and die’
Climbing vine that grow up to 12m. The root is the medicinal
part of the plant & is generally collected in autumn
 Properties : bitter ,acrid and cool
 Channels entered : liver
 Safety index : Toxic
 Chemical composition:
 Alkaloids (wilfordine, wilforine, wilforidine, wilforgine, wilfortrine,
wilforzine, wilformine, wilfornine, euonine, celacinnine, celafurine,
celabenzine, neowilforine, regilidine), terpenoids (triptolide T13,
tripdiolide, tripterolide, triptonide, triptolidenol T9, hypolide,
triptonoterpenol, triptophenolide methylether, neotriptophenolide,
isotriptophenolide, isoneotriptophenolide, triptonoterpene,
triptonoterpene methylether, tripdioltonide, tripdiolide T8, triptriolide
T11, triptolide T10, wilforlide AT1, triptotriterpenoidal lactone A,
wilforlide B, triptotriterpenic acid AT3, triptotriterpenic acid BT2,
triptoterpenic acid CT28, selaspermic acid, wilfornide, triptofordin
A,B,C-1,C-2, D).10
Epidemiology
 Tripterygium wilfordii Hook f. is the second most
frequent herb associated with poisoning in China
 (Most common – Aconite roots)
 R.J.Ko A US Perspective on the adverse reactions from
traditional chinese medicine. J Clin Med Assoc 2004;67:109116
 Lei Gong Teng is now being actively investigated
with multiple clinical studies & research . Results
showed that there are therapeutic benefits.
 J.K.Chen. Herbal Safety. Acupuncture Today. 2004, Vol 05,
Issue 01
Medical Functions
 Effect on immune system
 Immunosuppression (Inhibition of PG E2 secretion & inhibited IL1, IL6,IL8,
TNF)
 Effect on antiinflammatory
 Effect on arthritis
 Effect on anti-cancer –leukemia (mice)

Triptolide and tripdiolide
 Effect on contraception
 Effect on urinary system
 Others: anti-rejection on transplant (mice)
Modern Clinical Application
 Inflammatory of spinal cord- AS
 Proliferative arthritis – RA
 Lupus – SLE
 Purpura
 Kidney inflammation- focal segmental Gs
 Asthma / Bronchitis
 TB lung
 Psoriasis
 Dermatitis
 Reiter’s syndrome
Clinical Studies and Research
 Using alcohol extract of lei gong teng (LGT),
triptolide(雷公滕甲素) or tridiolide(雷公滕乙
素) on mice with leukemia, showed the the
therapy was highly effective
 One study suggested that triptolide in LGT
could inhibit the acute phase of transplant
rejection
 Many studies published on the potential use of LGT
for treatment of arthritis. These in vitro & in vivo
studies confirm the therapeutic benefits of this herb
 Extract of lei gong teng (LGT) exhibited marked effect to
suppress the development of arthritis, antiB production &
delayed type hypersensitivity to type II collagen
 University of Texas and the National Institute of Health
showed that the LGT has anti-inflammatory &
immunosuppressive effect comparable to prednisone
 On RCT reported that ~90% of sampled patient with RA
treated with LGT experienced sig. improvement
 One study found that LGT have a powerful suppressive
effect on human immune responses for tx of RA
 mech : inhibition of PG E2 secretion from monocytes & inhibited
IL1, IL6 , IL8 & TNF)
 Another RCT showed that use of LGT for 20 wks showed
therapeutic benefit in patient with RA refractory to
standard western drug tx
Overdosage
 Entire tripterygium plant is toxic
 Toxicity : root & bark > other parts
fresh form > dried
 Daily dose – between 5-12 gms
 MAX dose 15 gms

Overdosage
 Toxic sign : local irritation of the GIT ,
damage to CNS , internal bleeding and
necrosis of organs
 In severe cases, gross overdose may cause
bleeding in the stomach, intestine, liver and
lungs
 Other symptoms – dizziness , dry mouth,
palpitation, necrosis of mucous membranes
and irregular menses
Overdosage
 Any adverse reaction – generally occur
within 2-3 hrs after ingestion
 Headache, dizziness, palpitation, fatigue,
severe vomiting, chills , fever, abd pain,
diarrhea, generalized aches and pain,
tachycardia, irregular heart rhythms, urinary
frequency & urgency
Overdosage
 Delayed symptoms- 2-3 days
 LBP, hair loss ,facial edema, ↑or ↓u/o, ↓BP,
↓temp, altered consciousness, convulsions,
difficult respiration
 One case report – after ingesting the herbs, the
patient developed hypovolemic shock and cardiac
damage, and died three days later..
Side effects
 Common SE 45%
 Skin rashes , skin pigmentation, stomatitis and
softening of finger nails
 Female –reduction of menses (1mth),
amenorrhea (3-6mths)
 Male – sperm count & motility was reduced & the
sperm disappeared completely (1 mth)
Side effects
 Decrease total blood cell counts
 Mutation type of illness
 Using Lei Gong Teng tincture for external use
can cause mutation type of illness
 Long term
 Significant decrease bone mineral density in
female SLE
 Hair loss & malfct of immune system
 Larger doses &/or long term usage can be
toxic to Kidney
Antidotes for Toxicity
 Emetic method and gastric lavage if early
 In early stage, use adrenocorticol hormone
 Dexamethasone 5-10mg with added 40 ml D50
IVI followed with dexa of 1.5 mg tds for 2-3 wks
 Use dextran 40 500 ml IVI, when toxic has
been absorbed but no symptom of toxication.
Mannitol / Furosemide can be used.
 Attention to balance of electrolyte and correct
acidosis
Antidotes for Toxicity
 Skin allergy
 Antihistamine OR traditional Chinese herbs for
dispersing heat and neutralizing toxin
 Chinese herbs Treatmnet
 Feng wei cao
 San qi
Prevention
 For external use – use ointment & avoid tincture
 Pay attention to the dosage according to body
constitution of individual patient
 Daily dose – between 5-12 gms , MAX 15gms
 Pay attention to the use of the drug
 Need to peel & discard the root bark of this herb before
decocting
 Should be cooked for at lease 60 mins before the
addition of other herbs, then cooked for another 15 min
 Prolonged decoction (1-2 hrs) is recommended to
decrease its toxicity
Prevention
 Avoid using in patient with liver problem
 Contraindicated in pregnancy
 Caution in geriatric & pediatric patient
 Caution in patient with heart, stomach &
spleen disorders
 Should not use in patient with compromised
hepatic function
Discussion
 雷公滕片 vs 雷公滕 herb ?
 Formulation in Chinese herbs
 Raw herb
 Capsule / pill
 Powder
 Water decoction
 Alcohol extract
 Etc….
 Different formulation – different efficacy?
Different toxicity?
Thank You