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Herb-Drug InteractionsWith the increasing use of herbal products by the general public, the potential for interaction with pharmaceuticals is great. Get full access to all EB Medicine articles published 3 years (or more) ago, including evidence-based, peer-reviewed diagnosis and treatment recommendations.
Certain prescription medications have pharmacologic activity that can be accentuated by herbals.
A recent survey identified a small group of ED patients who were at risk for such interactions.145 With the prevalence of herbal use increasing, it makes sense for the emergency physician to obtain a history of herbal use and to consider an herb-drug interaction. Patients will often not consider herbal remedies to be medications, so it is helpful to specifically question patients about all over-the-counter medicines, herbal medicines, dietary supplements, or alternative therapies they use. Table 4 presents some common examples of herb-drug interactions.145-158AdulterantsMajor problems with current herbal preparations are the lack of uniformity in preparation and in constituent concentration. Essentially one can’t really know what is in the product being purchased.159 Also, another alarming and well-documented problem is the potential for adulteration with unlabeled active agents and toxic contaminants.
In this and the following section on Chinese herbals, we willtouch on these issues that come up frequently in the medical literature.Heavy metals are a common contaminant in many herbal products, particularly in Asian traditional remedies. It has also been reported as an adulterant in folk medicines from Oman, Mexico, Pakistan and other Middle Eastern countries.162 Azarcon (lead tetroxide) and greta (lead oxide) are 2 Mexican remedies that have caused lead poisoning. Having been used for the treatment of colic, diarrhea, and other gastrointestinal illnesses, they have been responsible for numerous cases of lead poisoning.163-164 A Hmong folk remedy used by refugees from Northern Laos has caused similar lead toxicity. The remedy, known as “pay-loo-ah,” is a red and orange powder that also contains a high concentration of lead.165Thallium poisoning has resulted from a Chinese herbal medication, “Nutrien,” purchased in the United States. This toxicity manifested as alopecia and sensory neuropathy.166Cosmetics have been documented as a source of heavy metal poisoning. Surma is a fine powder that looks like mascara but is applied to the conjunctival surfaces of eyelids.
Since antimony is scarce, lead has been substituted and has caused cases of elevated lead concentration.167 This substance, also known as kohl, is used in Israel and Middle Eastern countries.
Surma has been documented to contain up to 86% lead sulfide.168Ayurveda is a traditional system of medicine practiced mostly in India, Sri Lanka, Bangladesh, Pakistan, Burma, Bhutan, Tibet, and Mongolia.
Many of these ingredients will not be contained on the label.172 Ko conducted an analysis of 260 Asian patent medicines that were collected from California herbal stores. The most common ingredients were ephedrine, chlorpheniramine, methyltestosterone, and phenacetin. Twenty-four products contained lead in at least 10 parts per million, 36 contained arsenic, and 35 contained mercury.
The 2 patients ingesting the contaminated wei ling xian developed encephalopathy or neuropathy. In the other 4 cases, the flowers were contaminated with Datura metel, which is an anticholinergic preparation causing drowsiness and confusion.
173Vanhaelen analyzed 12 batches of so-called Stephania tetrandra and found that all but 1 batch contained the contaminant aristolochic acids, not the expected tetrandrine.
In Belgium 70 cases of progressive interstitial fibrosis of the kidney (30 end-stage) have been identified.
In an investigation of 21 over-the-counter ginseng products, 5 samples contained chlorinated pesticides exceeding 100 ppb. None of the samples tested contained detectable quantities of chromium, mercury, or arsenic.175Undeclared pharmaceuticals are often found in Asian patent medications. Black balls from China have been purported to contain “stealth steroids.” The contents of these products are not listed on the packaging. A Malaysian man developed recurrent hypoglycemia after taking a product known as “ZhenQi” for diabetes. Along with a large number of Chinese Americans, CPMs are in wide use among other segments of the US population. The emergency physician should be aware that these medications have similar problems as discussed with other herbals. There is wide variation in preparation, and there can be significant contamination (see section on adulteration).In a New York City survey serving a large ChineseAmerican population, 43% of those ED patients had used a Chinese therapy within 1 week of their ED visit.
The majority of cases were asymptomatic, but 28 had symptoms of minor gastrointestinal irritation or salicylate poisoning.
Recently it has been found to possess immunosuppressive effects that may be useful for autoimmune disorders.



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