Case 5 - Tripod.com
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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