Transcript Herbal 2001

Herbal M&M
Kent R. Olson, MD
Medical Director, SF Division
California Poison Control System
Clinical Professor of Medicine & Pharmacy
UC San Francisco
What’s Up with Herbs and
Alternative Medicines?
 Increasing use in US
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$1.5 billion/year industry and growing
many mistakenly assume they are safer
increasing reports of adverse reactions and
deaths
 Herbs and Patent Medicines
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herbs may be purchased, grown or foraged
patent medicines may be domestic or
imported
Lack of strict FDA regulation
 Dietary Supplement Health &
Education Act 1994
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loosened FDA regulation
 Difficult to regulate quality
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inaccurate or incomplete ingredients
adulterants
inconsistent dosing
Case 1
 A 20-year-old college student on spring
break took 8 tablets of a product called
Ultimate Xphoria, although the
package recommended 2-4.
 The product was promoted as delivering
“increased energy, inner visions, sexual
sensations, and cosmic consciousness”
 Developed tingling sensations and a
headache
Case 1, cont.
 Later, he was found by friends in
cardiopulmonary arrest.
 Coroner’s report:
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Death from synergistic effects of
ephedrine, pseudoephedrine,
phenylpropanolamine, and caffeine
“Herbal Ecstasy”
 Variety of products: “Ener-Max”, “Herbal
Ecstacy”, “Ripped Fuel”, “Super Weight
Loss”, etc.
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Ma Huang or ephedrine
may also contain pseudoephedrine, PPA
often combined with caffeine (guarana)
 Typical sympathomimetic syndrome,
also may cause severe hypertension
Case 2
 A 5 day old infant was admitted
because of jaundice, hepatomegaly,
and ascites.
 36 week gestation, 2740 gm.
 Liver palpable 5 cm below RCM, hard.
 AST 3725 IU/L, ALT 760
 Total bilirubin 164 micromol/L (nl <21)
Case 2, cont.
 Abdominal ultrasound showed
homogeneous hepatosplenomegaly.
 Open liver biopsy:
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centrilobular fibrosis
neovascularization
widespread circumferential connective
tissue occlusion of small and medium sized
hepatic veins
 Child died 11 days later.
Case 2, cont.
 Mother admitted to consumption of
herbal tea throughout her pregnancy:
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Purchased as an expectorant from a
pharmacy… manuf. stated that 9% of
product consisted of leaves from Tussilago
farfara (horsefoot, coltsfoot, coughwort)
TLC: senecionine (a pyrrolizidine alkaloid)
Mother was asymptomatic.
Tussilago farfara (coltsfoot)
Courtesy of Time Life Plant Encyclopedia
Case 3
 An elderly couple attended a health spa
that recommended comfrey tea as an
herbal remedy for arthritis.
 Later, the woman picked what she
believed to be comfrey plants and made
a tea, which she & her husband drank.
 One hour later, both developed severe
nausea, vomiting, and dizziness.
Case 3, cont.
 Within a short period of time the wife
collapsed, and by the time the
ambulance arrived she was dead.
 The husband came to the hospital with
abdominal cramps and vomiting.
 ECG: fine atrial flutter vs. fibrillation,
with ventricular rate 30/min.
 Serum K 5.3 mEq/L
Case 3, cont.
 17 hours after admission, he vomited
then developed ventricular tachycardia
and ventricular fibrillation, and died.
 Serum digitoxin was >80 ng/mL (usual
therapeutic range 5-30 ng/mL)
 The “comfrey” was identified as
foxglove (Digitalis purpurea)
Comfrey vs. Digitalis
Courtesy of Time Life Plant Encyclopedia
Case 3, cont.
 Some plants and herbals containing
cardiac glycosides:
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Digitalis purpurea (Foxglove)
Nerium oleander
Convallaria majalis (Lily of the Valley)
Urginia maritima (Squill)
Bufo toxin (Ch’ an su)
Case 4
 A 23 year old man and his older brother
were foraging for wild ginseng in the
midcoastal Maine woods.
 The younger brother took three bites
from one of the plants collected in a
swampy area.
 Within 30 minutes he vomited and had
convulsions. On arrival of paramedics,
he was unresponsive and cyanotic.
Case 4, cont.
 Root was identified as water hemlock
 Water hemlock (Cicuta maculata):
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other names: beaver poison; children’s
bane; death-of-man; poison parsnip; fool’s
parsley or false parsley
same family as parsley, parsnips, celery,
and carrots
smells like fresh turnips, tastes sweet
 Toxicity: seizures
Water Hemlock vs. Ginseng
Case 5
 A 10-week old Hispanic infant was
admitted for lethargy, projectile
vomiting, and seizures on the 3rd day of
a viral upper respiratory infection.
 With onset of coryza, family had
reduced her formula and started herbal
teas (peppermint and chamomile)
Case 5, cont.
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CSF: clear fluid, 3 WBCs, nl glucose.
Blood glucose 186 mg/dL
Hematocrit 24.9%
EEG: multifocal epileptiform discharges.
Case 5, cont.
 Electrolytes: Na 112, K 4.6, Cl 82, CO2
20 mEq/L.
 Content of teas (mEq/L):
Na
K
Peppermint:
0.9 1.9
Chamomile:
1.7 2.5
 Estimated water intake during 3-day
period: 180-200 mL/kg/day
Case 6
 A 35 year old woman was admitted with
a 1-week history of nausea, vomiting,
and bloody diarrhea.
 Confused, oliguric, and BP 70/50 mm.
 Maculopapular erythematous rash with
desquamation all over the body.
 CXR: bilateral infiltrates.
 Initial Dx: Toxic Shock Syndrome
Case 6, cont.
 She was intubated endotracheally, and
hemodialyzed for acute renal failure.
 Vaginal swab, blood cultures negative.
 Fiberoptic bronchoscopy: edematous,
inflamed mucosa, purulent secretions.
 Improved over the next 6 days, but
renal function remained poor.
Case 6, cont.
 Her husband admitted that she had
been receiving treatment for vitiligo from
a “native physician” prior to admission
 Twice each day she was confined to a
room for 30 min, inhaling smoke from
burning substances over an open fire.
 Substances included a dried lime, a few
dried leaves, and a brick-red powder.
Case 6, cont.
 The dried lime was found to be filled
with liquid mercury and sealed with wax.
 The red powder was mercuric oxide.
 Serum Hg: 111.3 mcg/dL
 With BAL, her renal function improved
after 4 weeks; cerebellar ataxia and fine
tremor persisted for nearly 6 months.
Case 7
 A 35 yo man consumed a decoction
prepared from Chinese herbs for
rheumatism. After 30 min, he developed
chest discomfort and dyspnea.
 At the hospital, he was semiconscious,
tachypneic, restless, and sweating.
 BP 70/40, HR 150/min
 ECG: ventricular tachycardia.
Case 7, cont.
 Serum K 2.6 mEq/L
 ECG: ventricular tachycardia, which
rapidly deteriorated into v. fibrillation.
 Resuscitation efforts unsuccessful.
 The prescription contained 11 different
herbs, including aconite
Aconite
Case 7, cont.
 Aconite: aconitine & related alkaloids
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As little as 0.2 mg aconitine toxic
Activates sodium channel in cardiac,
neural, muscle tissues
Nausea, vomiting, parasthesias
Enhanced inward Na current during action
potential plateau may prolong
repolarization phase, induce arrhythmias
Even Chemicals Can Be “Herbals”
 GHB (gamma hydroxybutyrate) & GBL
(gamma butyrolactone)
 Potent CNS depressants w/ short
duration of action
 Popular among bodybuilders, Rave
partygoers, used for sexual assault
 Recently, severe withdrawal syndrome
described
Some Herbal-Drug Interactions
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Warfarin + ginkgo, dong quai, garlic, etc
St John’s Wort + SSRIs or MAOIs
St John’s Wort:  F of several drugs
Ginseng + antidepressants: mania
Shankapushpi (Ayurvedic)  phenytoin
Siberian ginseng, plantain + digoxin
Many others . . .
Where to Get Information?
 Natural Medicines Database
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www.naturaldatabase.com
 Facts & Comparisons’ Guide to
Popular Natural Products (formerly
Lawrence Review of Natural Products)
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www.drugfacts.com
 Poison Control Centers