Debbie Shaw

Traditional remedies and food supplements. A 5-year toxicological study (1991-1995).

SummarySince 1991, the Medical Toxicology Unit (MTU) at Guys’ Hospital, London, has been assessing the toxicological problems associated with the use of traditional and herbal remedies and dietary supplements. This assessment was carried out by evaluating reports to the National Poisons Information Service (London) [NPIS(L)] which provides emergency information to medical professionals. Relevant telephone enquiries to NPIS(L) were identified. Further case details were obtained by follow-up questionnaire, clinical consultation, toxicological analysis of samples from patients and/or products and botanical identification of plant material.Of 1297 symptomatic enquiries evaluated there was a possible/confirmed association in 785 cases. Case series have been identified which substantiate previous reports, including liver problems following the use of Chinese herbal medicine for skin disorders, allergic reactions to royal jelly and propolis and heavy metal poisoning caused by remedies from the Indian subcontinent. Although the overall risk to public health appears to be low, certain groups of traditional remedies have been associated with a number of potentially serious adverse effects.Considering the extent of use of herbal remedies and food supplements a comprehensive surveillance system for monitoring the adverse health effects of these products is essential. Surveillance of a large population is needed for the complex task of identifying the uncommon and unpredictable adverse effects which are potentially serious. In the UK, the Medicines Control Agency responded to the MTU report by recognising the need for vigilance and by incorporating adverse reactions reporting on unlicensed herbal remedies into their drug reaction monitoring function. As a further step to safeguard the patients/consumers an effective single regulatory system is required which would ensure the safety and quality of all herbal remedies and food supplements available in the UK.

International monitoring of adverse health effects associated with herbal medicines

Herbal medicines are used in health care around the world and may increase in importance. There is much uncertainty, however, with regard to their composition, efficacy and safety. There is substantial evidence that herbal medicines can cause serious adverse reactions, but more data are needed as regard their nature, frequency and preventability. In this respect the Uppsala Monitoring Centre of the World Health Organization can play a crucial role. Better reporting of adverse reactions to herbal medicines is needed, in particular with regard to the precise identity and composition of these products. A consistent use by producers, regulators and reporters of the international Latin binomial nomenclature and the use of the new Herbal Anatomical Therapeutic Chemical (ATC) classification are recommended. Copyright

Toxicological Problems Resulting from Exposure to Traditional Remedies and Food Supplements

SummaryThe National Poisons Unit, London, carried out a pilot survey to investigate the frequency and severity of adverse effects/toxicity from exposure to traditional medicines and food supplements reported to the Unit. Enquiries related to suspected poisoning events were reviewed retrospectively from January 1983 to March 1989, and prospectively in 1991. Further information about cases identified by the prospective review was obtained, when appropriate, by follow-up questionnaire, clinical consultation by a consultant toxicologist, toxicological analyses of samples from patients and from products, and botanical identification of dried plant material.In total, 5536 enquiries were identified. Symptoms were reported in 657 (12%) of these. There was a large number of reports of accidental ingestion of vitamin preparations by children under 5 years. Appropriate assessment was possible in only relatively few cases, due to insufficient documentation, and poor labelling of certain products.A probable link between exposure and adverse effects was identified in 42 cases, and was highly probable in two. Heavy metal poisoning resulting from use of contaminated traditional remedies was confirmed in 5 cases. There was evidence that some patients took excessive doses of food supplements, without realising that this might result in toxic effects.The results of this pilot study suggest that there is a need for further surveillance to provide an appropriate risk assessment of food supplements and herbal remedies, improved quality control and labelling of these products, and increased awareness of their potential hazard.

Heavy metal poisoning from Ayurvedic traditional medicines: an emerging problem?

The use of Ayurvedic medicines is common in both adults and children and is increasing in many areas of the world. This paper will discuss the risks of heavy metal poisoning associated with the use of Ayurvedic medicines and illustrate this with some cases managed by the authors. Many Ayurvedic medicines contain heavy metals, including lead, mercury and arsenic, and there have been numerous reports of clinically significant heavy metal poisoning related to their use. However, there have been few studies that allow quantification of the incidence of this problem. There is limited regulation of these products in most areas of the world. Recent European legislation may help to improve safety of products bought in shops, but it is likely to have a relatively limited overall impact as it will not cover personal imports or products prescribed by traditional medicine practitioners. There is an urgent need for studies to quantify the frequency and potential risk of heavy metal poisoning from Ayurvedic medicines and for culturally appropriate education to inform the public of the potential for toxicity associated with these products.

Characteristics and practices of Traditional Chinese Medicine retail shops in London, UK: A cross-sectional study using an observational approach

ETHNOPHARMACOLOGICAL RELEVANCEnTraditional Chinese Medicine (TCM) is a popular form of ethnomedicine in the UK, and is accessed by Western, Chinese and other ethnic groups. The current regulatory regime does not effectively protect the public against poor-quality and unsafe TCMs. Understanding ethnopharmacological information on how TCM is promoted and practiced may help to inform initiatives aimed at ensuring the safe use of TCMs in the UK, and put laboratory-based ethnopharmacological investigations of TCMs in a broader context.nnnAIM OF THE STUDYnThis study aimed to examine the characteristics and practices of TCM retail outlets in London, UK, and to identify factors relevant to the safe use of TCM in the UK.nnnMATERIALS AND METHODSnTCM retail outlets (shops) in London, UK, were identified using a systematic approach. A structured questionnaire including questions on shop business type was used to recruit participant shops. Shops consenting to participate were visited within six weeks of providing consent. A piloted semi-structured questionnaire on shop characteristics was used for data collection following observation. The British National Formulary 53 was used to classify medical conditions/uses for TCMs promoted in the shops. Data were stored and analysed using MS Access 2003, MS Excel 2003 and SPSS 13.nnnRESULTSnIn total, 54 TCM shops in London were identified, of which 94% offered TCM consultations with a TCM practitioner. Detailed characteristics were described within 35/50 shops that gave consent to observing their premises. Most shops labelled and displayed over 150 Chinese Materia Medica (CMMs; crude materials, particularly herbs) for dispensing after consultations with a TCM practitioner. Medical conditions/uses and Patent Chinese Medicines (PCMs) were commonly promoted. In total, 794 occurrences of 205 different medical conditions/uses (median=32, QL=19, QU=48) were identified. These conditions/uses most commonly related to the following therapeutic systems: central nervous system (160/794, 20.2%); musculoskeletal and joint disease (133/794, 16.8%); obstetrics, gynaecology, and urinary-tract disorders (122/794, 15.4%); skin (102/794, 12.9%); gastrointestinal system (62/794, 7.8%). Specific conditions/uses that were frequently promoted included eczema (19/23 shops, 82.6%), arthritis (18/23, 78.3%), acne (17/23, 73.9%), obesity/weight loss/slimming (17/23, 73.9%) and psoriasis (17/23, 73.9%). Claimed conditions/uses included some serious medical conditions (e.g. diabetes, cancer and hypertension) and those focusing on vulnerable groups (e.g. childrens diseases and pregnancy treatments).nnnCONCLUSIONSnTCM shops in London, UK, typically displayed names of a wide range of medical conditions/uses for TCMs using readily understandable medical terms, implying TCM can be used to prevent or treat these conditions. However, many of these advertisements did not comply with UK regulations on medical claims for herbal medicines. Future studies should explore how these advertisements influence consumers decisions to access TCM in the UK, practices of TCM shop staff towards the supply of TCMs in the UK, and what are the health implications at the individual and population levels.

Use of Wau Wa in dermatitis patients

Sir—The parents of three different children with atopic eczema seen in our paediatric dermatology clinics informed us that they were applying a product called Wau Wa cream to their children’s skin, with substantial benefit. In every case, the parents had presumed that this product was free from corticosteroids, which they believed to be harmful. One child had skin atrophy at several sites. Wau Wa cream is widely available in the UK, especially in southeast England. Its label states that it contains extract of Wau Wa root and cream, and is made in Ghana. Independent analysis shows that Wau Wa cream contains 0·013% clobetasol propionate. This corticosteroid molecule is the same as that present in one of the most potent commercially available prescription topical corticosteroid treatments, although the concentration is about a quarter of that used in the commercial preparation, in which the concentration is 0·05%. The data sheet for the prescription cream states it must not be used long term in children. The Wau Wa tree grows in Ghana and, paradoxically, causes severe dermatitis in timber workers; no therapeutic use for it is known. Clobetasol propionate is a synthetic steroid molecule and does not occur naturally; therefore, it is highly improbable that it is derived from the root of the tree. Parents are using this Wau Wa cream as an alternative to steroid treatments, unaware that is it not purely a herbal product. Doctors, under the same misconception, have recommended it to patients. Anyone known to be applying it should be made aware that it contains a potent corticosteroid that could damage the skin under certain circumstances. The Department of Health has been informed of the illegal sale of this cream. There have been previous concerns about steroids in herbal creams from China and Ireland. The wide availability of this cream emphasises the need for improved quality control for all herbal products. Also, more effective controls of the entry into the UK of illegal drugs of all types is desirable. *Justin Daniels, Debbie Shaw, David Atherton