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Herbal remedies may cause or aggravate medical conditions
Use of herbal remedies has dramatically increased in the past five years, reports Thomas Moss, MD, a staff physician at Scottsdale Healthcare (AZ) and medical director of Core Healing International in Fountain Hills, AZ.
A recent study comparing current usage of herbal remedies with data from 1992 showed a 10% increase, he reports. "As of 1994, 8% of U.S. citizens had therapeutically used herbs in the past year. ED nurses will possibly be seeing more and more allergic or toxic reactions."
Many ED patients take over-the-counter herbal remedies on a regular basis and believe them to be safe, and though that’s often the case, it isn’t always.
"The greatest risk lies in the belief that herbal medicine is inherently without risk because it is natural," warns Karen Sheeks, RN, MS, CEN, a wellness consultant and educator at St. Joseph Health System Humboldt County in Eureka, CA. "There are risks involved in the use of any medications, whether herbal, homeopathic, or allopathic. Patients need to be well-informed about the actions, uses, and interactions of herbal medicines before they begin treatment."
Prolonged or excessive dosing can cause toxic reactions, notes Moss.
"Also, the potency of the herbs is increasing because of the standardization going on in the herbal industry," he explains. "For example, the manufacturer may discard the aqueous portion of saw palmetto to concentrate the herb. We may see some new toxicities that we did not expect before."
Inconsistency of quality is another issue that effects toxic reactions, Moss adds.
"More and more manufacturers are getting into the business, so the quality of the herbs varies widely," he explains. "Even once you standardize for a minimum level for a certain ingredient, a product may have quite a difference in dosage depending on the potency of the herb. Some of the active ingredients may be stronger in wild herbs than in those which are cultivated."
Although interactions with herbal remedies do occur, they are relatively safe, stresses Patty Campbell, RN, MSN, CCRN, ANP, CS, a Phoenix-based emergency nurse practitioner and assistant editor of the Journal of Emergency Nursing.
"It’s important to keep it in perspective," she says. "Last year, 100,000 people in the United States died from drug reactions, overdoses, interactions, and adverse side effects from prescription medications both in and out of the hospital."
In comparison, deaths from herbal remedies are much rarer, Campbell notes.
A recently published study in the New England Journal of Medicine reported six deaths attributed to "alternative therapies" but failed to compare the statistics for deaths from prescription drugs.1
"Relatively speaking, the herbal remedies are much safer than prescription medications," says Campbell.
Traditional pharmaceuticals block a single, pathological, biochemical/molecular pathway, while herbal medicinals affect multiple pathways, Sheeks explains.
"For example, bilberry contains 19 phytochemicals with antiarthritic activity, four analgesic compounds, five general antiarthritics, eight antiedemics, 13 anti-inflammatories, one antirheumatic, two antileukotrienes, one cyclooxygenase inhibitor, and three lipoxygenase inhibitors," she notes.
Still, suspect reactions to herbal medications if things don’t add up, says Moss.
"If something doesn’t make sense, that’s a good time to ask what supplements the patient is taking," he says. "It may be overwhelming to try and understand all of the different supplements every patient you see has been taking, but if something triggers your memory, such as some sort of rash you’ve seen before when a patient was taking a particular vitamin or herb, it doesn’t hurt to ask."
Here are some potential responses to herbal remedies:
• Bladder wrack. Patients may not realize that weight loss products such as "The Patch" may contain the herb bladder wrack, which is a source of iodine. "One patient came in with a generalized maculopapular rash, and knew she had an iodine allergy. But she didn’t know iodine was in the product," recalls Moss.
• Chamomile. A widely used herb, chamomile can also cause an allergic reaction in some patients, says Sheeks. "In rare cases, it can cause an allergic reaction in patients who have sensitivity to ragweed, asters, or chrysanthemums," she says.
• Comfrey. "Rare cases of hepatic disease have been linked to consumption of comfrey, which is widely used for topical treatment of sprains, boils, and skin ulcers," says Sheeks. "Canada has banned the use of comfrey root products, and Germany allows only low doses of the leaves and roots to be marketed."
• Ginko biloba. If a patient presents with any kind of unusual bleeding, subarachnoid or subcontact bleeds, or easy bruising, ask about herbal therapies, Moss advises. "There is some concern about bleeding diathesis from ginkgo biloba, which is used for dementia, circulatory disorders, and asthma," he says.
• Echinacea. Patients with autoimmune diseases such as lupus may develop a rash from taking Echinacea, an immunostimulant, says Moss. "One woman with rheumatoid arthritis improved after starting a new medication, and then started taking Echinacea on top of that. It got much worse, and after she stopped taking the Echinacea, she improved again. There are warnings against taking Echinacea if you have an autoimmune disease."
• Niacin. "A patient came in with episodes of profound facial and body flushing," recalls Jay Kaplan, MD, FACEP, chairman of the department of emergency medicine at Saint Barnabas Medical Center in Livingston, NJ. "It turned out that was among the vitamins the patient was taking, which can cause flushing and a general feeling of heat throughout the body."
• Garlic. "A woman who was breastfeeding brought her baby in because the baby was refusing the breast and was in danger of getting dehydrated," reports Kaplan. "The woman was taking excessive amounts of garlic and didn’t realize the garlic was being transmitted to the breast milk."
• Ma huang. Ma huang (Ephedra) is used in the treatment of asthma, URIs, and edema, notes Sheeks. "This herb has ephedrine-like actions and has been used in combination to create recreational street drugs such as Herbal Ecstasy, as well as weight loss preparations," she says. "The FDA has received more than 600 adverse reaction reports on products containing this herb. Side effects may include acute myocardial infarction, stroke, seizures, psychosis, and depression."
Ephedra can be life threatening when used in combination with caffeine products, Moss stresses. "There have been at least 16 deaths reported from this ingredient," he reports. "We still see people with high blood pressure who ask if they should try a metabolite, and we tell them no, because it has ma huang in it."
Ephedra can also cause problems in patients with prostate problems, Moss says. "It can make you make you unable to urinate by stimulating the spincter muscle," he adds. "People with glaucoma, hyperthyroidism, or anxiety shouldn’t use it."
• Licorice. Licorice can also cause high blood pressure or hypokalemia, notes Moss. "Licorice is often mixed with combinations in Chinese herbal preparations," he says. "I know of two cases of hypokalemia and elevated blood pressure in patients taking licorice candy daily for many weeks. However, patients would have to eat 30-40 grams a day to cause this."
Glycyrrhizin, a component of licorice root, has physiological effects similar to alsosterone and corticosteroids, notes Sheeks. "Some patients taking herbal combinations that contain licorice may experience headache, lethargy, sodium and water retention, and, in rare cases, hypertension and excess potassium excretion."
• Saw palmetto. "Saw palmetto, used for symptoms of benign prostatic hypertrophy, may cause GI upset," says Sheeks.
• Pyrrolizidine. Toxic alkaloids called pyrrolizidine may cause increased liver function tests (LFTs), says Moss. "They can cause venous occlusion known as the Budd-Chiari syndrome. This is caused by toxins, including pyrrolizidines," he says. "However, you don’t see as much of this anymore, because a lot of companies took it off the market altogether to avoid possible problems. Manufacturers label herb bottles as pyrrolizidine free,’" he notes. "Some experts say not to use it at all; others say to only use for a short period of time. They’re not sure how toxic it is, so patients should be prudent and stay away from them."
• Peppermint. "One patient had been eating peppermint candies, and she was coming in for heartburn and asked if peppermint can make it worse, and I told her, Absolutely,’" recalls Moss. "Some herbalists say you can still use it for reflux. There may be certain individuals that it may help if bloating, gas, or intestinal spasms is causing the reflux."
• Tea tree oil. "Australian tea tree oil is a great herb for many conditions, but it can cause contact dermatitis," Moss notes. "Also, the Chinese herbs lu shen wan and tien tu yao ging can cause contact dermatitis."
• Chinese black balls. "Patients may use Chinese black balls for rheumatoid arthritis or other problems," says Moss. It is an amalgam of herbs, non-steroidals, and non-plant medicinals available through mail order. "There may be non-steroidals in the herbs, such as ibuprofen, and [patients] can have a bleeding ulcer or any kind of gastritis from it. There are several reports of Cushing’s syndrome in adulterated herbs with prednisone. They basically can cause any reaction that non-steroidals cause."
• Goldenseal. "Some herbs, such as goldenseal, can drop your blood sugar. Patients may be taking it to ward off colds, and may not know it can drop your blood sugar," says Moss. "If you are hypoglycemic or diabetic, you need to be very careful using goldenseal."
• Feverfew. Feverfew can cause mouth ulcers in up to 11% of patients taking that supplement, notes Moss. "It has been shown to suppress the frequency and intensity of headaches; but if you stop taking the feverfew, your headache intensity is usually the same or worse." he says.
• Peppermint oil. "Patients should not take peppermint oil in large quantities, if at all, because it can be toxic to the liver," says Moss.
• Juniper oil. "Juniper oil can be toxic to the kidneys, and there have been cases of renal dysfunction with long-term use," says Moss.
• Aloe. "A lot of patients don’t realize that aloe can cause diarrhea. It depends on how it’s processed. The clear part is very soothing, but the yellow latex is a very powerful cathartic," says Moss. "If you have a patient taking aloe for peptic ulcers, you have to be careful of the type they get. Because, if it has that yellow tint to it, it could cause him or her to have diarrhea and cramping."
• Kava kava. "Kava kava has caused dry, scaling skin in high doses, but the patient would have to be overdosing. They call it kavaism’ in the Pacific islands when it occurs, but it doesn’t happen with therapeutic doses," says Moss. "Other symptoms include yellowishness, skin discoloration, and red eyes. Drinking alcohol can make it worse."
Kava is used in the treatment of anxiety and insomnia, and may also interfere with the way the body handles dopamine, which may be significant for patients with Parkinson’s disease," Sheeks says. "Kava may also increase the effects of benzodiazepines."
• St. John’s Wort. "The active ingredient in St. John’s Wort is hypericum, and it has the same action as the serotonin inhibitors. If a patient takes it along with a selective serotonin reuptake inhibitor (SSRI) such as Prozac and Paxil, they will be double-dosing," says Campbell.
St. John’s Wort affects specific neurotransmitter levels and can interact with monoamine oxidase (MAO) inhibitors, causing hypertensive crisis, says Sheeks. "Patients on drugs such as Redux, Prozac, or other SSRIs may experience agitation, confusion, tremor, and muscle spasms when [they are] taken in combination with St. John’s Wort," she explains.
• Black cohosh. "A woman with a history of migraines came in because they had increased in frequency," says Moss. "I found out she was taking black cohosh, which can cause an increase in migraines."
Here are some ways to address the issue of drug interactions:
• Do a complete medical history of prescription medications, over-the-counter (OTC) herbal remedies, and food supplements. "After you find out exactly what the patient is taking, it’s a matter of having the expertise to determine if the symptoms they’re having are caused by reactions to supplements," says Campbell.
The information is sometimes overlooked, adds Campbell. "Most patients assume the only thing they need to reveal is prescription medication; they may not think to reveal the other things they’re taking," she says.
Patients taking Chinese herbal mixtures prescribed by acupuncturists and other eastern medicine practitioners may be unaware of the ingredients, notes Sheeks. "Some homeopathic remedies also come in compounds, which combine several substances; these compounds often have an identifying number or trade name, rather than a list of ingredients."
• Use Herbal Physicians’ Desk Reference (PDR). A newly published reference, the Herbal PDR, is an excellent resource to have on hand, Campbell says. "This reference has an herbal/drug interaction guide, and will answer a lot of your questions about effects and interactions," she explains. "We have one in our ED that is very helpful."
• Use poison control centers. "Poison control centers have all the databanks on herbal medicine. If you ever have questions, they will be able to help you. The hospital pharmacy will also have information on drug interactions," says Campbell.
• Be informed about alternative therapies. "It’s important that ED nurses become familiar with the therapies that their patients are using," advises Campbell. "Whether or not you personally believe in it, we have an obligation to educate ourselves about the therapies and the side effects, and that’s the bottom line."
When a patient indicates that they have tried other forms of treatment before seeking help in the ED, find out whether or not it includes the use of medicinals, advises Sheeks. "Other types of therapies, such as massage, energy work, acupuncture, therapeutic touch, imagery, or Reiki, have little effect on allopathic treatments, and do not pose a risk [when used] in combination with Western medicine," she says.
• Educate patients about possible side effects. "The best way to educate patients about this issue is to have a reference that gives information the patients can take home and read," Sheeks recommends. "The newest and most complete data bank is called the Complete German Commission E monographs. Required by German law, the monographs were developed by a panel of physicians, toxicologists, epidemiologists, and scientists for the German government’s Institute for Drugs and Medicinal Devices."
The reference has been peer reviewed by U.S. and German experts, Sheeks explains. "This monograph allows health care professionals easy access to clinical information on herbs and interactions for their patients who self-administer herbal medicines."
1. Angell M, Kassirer J. Alternative medicine: The risk of untested and unregulated remedies. N Engl J Med 1998; 339:839-841.