Herbal medicine
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7216.1050 (Published 16 October 1999) Cite this as: BMJ 1999;319:1050All rapid responses
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While dealing with safety of herbal medicines (HM), Vickers and
Zollman (1) have not mentioned the problems associated with the
heterogeneous nature of these traditional remedies. Amount of active
constituents varies tremendously from batch to batch of a plant product
(2). This quantitative variation makes correct dosing a difficult task.
Sometimes
practitioners of HM give different drugs under the same trade name. A
letter, published earlier, reported the experience of a young man, who
developed jaundice after taking "Eternal Life" , a herbal tea. Subsequent
investigations revealed that the contents of "Eternal Life" may not be
always the same. Each preparation is adjusted according to the
requirement of the patient (3). Needless to say that due to the lack of
homogeneity of a medicinal product, it becomes very difficult to suggest
a remedy when any complication arises following its use.
M.K.Chattopadhyay
Centre for Cellular and Molecular Biology,
Hyderabad 500 007,
India.
1.Vickers A; Zollman C. Herbal medicine. BMJ 1999; 319:1050-1053 (16
October).
2.Harper J . Traditional Chinese medicine for eczema. BMJ 308:489-490
(19 February ).
3.Sanders D; Kennedy N; McKendrick MW. Herbal remedies have a
heterogeneous nature. BMJ 1995; 311:1569 (9 December).
Competing interests: No competing interests
EDITOR-We enjoyed your series the ABC of complimentary medicine. Of
particular interest was safety and we would like to offer a further side
effect of chinese herbs.1
A forty-one year old Vietnamese male chef was
referred with a large haemoptysis. He reported no symptoms of chest pain,
weight loss, dyspnoea, and denied fevers, tuberculosis contact and
haematuria. He was an ex-smoker. However, he had been taking a Chinese
herbal remedy for the promotion of general well-being that had been
purchased in China . A chest radiograph showed normal heart size and some
air space shadowing in the right lower zone. All routine bloods were
normal. GBM antibodies were negative as were antinuclear antibodies and
ANCA. Arterial blood gases on air showed a PaO2 of 8.98kPa and a PaCO2 of
5.55. Bronchoscopy was performed that day.
Blood clot was seen in the
right middle and lower lobes that was cleared with suction. No active
bleeding point and no endobronchial lesion were identified. Samples from
bronchoscopy were negative for AAFB, cytology and no organism was
cultured. HRCT scan of the chest showed no evidence of bronchiectasis and
a V/Q scan was also normal. Bronchial angiography was performed four days
after admission. This showed a large bronchial artery coming off at T5
with a hypertrophied blood supply to the right and left lungs,
particularly the right lower zone. This was thought to be the source of
bleeding and was successfully embolised. No other treatment was given and
he remained well with no further haemoptysis.
A sample of the herbs was sent to a Medical Toxicology Unit for analysis.
They were found to contain Reishi mushroom, Ganoderma Lucidum. In humans
Ganoderma Lucidum suppresses the proliferation of peripheral blood
mononuclear cells in vitro whilst in mice it has anti-tumour activity by
increasing the production of cytokines by macrophages and T
lymphocytes.2,3 Polysaccharides from ganoderma lucidum are being
investigated as antifibrotic agents to inhibit the deposition of collagen,
particularly in hepatic fibrosis.4 Of most relevance is that it has been
shown to have vasoactive properties resulting in a 20-25% increase in
coronary blood flow and similar decrease in coronary vascular resistance
in rats.5 Research is continuing to isolate the vasorelaxant constiuent
of this fungus and the specific mechanism of action.
We postulate that
this vasoactive fungus may have increased pulmonary flow in a gentleman
with an abnormal pulmonary circulation and therefore caused massive
haemoptysis.
We would like to thank Dr. A Belli for performing the pulmonary
angiography and D.Shaw (Guy's and St Thomas' Hospital Trust Medical
Toxicology Unit) for her help and advice.
E Frances Bowen
senior registrar
AL Brackenridge
senior house officer
CFJ Rayner
consultant physician
Department of Respiratory Medicine, Chest Clinic, St George's Hospital,
Tooting, London, SW17 0QT
1. Vickers A, Zollman C. Herbal Medicine. BMJ 1999;319:1050-53.
(16th of October)
2. Wang S, Hsu M, Hsu H et al. The anti-tumour effect of ganoderma
lucidum is mediated by cytokines released from activated macrophages and T
lymphocytes. Cancer 1997;70:699-705
3. Kim R, Kim H, Kim B. Suppresssive effects of Ganoderma lucidum on
proliferation of peripheral blood mononuclear cells. Molecules and cells
1997;7:52-7.
4. Park E, Ko G, Kim J et al. Antifibrotic effects of a
polysaccharide extracted from Ganoderma Lucidum, glycyrrhizin and
pentoxifylline in rats with cirrhosis induced by biliary obstruction.
Biological and Pharmaceutical Bulletin 1997;20:417-20.
5. Andreacchi A, Wang T, Wu JHD. Cardiovascular effects of the
fungal extract of Basidiomycetes sp. YL8006. Life Sciences 1997;60:1987-
1994.
Editorial note
The patient has given his signed consent to publication.
Competing interests: No competing interests
Dr Morgan's comment is a timely reminder that evidence-based
practitioners should not trust the words of "authorities" but should look
up the original research and come to their own conclusions.
That said, I disagree that we "misquoted" the Linde review on
hypericum. We read the review and drew our conclusions from the results
presented. These differ from the authors' interpretation of their own
findings. I don't think such a difference of interpretation counts as a
"misquotation."
Competing interests: No competing interests
EDITOR
Vickers and Zollman(1) provide a rather simplistic account of Chinese
Herbal Medicine (CHM) and are clearly out of date in several other
respects. CHM is vastly more complex than simply balancing Yin and Yang
and over several thousand years of clinical observation it has developed a
detailed, internally consistent and clinically effective account of the
aetiology, pathology, diagnosis and treatment of disease.
Although RCT's on CHM are limited- mostly through lack of funding-
recent research not mentioned in the BMJ article has been encouraging
(2,3). In addition to these RCT’s there are numerous other studies
exploring the physiological mechanisms underling CHM and pointing to
fruitful areas for future research (4,5,6,7,8).
Vickers and Zollman are also well behind the times in their account
of training for herbal practitioners. Herbal Registers under the auspices
of the European Herbal Practitioners Association (EHPA), which includes
both the National Institute of Medical Herbalists (NIMH) and the Register
of Chinese Herbal Medicine(RCHM),have recently agreed a common core
curriculum covering Human Sciences,
Nutrition, Clinical Sciences, Plant chemistry and
Pharmacology,Pharmacognosy and Dispensing, Practitioner development and
Ethics,Practitioner Research, Clinical Practice and a module specific to
each herbal tradition. This will ensure all EHPA members share the same
standards of training and marks a very positive educational development
within herbal medicine.
Vickers and Zollman are also incorrect in saying it is only the NIMH
that has a Yellow Card scheme. The RCHM has its own scheme up and running
and is working together with the NIMH within the EHPA to optimise the safe
and effective use of herbal medicines in the UK.
Andrew Flower
(President RCHM)
(1) Vickers A and Zollman C. ABC of Complementary Medicine, BMJ 1999;
319:1050-1053 (16 Oct)
(2) Bensoussan A et al. The treatment of Irritable bowel syndrome with
Chinese herbal medicine: a randomised control trial, JAMA,280(18):1585-9
Nov 11
(3) Batey RG et al. Preliminary report of a randomised , double-blind
placebo-controlled trial of a Chinese herbal medicine preparation CH-100
in the treatment of chronic hepatitis C, J Gastroenterol Hepatol,
13(3):244-7 1998 Mar
(4) Amano T et al. Effects of Chinese herbal medicine on sperm motility
and fluorescence parameters, Arch Androl, 37(3):219-24 1996 Nov-Dec.
(5) Chang DM et al, The effects of traditional antirheumatic herbal
medicines on immune response cells, J Rheumatol, 24(3):436-41 1997 Mar
(6) Suzuki F et al. Keishi-ka-kei-to, a traditional Chinese herbal
medicine, inhibits pulmonary metastasis of B16 melanoma, Anticancer Res,
17(2A); 873-8 1997 Mar-Apr
(7) Oishi M et al. The effectiveness of traditional Chinese medicine in
Alzheimers disease, Alzheimer Dis Assoc Discord, 1998 Sep, 12:3, 247-50
(8) Yoshida Y et al. Immunomodulating activity of Chinese medicinal
herbs and Oldenlandia in particular, Int J Immunopharmacol, 19(7):359-70
1997 Jul
Competing interests: No competing interests
EDITOR
Vickers and Zollman [1] misquote from their cited source [2] in
examining efficacy of St John’s wort for depression. They suggest that
this landmark meta-analysis demonstrated therapeutic equivalence to
‘antidepressants like amitryptyline’ but fewer side-effects.
In fact the
original paper cautioned against such extravagant claims, stating
‘hypericum preparations may work as well as other antidepressants, but the
evidence is still insufficient because of the limited number of patients
included in trials,’ ‘the classification of depression was not uniform and
in some studies quite vague’, before eventually concluding in their Key
Points that ‘current evidence is inadequate to establish whether hypericum
is as effective as other antidepressants and if it has fewer side
effects’. The full study is available on
www.bmj.com./cgi/content/full/313/7052/253.
John F. Morgan
Senior Registrar
Department of General Psychiatry, St. George’s Hospital Medical School,
London SW17 ORE, UK
e-mail: farnill@hotmail.com
1. Vickers A, Zollman C. ABC of complementary medicine - Herbal
medicine. BMJ 1999;319:1050-1053
2. Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W. St John's
wort for depression: an overview and meta-analysis of randomised clinical
trials. BMJ 1996;313:253-8
Competing interests: No competing interests
Re: Chinese Herbs
When talking about safety, we should know that Chinese medicine is a
kind of medicine. Any purchase over the counter in the western world may
not be suitable.
In China, because of the culture, people know Chinese medicine more
or less, so for those who have some knowledge about Chinese medicine, they
may purchase some pattern medicine on their own. And they may be able to
know that if the medicine is helping or not. More importantly, they may
know when they need to consult a practitioner. In western world, it could
be a different situation. Ideally, patients should see a practitioner
before taking Chinese medicine.
Prescribing a Chinese herbal formula, is strongly based on the
classification of syndromes. The diseases and the symptoms become
secondary. When the classification is correct, the herbal medicine would be
very safe.
Competing interests:
None declared
Competing interests: No competing interests