II. Epidemiology: United States

  1. Adults on Herbals and prescribed medication: 15 Million
    1. Adults alerting doctor of concurrent herbal use: 50%
  2. Americans spent $4 billion on Herbals in 1998
  3. Worldwide use: 4 billion people
  4. Most commonly used herbal products in the United States
    1. Echinacea
    2. St. John's Wort
    3. Ginkgo Biloba
    4. Garlic
    5. Saw Palmetto
    6. Ginseng
    7. Goldenseal
    8. Aloe
    9. Siberian Ginseng
    10. Valerian

III. Background

  1. Traditional medicine is basis for 80% world healthcare
  2. Most medications are synthesized from plant sources
    1. Plant Derivatives: 75% of modern medications
    2. Direct Extracts: 25% of modern medications
  3. Little efficacy data exists for Herbals
    1. Only 30-40 of 1200 herbs have evidence of benefit
    2. Prescribed medications by contrast must show benefit
  4. Modern drugs directly derived from plant sources
    1. Acetylsalicylic acid (Aspirin) from willow bark
    2. Atropine from deadly nightshade plant
    3. Cantharidin from Blister beetle (for Wart Treatment)
    4. Colchicine from meadow saffron plant
    5. Cortisone from Mexican Discorea species
    6. Digitalis (Digoxin) from the foxglove plant
    7. Metformin from French Lilac
    8. Morphine and other Narcotics from the opium poppy
    9. Pilocarpine from the South American Jaborandi Tree
    10. Podophyllin or Podophyllum from mayapple plant
    11. Pyrethrins from chrysanthemums (for lice treatment)
    12. Quinine from yellow cinchona
    13. Reserpine from the snakeroot plant
    14. Scopolamine from Colombian Datura arborea tree
    15. Senna Laxatives from the senna plant
    16. Taxol from the yew tree
    17. Vincristine, Vinblastine from rosy periwinkle plant
    18. Yohimbine from black currant trees (Rubiaceae)

IV. Disadvantages: Related to herbal medication use

  1. No enforced labeling of efficacy
  2. No quality control regulation
    1. USP Verified Mark may be found on some products
  3. Adverse effects are not routinely labeled
    1. See below as well as specific herbal medications
    2. Some touted products (e.g. colloidal silver) have no significant benefit and carry great risk (see agyria)
    3. Serious Drug Interactions may exist
      1. St. John's Wort reduces Oral Contraceptive effectiveness
      2. American Ginseng decreases INR for patients on Warfarin
  4. No standardization of concentration and potency
    1. Many herbal preparations are mislabeled
    2. Some contain little if any active ingredient
  5. Toxin concentrations vary by part of the plant
    1. Toxins may concentrate in roots, stems, nuts and seeds
    2. Leaves tend to have lower toxin concentrations
  6. Preparations may contain contaminants
    1. Serious, permanent injury has occurred in epidemic outbreaks from contaminated products (e.g. L-Tryptophan)
    2. Pesticides
    3. Heavy Metals (often found in folk remedies)
      1. Arsenic
      2. Mercury
      3. Lead (see Lead-Containing Herbal Remedies)
      4. Cadmium
      5. Cyanide (home cooked elderberry syrup)
    4. Prescription drugs illicitly placed in product
      1. Phenylbutazone
      2. Aminopyrine
      3. Prednisone
      4. Testosterone
      5. Diazepam
      6. Indomethacin
  7. Serious Drug Interactions may occur
    1. Goldenseal (high risk of interactions with multiple agents)
    2. St John's Wort (high risk of interactions with multiple agents)
    3. Ginkgo Biloba (increased bleeding risk with Warfarin)
    4. Milk Thistle (multiple interactions)
    5. Asian Ginseng (multiple interactions)
    6. Curcumin (decreases levels of many psychiatric medications)
  8. Many plants are highly poisonous (fatal at low dose)
    1. Deadly nightshade
    2. Hemlock
    3. Mistletoe
    4. Oleander (see Cardiac Glycoside Overdose)
    5. Daphne Berry
    6. Rosary Pea
    7. Jasmine
    8. Red sage
    9. Yew
    10. http://aggie-horticulture.tamu.edu/earthkind/landscape/poisonous-plants-resources/common-poisonous-plants-and-plant-parts/

V. Adverse Effects

  1. General
    1. Patient should report adverse effects to physician
    2. Notify FDA of adverse effects
      1. FDA MedWatch
        1. http://www.fda.gov/medwatch/
        2. Phone: 1-800-332-1088
  2. Cyanide Poisoning risk with seeds, bark, or leaves (toxicity typically requires large quantity ingestion)
    1. Apricot (or apricot pits/kernels/seeds)
    2. Cassava beans
    3. Cherries
    4. Choke cherries
    5. Peaches
    6. Plums
  3. Hepatotoxicity
    1. See Hepatotoxin
  4. Allergic Reaction Risk for those with ragweed allergy
    1. Goldenrod
    2. Marigold
    3. Yarrow
    4. St. John's Wort
    5. Chamomile (or Mayweed or dog fennel)
  5. Anticholinergic and Hallucinogenic Risks
    1. Catnip
    2. Juniper
    3. Lobelia
    4. Wormwood
    5. Nutmeg
    6. Jimson weed (thorn apple, angel’s trumpet)
      1. High concentrations of Atropine, Hyoscyamine, and scopolamine (esp. in seeds)
      2. Chan (2002) Perm J 6(4): 28-30 [PubMed]
        1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220643/
  6. Laxative abuse risk
    1. Buckthorn bark
    2. Senna
    3. Dock roots
    4. Aloe vera
  7. Abortion risk in pregnancy
    1. Devil's claw root
    2. Barberry
    3. Dong Quai
    4. High concentrations of Ruta, Hydrastis or Oregano
  8. Bleeding risk (Anticoagulant activity)
    1. Ginkgo Biloba
    2. Feverfew
    3. Garlic
    4. Ginseng
    5. Dong Quai
    6. Red Clover
  9. Neurologic Effects
    1. Nicotine (Status Epilepticus, paralysis with large ingestions)
    2. Water Hemlock or cicuta (Status Epilepticus with even small ingestions)
  10. Hallucinogens
    1. Morning Glory
    2. Hawaiian Baby Woodrose
  11. Altered Mental Status
    1. Rhododendron (including Azaleas) contain grayanotoxins
  12. Cardiovascular effects
    1. See Herbals Affecting Blood Pressure
    2. Arrhythmias
      1. Yohimbine
      2. Yew
        1. Taxine alkaloids affect Sodium and Calcium channels
    3. Cardiac Glycoside Overdose
      1. Aconite (Monkshood)
        1. Used in Traditional Chinese Medicine
        2. Effects Sodium channels with risk of ventricular Arrhythmia (including Ventricular Tachycardia)
      2. Almendra de quema grasa
      3. Asclepias sp. (milkweed)
      4. Cerbera odollam (Suicide tree, pong-pong)
      5. Colorado River Toad
      6. Foxglove
        1. Purple foxglove (Digitalis purpurea)
        2. Woolly foxglove (Digitalis lanata)
      7. Lily-of-the-valley (Convallaria majalis)
      8. Ouabain (Strophanthus gratus)
      9. Oleander
        1. Common oleander (Nerium oleander)
        2. Yellow oleander (Thevetia peruviana) has lethal levels of cardiac glycosides in 1-2 nuts
    4. Strong Stimulants (result in ED visits for Palpitations, Chest Pain)
      1. See Ephedra and Caffeine
      2. Guarana
      3. Yerba mate
      4. Kola nut
      5. Bitter Orange
  13. Local Reactions
    1. Araceae Toxicity
      1. Pain and swelling of mucosa on biting leaf (due to sharp, lancinating Calcium oxalate crystals)

VI. History

  1. Do you use Alternative Medicines?
    1. Herbal Product?
    2. Herbal Supplement?
    3. Natural Remedy?
  2. What other prescribed or OTC medications do you use?
  3. For how long have you used this herbal product?
  4. Do you have any allergies to plant products?
  5. Are you currently pregnant or Breast Feeding?

VII. Precautions: Pointers for patients purchasing herbal products

  1. Purchased products should be labeled appropriately
    1. Botanical name of herb
    2. Strength or concentration of active ingredient
    3. Batch or lot number
    4. Expiration date
    5. Name of manufacturer and contact information
  2. Avoid herbal products in pregnancy and Lactation
    1. Be particularly cautious in first trimester
    2. See adverse effects above or see specific herb
  3. Use herbal therapies with caution if Immunocompromised
    1. Herbal therapies may be contaminated with microbes
  4. Use the lowest effective dose of a product
  5. Avoid prolonged use of any product
  6. Stop herbal therapies 2 weeks before elective surgery
  7. Avoid mixing herbal products
  8. Discuss herbal use with your physician
    1. Discuss potential Drug Interactions with physician
    2. Discuss adverse effects (see above)
    3. Reevaluate efficacy and safety on regular basis
  9. Avoid potentially sedating agents prior to driving or other activity requiring full concentration
    1. Relaxation drinks (e.g. Neuro Bliss, Just Chill, Marley's Mellow Mood)
      1. Contain Valerian Root, Kava xtract, GABA and Melatonin
      2. (2014) Presc Lett 21(1): 5
  10. Check manufacturer quality
    1. ConsumerLab.com
      1. http://www.consumerlab.com

Images: Related links to external sites (from Bing)

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English HERB THER, HERBAL THER, PHYTOTHER, Botanical Therapy, Phytotherapy or Herbalism, Herbal Medicine / Botanical Therapy, Phytotherapy, herb therapy, phytotherapies, herbal therapy, herb therapies, herbal therapies, herbs therapy, phytotherapy, Herb Therapy, Herbal Therapy, herbal medicine, Herbal therapy (regime/therapy), Herbal therapy, herbal medicine / botanical therapy
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Polish Fitoterapia
Croatian Not Translated[Phytotherapy]
Hungarian Fitoterápia
Norwegian Urteterapi, Fytoterapi
Portuguese Terapia Herbária, Fitoterapia, Terapia de Ervas
Dutch phytotherapie, Phytotherapie, Kruidentherapie
German Phytotherapie, Kräutertherapie
Spanish terapia herbaria (régimen/tratamiento), terapia herbaria, Fitoterapia, Terapia Herbaria

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Portuguese Produtos Naturais
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Concepts Injury or Poisoning (T037)
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Portuguese Toxicidade de uma fitoterapia
French Toxicité d'une phytothérapie
Italian Tossicità di erbe
German Toxizitaet von Kraeutern
Dutch kruiden toxiciteit
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Concepts Pathologic Function (T046)
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Spanish Interacción de fitoterapia
Portuguese Interacção de fitoterapia
Italian Interazione da erbe medicinali
German Wechselwirkung mit pflanzlichen Mitteln
French Interaction de phytothérapie
Japanese ハーブソウゴサヨウ, ハーブ相互作用
Czech Rostlinná interakce
Hungarian Gyógynövény kölcsönhatás