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Understanding Herbal Medicine and Liver Toxicity MD Letter

The September 2017 issue of BC Medical Journal (bcmj.org)—a magazine that “provides clinical and review articles written primarily by BC physicians, for BC physicians”—published a letter in the “Personal View” section about herbal medicine and liver toxicity

The letter reports on two patients who were transferred from local hospitals to the Liver Transplant Program of Vancouver General Hospital (VGH) for assessment and liver transplant because of acute liver failure. The patients were reported to be previously healthy, with one middle-aged and the other young. Though one was also on antidepressants, it was “strongly felt” that the cause of illness in both was the use of commercially-obtained herbal remedies—one was traditional Chinese herbal medicine and the other was traditional Indian herbal products.

The authors lament that “These two tragedies could have been avoided, and it behooves physicians to be aware of what nonprescription products their patients are consuming and the associated risks.” 

They then assert that “Drug-induced liver injury from these products is not uncommon. In China, such injury from Chinese herbal medicine is estimated to be 25% of all reported cases (unpublished work from Dr Qi Xing-shun, General Hospital Shenyang Military District, 8 August 2017).”

Next, the letter authors state that they “strongly feel that regulation of these products, on either the federal or provincial level, needs to be consistent with that applied to the pharmaceutical industry” and that “the public needs to be made aware of the potential dangers of these products.”  

I do agree with this letter on a few points.

  1. For those two patients who needed to undergo liver transplants, this was indeed tragic (though I might argue that that word is most often associated with death, and there is no statement that that is what occurred).
  2. It is absolutely important for medical physicians to ask their patients about their use of any herbal products or supplements.
  3. Just because a product is herbal or “natural” doesn’t mean that it is always safe—for everyone, in any dose, for any length of time.

However—and this is clearly the whole reason why I bother to write about this letter—there are several points that I hold issue with.

Firstly, while these two cases are important and may be reflective of a much larger issue, they are basing their letter on two cases, without giving any idea of whether there is a grander scale to consider. That is, is there truly a danger or might these have been isolated incidents?

What are not isolated incidents, are the adverse effects from proper use of pharmaceuticals, improper prescription of pharmaceuticals, and other medical errors. According to the Canadian Institute for Health Information and the Canadian Patient Safety Institute, in 2014-2015, “patients suffered potentially preventable harm in more than 138,000 hospitalizations in Canada.” That’s about 1 in 18 hospitalizations. And “of the patients who experienced harm, about 20% experienced more than 1 harmful event while in hospital.” (summary report: https://www.cihi.ca/sites/default/files/document/hospital_harm_summary_en.pdf; full report: https://www.cihi.ca/sites/default/files/document/cihi_cpsi_hospital_harm_en.pdf; technical notes: https://www.cihi.ca/sites/default/files/document/hospital_harm_technical_notes_en.pdf)

I don’t want to be alarmist. But those are numbers that stand out and should provoke a response. A letter reporting just two cases needs further elaboration.

Furthermore, using unpublished work from a Dr. Qi Xing-shun practicing in China (not in Canada), the authors of this letter state that damage to the liver from Chinese herbal medicine makes up about 25% of all reported cases. That makes it sound like 25% of people who take Chinese herbs end up with liver damage. That’s not the case. Assuming the 25% noted, but not published, by some Dr. in China is correct, we still have no idea of how many people that is. It’s like saying, “Nine out of ten doctors agree, this is the best toothpaste.” It sounds like 90% of all doctors. But it could be that 10 doctors were selected, and 9 of them like the toothpaste. In other words, if there were 8 total reported cases of injury from Chinese herbal medicine in China, then that would be just 2 liver-affected cases. Again, not noteworthy.

Even if the numbers are, in fact, noteworthy, let’s keep in mind that those are unpublished statistics from China, not here. And that brings me to my second point.

Herbal remedies—just like over-the-counter pharmaceuticals, alcohol, and even fibre powder—can be taken inappropriately. They may be taken in combination with other things that don’t mix well with them. They can be taken at dosages that are too high or for too long. They can be taken by the wrong person for the wrong reason. The Chinese herb ma huang (ephedra) is an example of that. The herb is not unsafe. In TCM, we prescribe its ingestion (combined with other herbs), mostly for opening the sinuses and getting rid of a cold. Unfortunately, people started taking it to lose weight. Wrong use. Wrong dose. Wrong duration of use.

medicine liver damageBut you could say the same of alcohol use. Or of cough medicine, nasal decongestants, motion sickness pills, or narcotic painkillers used to get high. Or laxatives or diuretics used to lose weight. And, how many people have caused stomach ulcers because of overusing anti-inflammatory medications?

Specifically, when it comes to liver damage, Dr. Michael Rieder, a pediatric clinical pharmacologist at Western University states that acetaminophen is the “most common cause for liver injury. Period. Full stop.” Every year there are about 4500 hospitalizations in Canada caused by acetaminophen overdose, with approximately 700 of those accidental, according to Health Canada

Dr. Yoshida himself, the lead author in this letter, “regularly sees patients with severe liver failure from accidental acetaminophen overdose.”

This is why I wonder about Dr. Yoshida et al’s word of warning to their medical physician colleagues that “the public needs to be made aware of the potential dangers of these [herbal] products.” The problem isn’t necessarily with the herbal remedy being dangerous. It’s the improper use that is the main concern. Just as we don’t need to be warned about the dangers potentially imposed by forks, though you could be seriously injured by one!

Of course, if a patient arrives at your office with four small, closely placed puncture wounds in his leg, you might consider that a fork was the cause. And you should ask.

In fact, health care providers should always ask our patients about their use of medications (both prescription and over-the-counter), recreational drugs, medicinal narcotics, alcohol, cigarettes, and herbal and supplement remedies. We should be specific and ask for details, not just, “Are you taking anything?” When I phrase the question that way, people often answer no. But, when I ask in more detail, they may say, “Oh, yes. I’m on the birth control pill.” Then, “Oh, that. Yes, I take a sleeping pill every night.” And, “Um, yah. The only way I can sleep is if I also smoke a joint.” So, yes, we should ask in detail.

And, we should remember that our attitudes will influence whether they answer us truthfully or not. I’ve heard time and time again from patients that they don’t tell their physicians about their supplements. I encourage them to do so, but they say that their docs will shame them and tell them they are wasting their money. Some patients have even told me they’re afraid that their doctors won’t even see them anymore.

In terms of having regulation of herbal products being on par with that applied to the pharmaceutical industry, I disagree. Some people wrongly think that the world of natural health products is like the wild west—anyone can sell anything with any claim. This is fully false. We already have good regulations in place. All natural health products on the shelves in Canada are required to have a Natural Product Number (NPN). From the Government of Canada website:

“All natural health products must have a product licence before they can be sold in Canada. To get a licence, applicants must give detailed information about the product to Health Canada, including: medicinal ingredients, source, dose, potency, non-medicinal ingredients and recommended use(s).

Once Health Canada has assessed a product and decided it is safe, effective and of high quality, it issues a product licence along with an eight-digit Natural Product Number (NPN) or Homeopathic Medicine Number (DIN-HM), which must appear on the label. This number lets you know that the product has been reviewed and approved by Health Canada.”

If anything, patients can be informed to make sure that any of the natural health products they buy are either from a qualified and licensed health professional or that the product has an NPN. Where did those two liver patients get their herbal products? That’s the question I would ask.

Rather than try to scare medical doctors into scaring their patients away from all herbal products, let’s try to educate ourselves about them. Let’s tell our patients to talk to the right type of healthcare provider when it comes to the remedies they are taking. Traditional Chinese Medicine practitioners (for Chinese herbs in British Columbia, that’s Dr.TCM, R.TCM.P., or R.TCM.H.) can make sure the herbal medicine is prescribed appropriately.

I work in an integrative clinic with medical physicians as part of the team. We fully respect and appreciate each other’s knowledge, skills, and type of practice. And, it was one of those medical physicians who alerted me to this letter in the BC Medical Journal. He told me, “this is what MDs are reading” because he wanted me to respond in a clear fashion that could inform both my TCM and other natural health colleagues, and perhaps help inform medical doctors as well, so we could all work together. With the facts. And with patient interest at the forefront.

While fear might provoke action faster than any other emotion, it doesn’t help us in the long-run when it comes to our health care system.

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The Media Loves to Write About “Dangerous Chinese Herbs”

The Vancouver Sun recently wrote an article titled, “Chinese herbs mixed with medications can be hazardous.” Now, the article doesn’t really say that Chinese herbs themselves are dangerous. It discusses how patients (particularly those from China) often take Chinese herbs, but don’t tell their medical doctors about it. And the onus of blame for health risks from drug-herb interactions always lands on the herbs, not the pharmaceuticals.

Chinese herbs mixed with medications can be hazardous

Using traditional Chinese herbal remedies while also taking prescription medications can cause potentially life-threatening reactions. After a survey of Chinese immigrants in Vancouver found that many use traditional herbs and fail to disclose it to
 
Chinese herbs, drug-herb interactions, Vancouver Sun dangerous Chinese herbs
 

The Good Side of Awareness for Drug-Herb Interactions

A group of medical students is working with an emergency medical doctor at Vancouver General Hospital to provide a checklist of common Chinese herbs with a listing of the herbs’ actions. The intent is to provide the list to TCM practitioners, TCM herbalists, and TCM doctors to have them check the box next to any of the herbs they prescribe to each of their patients. The idea is that the patient would then provide this checklist to their MD.

I do agree that dangerous drug-herb interactions need to be avoided. 

I do agree that it’s important that patients notify their MDs about any herbs or supplements they are taking. And that they also tell their TCM health professional (and any other health providers) about medications they are taking.

I do agree that Chinese herbs can have powerful medicinal effects. This actually is refreshing to me to hear medical students and a VGH ER doc note the potent physiological actions of Chinese herbs. TCM offers effective medicinal results, and too often the conventional side questions the efficacy. This group of conventional health providers do not question that there are medicinal effects. Bravo! 

Should We Be Concerned About Dangerous Chinese Herbs?

But, is it really the Chinese herbs themselves that are the problem?

How herbs are being taken

Part of the problem is it that patients may take herbs improperly, taking the health advice of a friend or family member (or Dr. Google), rather than seek the help of a qualified TCM doctor or herbalist.

As a registered doctor of Traditional Chinese Medicine, I know that when we prescribe Chinese herbs, the herbs are almost never prescribed as a single herb. We gather a lot of information from our patients about their health conditions, their medications (we too learn about drug-herb interactions), their other supplements, and a long list of symptoms, life patterns, and medical history. We do this so that we can work to avoid side effects and negative interactions.

British Columbians are lucky. TCM is a regulated profession. TCM herbs are prescribed by health professionals who are registered, licensed, and insured. We are held accountable, just like MDs, nurses, physios, and other health professionals under the Health Professions Act. So, make sure the person who tells you to take your Chinese herbs is actually qualified to do so. Note that if you want Chinese herbs, check our regulatory body’s website and choose only those with Dr.TCM, R.TCM.P., or R.TCM.H. Registered acupuncturists (R.Ac.) are not qualified to prescribe Chinese herbs.

What about the pharmaceuticals?

How about the pharmaceutical medications themselves? Do they hold some responsibility, or is it a dysfunctional blaming relationship? “It’s not me, it’s you.”

For example, the blood thinning drug warfarin (that they mention in the Vancouver Sun article) does not play well with others. Many others. Including A.S.A. (e.g. Aspirin), ibuprofen (e.g. Advil), and acetominophen (e.g. Tylenol); thyroid medicine, some antibiotics, and some antidepressants; and even many foods, like grapefruit, avocado, large amounts of kale or other otherwise healthy dark leafy greens, and store-bought mayo, salad dressings, and margarine.

I’m not against the proper use of pharmaceutical medicine. I work in an integrative medicine clinic with MDs and an ND who prescribe them. My mother is a nurse practitioner. I will take an Advil or Tylenol if I am suffering pain and need quick relief. But, too many people are too over-medicated because it’s easy to do. Because MSP or extended health plans pay for the medications, but not our herbs, vitamins, and other supplements. Because of scary articles like this one in the Vancouver Sun.

Why aren’t patients telling their MDs about their herb use?

Then, of course, there’s the big question…why aren’t patients telling their MDs about the herbs, vitamins, and other supplements they are taking? This article provides an answer, “A survey her group conducted of more than 300 Chinese immigrants to Vancouver revealed many don’t disclose their use of such remedies because they feel they’ll be harshly judged.” 

That is a problem!

And it’s not just Chinese immigrants who feel that way. Many patients have told me that they take supplements or get treatments (like acupuncture, chiropractic, osteopathy, and more) despite the flak they take from their MDs. Some have learned to just shut it when it comes to that discussion. Easier not to have to argue. Or justify. Or try to explain how it’s actually working for them. 

So, will my taking the time to print, fill out, and hand that checklist to each patient who receives Chinese herbs from me help?

Maybe a bit. Maybe it will open up some much needed dialogue between health professions so we can work better together. *I’m lucky because I work in an integrative medical clinic alongside MDs who are open-minded and who practice functional medicine–which really actually uses TCM foundational principles.

But, if only 1% of the herbal formula I make for someone is licorice root, will the MD still have them stop their herbs if they are taking warfarin? 

And, above all, if patients feel they can’t discuss their health choices with their MDs, will they even hand that list to their MD? 

 

http://www.webmd.com/drugs/2/drug-3949/warfarin+oral/details/list-interaction-medication 
http://www.ihtc.org/patient/blood-disorders/clotting-disorders/coumadin-interactions-with-food/ 

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TCM is a New Medicine!

Yes, Traditional Chinese Medicine has been around for 3000-5000 years. Yes, it is the oldest continuously practiced medicine in current practice. Yes, other medicine like Aryuvedic and other native medicinal practices also have long historical records of practice.

But, the “new” medicine, the current buzz word in conventional medicine, is “Functional Medicine”. What is functional medicine?

  • It addresses the underlying cause of disease
  • It focuses on the patient instead of the disease
  • It addresses the whole person–body, mind, and spirit
  • Practitioners spend more time with their patients to gather information on a variety of levels
  • Practitioners create an individualized treatment plan for each patient

Hmmmm…that’s what TCM does. We have always done that. But conventional medicine has relatively recently identified this “new” way of practicing medicine!

It kind of reminds me of this quote:

2001 BC Here, eat this root.

1000 AD That root is heathen. Here, say this prayer.

1850 AD That prayer is superstition. Here, drink this potion.

1920 AD That potion is snake oil. Here, swallow this pill.

1945 AD That pill is ineffective. Here, take this penicillin.

1955 AD Oops… bugs mutated. Here, take this tetracycline.

1960-1999 AD 39 more “oops”… Here, take this more powerful antibiotic.

2000 AD The bugs have won! Here, eat this root.

I love it! 🙂

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More from Dr. Frank Lipman (MD)

Written by an MD, this newsletter that I have just subscribed to puts conventional medicine in perspective. This is a cut and paste of the last e-newsletter I received. You can check it out yourself by googling his name and signing up for it yourself. Of course, I’ll probably post more from him if it keeps of interest to me.

Changing our Disease care system to a Health care system

Although we call our system a health care system, it is actually a disease care system. Doctors are trained to treat disease, not to keep people healthy. Our two primary tools as Doctors of Modern Western Medicine are drugs and surgery. We have no tools to keep people healthy.

We are not trained in nutrition or other lifestyle modalities that keep people healthy, nor other medical systems that have been helping other cultures for centuries. At medical schools, we doctors are taught to treat the symptoms of disease, rather than how to create health and prevent people from getting sick. For example, in our entire training as doctors, we receive very few lectures on nutrition, even though diet is fundamental to good health.

I am not saying there is no place for this disease care model in the new model of medicine I am proposing. I am the first to acknowledge that Modern Western Medicine and science have made phenomenal advances and alleviate much pain and suffering. Surgery is often lifesaving and many new surgical techniques are quite remarkable. Trauma treatment, burn treatment, emergency room management and the management of acute medical and surgical emergencies are incredible. And certain drugs when used appropriately are life saving. We are blessed to have all this as part of our arsenal and we need Modern Western Medicine for all this. I would not encourage someone to see a herbalist or Acupuncturist for any of the above.

But this medical model is not adequately addressing almost 75% of the problems that most people go to their Doctor for, including most chronic problems. It has failed miserably to address the majority of problems people have today and because of this, many people suffer unnecessarily.

Apart from antibiotics where the drug can kill the bug causing the problem, most drugs treat symptoms, not the cause. Similarly with surgery, it usually addresses the symptoms, not the cause. For instance, bypass surgery, (which can be lifesaving!!!), does not address the underlying reason why your arteries are getting blocked in the first place.

And with both drugs and surgery, there are often side effects, which are then addressed with more drugs. Many patients end up on multiple drugs and often it is only the first 1 or 2 which were given for the original problem. The other 5-10 are dealing with the side effects of the original 2 drugs or the interactions of the other drugs.

The tragedy is that for many of these problems, changing lifestyle, behavior, diet and taking some supplements can often deal with the underlying processes causing the problems and no drugs (and therefore side effects) would be necessary. Unfortunately, it does not suit the drug industry to have patients take a drug which cures or eliminates the problem. It is much more lucrative for them if the drug can manage the symptoms, so you have to stay on them for life (eg statins, anti- hypertensives etc)

Modern Western Medicine is a disease care system, it is not preventive nor does it teach patients how to stay well. In fact what we call Preventive Medicine in Modern Western Medicine…Pap Smears, Breast exams, certain blood tests etc are really early detection medicine. They are not teaching patients how to stay healthy.

So the best medicine is using Modern Western Medicine for what it is good at….crisis care medicine, acute medical and surgical emergencies, when you break a bone, when you are acutely ill etc, and using diet, supplements, exercise, stress management and other benign modalities for prevention and initially for most non acute problems.

In this new model of medicine I am talking about or in a true health care system, we look for the underlying imbalances or dysfunctions and the root causes of the problem (to be discussed in a future “pearl”). We are not content with waiting for disease to occur nor with just suppressing symptoms.

One Love,

Frank

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