Herbal Hazards

Many people put their trust in herbal medicines in the belief that, because they are natural, they must be safe and pure. But doctors warn that some herbal remedies can be hazardous to your health.

EVERYONE knows to avoid drugs when pregnant. I kept away from smoky rooms, drank no alcohol and resisted my obstetrician’s suggestion that I take a mild sleeping pill when the aches of late pregnancy kept me awake at night. But I was quite happy to take a naturopathic remedy, L-tryptophan; after all, it was merely the amino acid in milk that helps make you sleepy. My doctor agreed; what harm could there be? Lots, I discovered a year later. In 1989, L-tryptophan was taken off the market in America after it was linked to the deaths of between 30 and 40 people, and made up to 40,000 seriously ill with eosinophilia myalgia syndrome, or EMS, which causes muscle pain and weakness. Two suspected cases of mild EMS were reported in Australia. It was later found that nearly all the US cases were linked to contaminated batches, and authorities decided that a recall would solve the problem. L-tryptophan is still banned there, however, because doctors now suspect that even in its pure form, it could trigger the syndrome in sensitive people. Australia has recalled high-dosage tablets, but L-tryptophan is still available here in forms that do not exceed 100 milligrams a day.

Scares about adverse reactions to multi-vitamin and herbal remedies have raised questions about how they are used. Does alternative medicine deserve its reputation for being safer than more orthodox doctoring? Is it naive to assume that because a remedy is “natural”, it is less toxic and has fewer side-effects than pharmaceutical drugs? The debate about alternative medicine has tended to focus on whether it works; perhaps a more pressing issue is whether it hurts.

A recent inquest in Sydney was told that a 21-year-old woman stopped breathing 15 minutes after taking a Chinese herbal concoction for the flu. She died in intensive care the following day from hypoxic encephalopathy _ lack of oxygen to the brain _ as a result of water in her lungs. Police told the inquest that one of the herbs, Perilla frutescens, or herbal mint, had been reported to cause a build-up of water in the lungs of livestock. The doctor who performed the autopsy said tests to try to establish a link between the herbs and the woman’s death were inconclusive, but that she might have had an allergic reaction to one or more of the herbs. It was also possible that the herbs, traditionally considered safe, might have been contaminated.

Such dramatic alarms are unusual, but the federal Health Department has documented many suspected adverse reactions to natural remedies.

The Adverse Drug Reactions Advisory Committee in Canberra warned about side-effects of the herb chaparral following reports of several cases of liver damage. The committee says that comfrey, coltsfoot, butterbur, senna, germander, skullcap, echinacea and valerian, as well as some Chinese herbal medicines, have also been linked with liver disease.

Royal jelly has been associated with bronchospasm and anaphylactoid reaction, which cause breathing difficulties. Milk thistle is suspected of having caused thrombocytopenia, a shortage of platelets in the blood that could trigger uncontrolled bleeding. Raw guarana powder has been linked with drug psychosis, apricot kernel oil with diarrhoea and vomiting, and a slimming formula with amnesia, confusion and hallucination. Unspecified herbal mixtures have been suspected of causing haemorrhagic gastritis, haemolytic anaemia and angioedema.

The committee has urged caution with the herbs four-anthered stephania and lamp post, following reports from Belgium of kidney failure in 48 women on a slimming regimen that included the herbs. Eighteen of the women are in terminal renal failure. The committee suggested doctors consider the possibility that natural remedies might be the cause of unexplained illness.

To doctors grappling with today’s better-informed patients, fielding sharp queries about prescriptions and their potential side-effects, such accounts are exasperating. Why is it that natural therapists are not put through the same hoops? A recent editorial in an Australian medical magazine said: “Our patients are often frightened to take hormone therapies for fear of cancer, but will take mega-dose multi- vitamins and herbal extracts without a thought of the risks. ANY therapy that claims a therapeutic effect MUST have the potential for short and long-term side-effects.” The editorial went on to claim that orthodox medicine, unlike herbalism, demands standardisation of dosage and purity, as well as proof that the drug works and is safe in the short-term.

Doctors cannot altogether take refuge on the moral high ground. Modern medicine lost its hero status long ago. “Scientifically tested” drugs and devices have wreaked terrible unforeseen harm: thalidomide caused birth deformities, the Dalkon shield killed or mutilated many women who used it, and common tranquillisers have caused severe addictions. In cases such as these, it is doctors who have unwittingly played shaman.

But it is undeniable that, when it comes to clinical testing, pharmaceutical drugs are usually far more rigorously assessed than natural remedies. They are also used, generally, for particular conditions that have been clearly diagnosed. Dr Alain Rohan, the secretary of the Adverse Drug Reactions Advisory Committee, says: “The concern that I would have (with natural remedies) is when the therapy isn’t essential to the treatment of an illness, or the efficacy of the treatment hasn’t been demonstrated in terms of improving well-being.” Dr Rohan says that some prescription drugs, such as those used with cancer, have severe side-effects but are tolerated because they save lives. “Where the benefit is not established, but the risk is quite clear, any adverse effects must be taken very seriously.”
Dr Richard Gordon argues that successes by natural therapists are unproved, and that any apparent improvement is largely due to the placebo effect, which can help up to 60 per cent of people with certain illnesses, or to the cyclical nature of the patient’s condition.

Dr Gordon is the national spokesman on alternative medicine for Australian Sceptics and chairman of the committee on quackery with the New South Wales branch of the Australian Medical Association. He says that many conditions natural therapists treat, such as arthritis, migraines and menstrual problems, have natural cycles that can be mistaken for a response to treatment.

To be accepted as effective, natural remedies would have to be put through the same testing as other drugs, he argues. This would include basic checks for toxicity and efficacy tests such as the double blind trial, in which even the person handing out the tablets doesn’t know which ones are real and which are placebo. Dr Gordon is also concerned about the purity and dosage of herbal medicines. “If you take the leaves off a plant and try and make an infusion, its strength can be very variable, depending on where the plant was grown, what sort of soil it was in, and the time of year. You’re also not getting one substance. There might be 30 or 40 active chemicals in that plant; two of them might have the effect you are looking for, and if you are lucky, the others might be just neutral _ but that’s not always the case.”
Some groups are more vulnerable than others. Pregnant and breastfeeding women have been warned about taking some vitamin and herbal preparations. Babies and children might be at special risk from herbal teas because toxic effects are cumulative, according to a 1989 article in the magazine `Australian Family Physician’. The authors, two of whom were senior paediatric dietitians at a NSW children’s hospital, recommended against herbal teas for babies (calming teas such as camomile are often recommended for colicky babies). They said some teas hold potentially poisonous compounds, others have undesirable ingredients such as caffeine or tannin, and any might be contaminated with other herbs, weeds or seeds, or lead.

Nature is not always motherly. Her offspring include poisons such as arsenic and deadly nightshade as well as medicines such as digitalis and aspirin; her produce has as much power to destroy as it has to heal. Those who offer traditional medicine say that a heritage of thousands of years of use has shown them how to pick their way between the benefits and the dangers.

Raymond Khoury, the secretary of the National Herbalists Association and the Natural Therapists Forum, says that of about 40,000 medicinal plants identified worldwide, only 200 or so are used in Australia: “All of them have had chemical studies done
to ascertain their components to see that they are safe.”
Mr Khoury says some of the adverse reactions reported in Australia are merely anecdotes or suspicions, with no scientific credibility, and others involve patients who were taking pharmaceutical drugs as well: “It’s assumed that the problem is caused
by the herbal medicine. They need to look at each medicine individually.” More likely causes of problems are patients abusing the medication by exceeding the dosage, or a super-sensitivity to particular ingredients in some people: “How many people do you know who can’t drink red wine because they get a headache? People like that have to be careful. It’s the same with herbal medication.”
Mr Khoury argues that standardisation of dosage has never been a problem with herbal medicine, because its therapeutic agents are much milder than pharmaceutical drugs. But he says that there has been a dramatic push in Europe towards standardisation.

Australia has much better regulation of such substances now than a decade ago. The national Therapeutic Goods Administration conducts regular testing of herbal and vitamin remedies to check for compliance with standards including purity and authenticity.

A traditional-medicines evaluation committee monitors and advises the administration on the registration of new products and any concerns with existing products. But practitioners are largely free to prescribe such substances as they see fit.

It is hard to put adverse reactions in perspective. For every problem reported in Australia there are thousands of uneventful visits to natural practitioners, many of which leave patients convinced that they have been helped. David Stelfox, principal of the Melbourne College of Naturopathy, says safe usage comes down to the knowledge and awareness of the practitioner prescribing the medicine. But advice can vary between practitioners, and individual consumers can dose themselves unwisely with over-the-counter preparations. Australia has limited the dosages of vitamin A following overseas cases of birth defects after pregnant women took mega-doses; the herb ephedra has been restricted because truckies were using it as an “upper” to keep awake.

There can be problems even with “normal” usage. In my second pregnancy, I went to a health food shop to buy some raspberry leaf tea, which folklore calls a uterine tonic. The girl at the counter looked at me doubtfully and said, “I wouldn’t take that if I were you. We’ve just been told to warn customers that it’s known to cause spontaneous abortion in some pregnant women, and it’s impossible to tell which women are at risk.” She did not have to tell me twice.

Mr Khoury says such warnings are “just rubbish; it’s very, very safe”. Mr Stelfox says: “Most herbalists should know that it should only be used in the last trimester of pregnancy.” Perhaps the lesson for consumers is that faith in any kind of treatment, orthodox or alternative, should not be blind.

First published in The Age.