Little's erroneously named presentation underlines the importance of including complementary and alternative medicines in the clinical picture.

1. Its natural, therefore it must be
safe!
OR
Do we really ask what people
are ingesting?
Mark Little
Emergency Physician & Clinical
Toxicologist
Cairns Base Hospital
SMACC 2013 Sydney

2. In this talk I will attempt to
link…
SMACC 2013 Sydney

3. SMACC 2013 Sydney

4. SMACC 2013 Sydney

5. SMACC 2013 Sydney

6. SMACC 2013 Sydney

7. SMACC 2013 Sydney

8. Take home messages
“We need to ask our
patients what else are
they ingesting”
All things ‘natural’ may
not 2013 Sydney
be safe
SMACC

9. So let me start with a case….
You are handed an ECG
SMACC 2013 Sydney

10. SMACC 2013 Sydney

11. •
•
•
•
•
•
39M
Presents to a tertiary hospital ED with
collapse
Unwell for 4 days, weak and some
diarrhoea
Two previous admissions in last month
with diarrhoea (1 admission) and collapse
in another
Both admissions K+ is 2.2mmol/L
No other PMH, medications or allergy
SMACC 2013 Sydney

12. •
Examination is unremarkable
•
Serum K 2.1 mmol/L
•
•
Other investigations – U&E, LFT, FBC,
cortisol, MSU, stool culture all N, no K+ in
urine.
Admitted medically
SMACC 2013 Sydney

13. •
•
•
He received IV K+
A few days later an observant RMO
notices a large full sports bag by his bed
In it he discovers …
SMACC 2013 Sydney

14. Boxes of
•
Ginko
•
MgSO4
•
Ginseng
•
Rodium
•
Selenium
•
Green lip mussels
•
Zinc, copper, manganese
•
•
KI
•
•
•
Tumeric, cumin
ginger
•
•
Vit C D3 B5
Human growth Hormone
Melatonin
•
Gotu kola
•
Riboflavin
Garlic oil
Omega 3
•
Himalayan mountain
salt
SMACC 2013 Sydney

15. Boxes of
•
Ginko
•
MgSO4
•
Ginseng
•
Rodium
•
Selenium
•
Green lip mussels
•
Zinc, copper, manganese
•
Tumeric, cummin ginger
•
KI
•
Garlic oil
•
Riboflavin
•
Melatonin
•
Vit C D3 B5
•
Gotu kola
•
Human growth Hormone
•
Omega 3
•
Himalayan mountain salt
SMACC 2013 Sydney

16. Himalayan salts
•
It allows for best food concentration in the intestinal parcel and
it promotes respiratory and sinus health. It is too used to
comfort menstrual cramps, strengthens our bones, helps heal
insomnia, boosts libido, and encourages vascular health. In
combination with water, it regulates our blood force. Himalayan
Salt is however pre-pollution and without environmental influence. It
is indistinguishable in minerals to the old primordial sea with all the
minerals and retrace elements our system needs. These normal
minerals are indistinguishable to the minerals, which our bodies
have evolved with and are too earlier establish existing in the
primordial sea.
SMACC 2013 Sydney

17. SMACC 2013 Sydney

18. Turns out instead of having 1
teaspoon/d having 8g/d for
weeks
•
So we did a test……
SMACC 2013 Sydney

19. Urine cesium
•
Sample A: 656,000mcg/gm creatinine
•
Sample B: 848,000mcg/gm creatinine
•
(N: <7.7mcg/gm creatinine)
SMACC 2013 Sydney

20. Cesium
•
•
•
•
•
•
•
Cs 55
Similar to K+
Seen as an alternative cure to cancer
Case reports of hypoK and torsades
Usually in setting of alternative therapy
Biological half life 50 – 200 days
Management is supportive
SMACC 2013 Sydney

21. We did not ask what else he
was taking
SMACC 2013 Sydney

22. Complementary and alternate
medications (CAM)
•
•
•
•
•
•
In Australia 2010 $3.1 B turnover
In Australia - 60% take at least 1 CAM regularly
Global sales over $US 100B and likely to exceed
$US 1T in 20 years
In the USA, from 1994 – 2005 number of CAM
products increased from 4000 – 29 000
In Singapore TCM usage has tripled from 2005 –
2007
The internet makes worldwide CAM available
SMACC 2013 Sydney

23. Drug interactions
Australian Prescriber Dec 10
SMACC 2013 Sydney

24. Ma Huang
•
•
•
•
Review of 140 reports
to FDA
Stimulant like – for wt
loss or increased
performance
HT (17%), tachycardia
(13%), MI (2%), arrest
(8%), stroke (10%)
Death or permanent
disability 26% cases.
SMACC 2013 Sydney

25. Black cohosh (Cimicifuga racemosa) and other
herbal remedies associated with acute
hepatitis MJA 2002
•
•
•
•
Case series
Black cohosh used for
treatment of menopause
6 patients with severe
hepatitis after herbal
preparations
One required
transplantation for FHF
SMACC 2013 Sydney

26. Summary of cases
SMACC 2013 Sydney

27. Conclusion
•
“…medical practitioners need to be aware
of the potential adverse effects and should
routinely ask about all medications
including herbal mixtures:.”
SMACC 2013 Sydney

28. Another case
•
•
•
•
62F no PMH or medications
Admitted medically with 7 days of vomiting
lethargy malaise joint pain
Rapid deterioration within 2 days – fulminant
hepatic failure (AST 19000, INR 2, BR 60,
ammonia 170) with respiratory failure, renal
failure, marrow failure needing ICU
admission, ventilation and dialysis
All usual causes for liver failure/ sepsis
negative
SMACC 2013 Sydney

29. Family then tell us
•
•
•
Unwell for 1 week
Started on a herbal preparation from local
TCM shop
Herbs from China – dried and sold in
Sydney
SMACC 2013 Sydney

30. SMACC 2013 Sydney
SMACC 2013 Sydney

31. •
•
•
•
Nine herbs (plants) present
Tea made – patient had been drinking a lot
Investigation from other TCM
experts/University of Sydney suggested 2
of these herbs caused the toxicity
One of the root instead of the leaves
increased hepatotoxicity risk
SMACC 2013 Sydney

32. Patient survives
SMACC 2013 Sydney

33. Adverse events from CAM from
Singapore 98 – 09 Clin Tox 2012
•
•
Reports of adverse events (AE) reported
to the Singapore Health Sciences
Authority
Those involving CAM 1998 – 2009
SMACC 2013 Sydney

34. Results
•
•
627 cases = 4% of all AEs reported
(includes conventional medicines)
Of the 627 cases
–
•
– 80% deemed serious, 78% required
hospitalisation
Indications for use
–
–
–
Sexual performance enhancement (46%)
Pain relief (36%)
Slimming (4%)
SMACC 2013 Sydney

35. Adverse events
•
Endocrine disorders 22%
–
•
CNS disorders 21%
–
•
(hypoglycaemia 228 cases, Cushings 17)
(coma 114, drowsiness 80)
Deaths 22
–
Hepatotoxcity 10, severe hypoglycaemia 9
SMACC 2013 Sydney

36. Adulterants
•
•
160/627 CAM products sent for testing
72/160 (45%) adulterated
–
•
44/72 had more than one adulterant
Adulterants
–
–
Sildenafil, dexamethasone, N
nitrosofenfluramine, phenylbutazone,
glibenclamide, paracetamol
Two products had lead (100x the allowed
level) and mercury (8x)
SMACC 2013 Sydney

37. Examples
•
Slimming product “Slim 10”
–
–
•
13 patients had palpitations, sweating,
hepatitis like (1 death FHF)
Adulterated with N nitrosofenfluramine,
fenfluramine and thyroid gland extract
Sexual enhancing products “Power 1
walnut” or “Santi Bovine Penis Erecting
capsule”
–
–
210 cases
Contained sildenafil and glibenclamide (5x
daily dose)
SMACC 2013 Sydney

38. Conclusion
•
“Health professionals should encourage
patients to disclose the use of CAM,
allowing detection of potential drug – herb
interactions, or sources of adverse events”
SMACC 2013 Sydney

39. Summary
•
•
•
•
•
The use of CAMs is common in our
patients
There is the risk of drug interactions and
adverse effects
Hepatotoxicity is a common cause of
death
Risk of drug adulteration
We tend not to ask…
SMACC 2013 Sydney

40. Take home messages
“We need to ask our
patients what else are
they ingesting”
All things ‘natural’ may
not be safe
SMACC 2013 Sydney

41. Questions?
SMACC 2013 Sydney