Chinese herbal medicine (hereafter referred to as TCM), as an important part of Chinese medicine, has made great contributions to human health. With the continuous development of health care reasons and the combination of Chinese and Western medicine in the treatment of diseases, the clinical application of TCM and its preparations is increasing. In recent years, there has been an increase in the number of reports of adverse reactions caused by herbal medicines and their products, and it has been reported that “drug-related hepatitis” caused by herbal medicines accounts for 21.0%-51.4% of the total cases of drug-related liver disease in clinical practice. It is one-sided to blindly believe that Chinese medicine is a natural medicine and has no adverse effects, so we should pay attention to liver injury caused by Chinese medicine.
The causes of “drug-related hepatitis” caused by Chinese medicine
1, Chinese medicine factors.
(1) misconceptions about Chinese medicine “natural drugs are not toxic” is a misleading propaganda, medicine is three points of poison. Chinese medicine is not only toxic, a small number of drugs have a big poison! There are clear discussions in the herbs, medical books and modern textbooks, such as the Chinese medicine to break the stasis and disperse the knots and kill insects should not be taken for a long time, and it is easy to hurt the righteousness.
(2) The chemical composition and pharmacological activity of herbal medicines are very complex, and many plants can synthesize chemicals such as alkaloids and periodic polypeptides, which have toxic effects on animals and gain their own protection. The liver, as a biological factory for processing chemicals in the body, may produce toxic intermediate metabolites while removing these toxic substances, leading to “drug hepatitis”.
(3) There are many cases of Chinese medicine with the same name or different names, which can lead to poisoning due to misidentification and misuse. For example, Fangqi has wide Fangqi, powder Fangqi, wide Fangqi clinical self reported to have liver and kidney toxicity.
(4) drugs due to the origin, planting, harvesting season, processing and concoction, transportation and storage conditions, can also affect its efficacy and adverse reactions, such as taking large doses of unconcocted raw shouwu will lead to liver damage.
(5) The use of Chinese medicine or proprietary Chinese medicine is not in accordance with the basic features of the diagnosis and treatment of Chinese medicine, and violates the principle of contraindication, such as avoiding the use of published medicine for surface deficiency and night sweating, and avoiding the use of laxative medicine for women before and after delivery.
2.Patient factors
(1) Patients may take some toxic Chinese medicines, proprietary Chinese medicines or secret recipes or prescriptions on their own, mistakenly or superstitiously, or due to the lack of understanding of the hepatotoxicity of some Chinese medicines, they may take too large a dose of Chinese medicines or use them for too long and cause “drug hepatitis”.
(2) Different age or health conditions, such as the elderly, children, infirmity, maternity and liver and kidney dysfunction, are more likely to cause toxic reactions.
(3) Toxic reactions can occur in a few people at regular doses due to individual differences.
In addition, since there is little research on Chinese medicine, especially compound Chinese medicine, for technical reasons, we do not know what kind of effect on the activity of drug metabolizing enzymes is caused by taking one kind of Chinese medicine, which may lead to the accumulation or metabolic transformation of other drugs in the body, thus producing toxic effects on the liver.
Commonly used herbs that can cause “drug-related hepatitis
poppy, mulberry, ginger, rhubarb, tiger scepter, guanzhong, mugwort, mugwort, senna, anthrax, bupleurum, nutmeg, shanglu, changshan, dafengzi, vermilion, spotted fungus, pandanus, scutellaria, valerian, aconite, white fruit, etc.
The following herbal compound preparations are known to cause “drug-related hepatitis”: Strong Bone and Joint Pill, Xiao Chai Hu Tang, Da Chai Hu Tang, Compound Qing Dai Capsule (Pill), Ke Yin Pill, Dissipative Yin Tablet (Pill), Dissipative Nucleus Tablet, Vitiligo Capsule, Bai Fu Kang Punch, Bai Etching Pill, Liushen Pill, Noma San, Ma Heng Shi Gan Tang, Ge Gen Tang, Da Huang Mudan Pi Tang, Fang Feng Tong Sheng San, Damp Poison Qing, Blood Poison Pill, Chasing Wind and Bone. The Chinese medicine is also used to treat coughs and asthma, Bone Stretching Capsules, Bone Immortal Tablets, Zeng Sheng Ping, Six Gods Pill, Niuhuang Detoxification Tablets, Tianma Pill, Compound Dan Shen Injection, Di Ao Xin He Kang, Kunming Shan Hai Tang Tablets, etc.
In addition, some topical Chinese medicines can also cause different degrees of “drug hepatitis” after being taken by mistake: fish gall bladder, fish vine, sea hare, stellaria, peppermint oil, raw cotton seed oil, tung seed and tung oil, etc.
Clinical manifestations of “drug-induced hepatitis” caused by Chinese medicine
Over the past 70 years, more than 350 plants worldwide have been found to contain hepatotoxic alkaloids that clinically resemble all forms of acute and chronic liver disease, including acute hepatocellular damage, cholestasis, chronic hepatitis with fibrosis, cirrhosis, and fulminant liver failure.
The common clinical symptoms of acute “drug hepatitis” are malaise, poor appetite, anorexia, abdominal distension, nausea and vomiting, and in a few patients, rash, fever, jaundice, etc., indicating significant hepatocellular damage or intrahepatic cholestasis, and in severe cases, hepatic coma, gastrointestinal hemorrhage, renal failure and even death. For example, senna, ephedra, jinbao, brahmi, daphyllanthus and xiaochaihu tang.
Cholestasis, whose clinical manifestations include jaundice, itching, nausea, malaise and fatigue. Biochemical features are elevated alkaline phosphatase, γ-glutamyl transpeptidase, 5’nucleotidase and other indicators of bile duct damage. Acute cholestasis has been reported to be caused by gibberellic acid. Glycopyrrolate has also been reported to cause bile duct disappearance syndrome.
Chronic hepatitis may be similar in presentation to chronic viral hepatitis and chronic autoimmune hepatitis. Chronic liver damage can be produced by long-term use of herbal medicines such as Xiao Chai Hu Tang and Jin Bu Xie.
Prevention of “drug-related hepatitis” caused by Chinese medicine
(1) Correctly understand the hepatotoxicity of Chinese medicine. Raise the awareness of adverse drug reactions and eliminate the misconception that Chinese medicine has no adverse reactions and is safe to use. The adverse reactions of Chinese medicine have many research work waiting to be done, but there are more difficulties, because Chinese medicine is often a compound preparation of multiple drugs, and the same drug, if the origin, planting, growth period, harvesting season, processing, preparation, transportation, storage and other links are different, not only the composition and efficacy of different, and adverse reactions are not the same. Whether it is a single medicine, multi-flavored Chinese medicine soup, Chinese patent medicine, or injection, all can cause liver damage.
(2) Strengthen publicity, education and guidance for patients, advise them to take drugs under the guidance of doctors, and prevent or correct their indiscriminate use of folk single prescriptions, Chinese and Western drugs or health products, especially certain Chinese health products often lack strict animal experiments and clinical observation before they are marketed, and adverse reactions are often unpredictable. This can not only reduce the metabolic burden on the liver, but also avoid the potential toxic damage to the liver from drugs.
(3) To use drugs rationally. Doctors should try to avoid the application of drugs that have been reported in the literature to cause “drug hepatitis” in the treatment process, and prescribe drugs in accordance with the pharmacopoeia or the recommended dose, method of administration and course of treatment; if it is really necessary to use Chinese medicine that has direct toxicity to the liver, liver function should be tested regularly; try to avoid taking drugs after drinking or in a state of hunger; malnutrition and elderly patients should not take drugs in the same way. The detoxification ability of drugs decreases in malnourished and elderly patients, which makes them more prone to drug-related liver damage, so the dosage of drugs should be reduced appropriately; avoid using too many drugs and avoid the combined application of multiple Chinese medicines or with multiple western medicines.
(4) During the application of Chinese medicine, once the patient is found to have symptoms such as weakness, poor performance, jaundice, or allergic manifestations such as rash and fever, liver function should be checked and the drug should be stopped in time.
Chinese medicines have dual pharmacological and toxicological effects, and even their active ingredients are their toxic ingredients. In clinical practice, physicians and patients should be encouraged to report adverse reactions related to TCM in order to study the incidence of hepatotoxicity of TCM preparations, so that our national essence can flourish and serve the people better and safer.