First of all, Chinese medicine is toxic, as evidenced by the old saying that medicine is three times poisonous. Folk people always think that Chinese medicine is non-toxic is a big misunderstanding. The reality is that there are many toxic side effects, but limited to the funding and scale of domestic clinical trials, many toxic side effects are underreported. Secondly, the therapeutic effect of Chinese medicine is not certain, and it is difficult to get the support of modern scientific theories. Some may talk about Tu Youyou and Artemisinin, but objectively speaking, it is still a validation of the inherent empirical medicine by modern science and technology. So many Chinese medicines and herbs, just this one example. So the majority of tumor patients are often interested in trying Chinese medicine, I think we should still be careful. [Core Tip] In 16 large hospitals across the country in cases of drug-related liver injury, Chinese herbs accounted for 20% of the causative factors. 3 large specialized hospitals data show that more than half of the cases of drug liver related to Chinese medicine. The most important cause of acute liver failure, a liver disease serious enough to kill, is herbal medicine. “It’s so necessary to call for public and government attention.” Numerous hepatologists interviewed took a clear stance on the current safety of herbal medicine use. They are most aware of the problem of drug-induced liver damage and have been exposed to a large number of patients with liver damage caused by herbal medicines. A series of problems, including private abuse and improper government regulation, have kept liver damage from Chinese herbal medicines a secret on the mainland for a long time. The reporter of Phoenix Weekly spent half a year visiting many authoritative hepatologists in mainland China, tracking down the most cutting-edge discussions in the pharmaceutical industry, and investigating the liver damage of Chinese herbs as a serious drug safety issue. From the public, pharmaceutical companies, to academia and government, the problem of herbal liver damage can no longer be ignored and covered up. Unlike chemical drugs (western drugs) that can cause liver damage with complete data, there are no in-depth toxicological studies on the liver damage of Chinese herbs widely used by Chinese people. Even Chinese and Western medical doctors who prescribe Chinese medicines are often unaware of the risk of liver damage from herbal medicines. A growing body of medical research has found that a large group of traditional Chinese herbs are damaging the nation’s liver. Long-term, high-dose use – both proprietary Chinese medicines and herbal remedies – can be fatal. A retrospective survey of medicinal livers covering 16 large hospitals across the country, conducted by Prof. Xu Jianming of Anhui Medical University in 2005, showed that among more than 1,200 cases of medicinal liver injury, the causative factors of Chinese herbs accounted for 20.6 percent.” In 2013, a paper from Xinqiao Hospital of the Third Military Medical University in Chongqing showed that of the 24,112 cases of drug-induced liver injury patients in China from 1994 to 2011, “Chinese herbal medicines were the second leading cause of drug-induced liver injury in China,” accounting for 18.6 percent. Topping the list of drug-induced liver injuries was anti-tuberculosis drugs, which accounted for nearly one-third of the cases. Guo Hong, the subject of the paper and deputy chief physician at Xinqiao Hospital of the Third Military Medical University, told Phoenix Weekly that the study didn’t take a first-hand survey of cases, but rather reviewed cases reported in previous medical literature in China. Due to the lack of original data, the paper has some limitations, and its main purpose is to call on physicians at home and abroad to pay attention to drug-induced liver damage, especially that caused by Chinese herbs. Some individual hospital data began to be disclosed and discussed in the industry.On May 23, 2014, at the 6th Forum on Drugborne Diseases and Safe Use of Medicines, organized by the academic journal Adverse Drug Reactions, many experts emphasized the risk of liver disease from Chinese herbal medicines in their reports, and gave several values for individual hospitals. Du Xiaoxi, director of the National Center for Adverse Drug Reaction Monitoring, introduced that the director of a Beijing hospital specializing in liver disease had previously told her that about 60% of the hospital’s medicinal liver cases were related to traditional Chinese medicines, while the director of another Western medicine hospital estimated in a private setting at the forum that traditional Chinese medicines might account for half of the hospital’s medicinal liver cases. Wei Lai, vice president of Peking University’s People’s Hospital, disclosed data on the proportion of herbal liver cases at that hospital. “The proportion of herbal and chemical (i.e., Western) medicines in drug-related liver disease is 51 percent for one and 49 percent for the other. There is a higher concentration of chemical drugs that cause liver disease, and which herbs cause medicated liver? We haven’t figured that out yet.” In the clinical setting, medicated liver disease is a diagnosis of exclusion, which is aided primarily by hepatologists relying on adverse drug reaction databases and based on prior knowledge. There are more than 900 chemical drugs available that are clearly known to cause drug-induced liver disease. The risk of liver injury is clearly communicated in the instructions for many chemicals, such as anti-tuberculosis drugs, antibiotics, and many chemotherapeutic drugs. Once the association between liver disease and the drug is identified and confirmed by the physician during the course of medication use, the drug may be discontinued and adjunctive liver protection therapy may be chosen. Internationally, drug-induced liver disease is attracting more and more attention from pharmacology, pharmaceutical companies, drug regulatory authorities and the public. However, due to the widespread use of Chinese medicines and the lack of toxicological studies, China faces a more complex and serious problem of drug-induced liver disease than foreign countries. The ingredients of chemical drugs are identified, domestic and international data on liver injury from chemical drugs are complete, and the whole process of detecting, diagnosing and discontinuing treatment for chemical liver disease is relatively clear. “We are well aware of its efficacy and risks, and doctors and patients are also careful to carry out liver function monitoring, be alert to liver disease that may result from taking the drug, and make timely adjustments and treatments.” Yan Jie, deputy chief physician of the Liver Disease Center of Beijing Ditan Hospital and associate professor of the Peking University School of Medicine, said. Due to the complexity of the composition of traditional Chinese medicine, no one abroad to study the hepatotoxicity of traditional Chinese medicine, and the lack of domestic safety research data, which leads to the use of Chinese herbal medicine in the process of the general public, even including the prescribing of traditional Chinese medicine, Western medicine doctors, are not aware of the risk of liver injury of Chinese herbal medicine. Many people have suffered from acute liver failure and other serious liver diseases, and even lost their lives. The Dangerous He Shou Wu Some hepatologists have found that the longstanding belief that Chinese herbs have no toxic side effects has led to their abuse. Some extremely serious cases of liver disease and death are caused by herbal liver disease patients who believe in folk remedies, abuse Chinese herbs or take Chinese herbs in excessive dosage or over the course of treatment. Cai Haodong, director of the Liver Disease Center at Beijing Ditan Hospital of Capital Medical University (which mainly treats patients with liver disease), is involved in adverse drug reactions and has long been concerned about medication safety. One type of email that appears frequently in one of her public mailboxes is: pregnant and having a baby or self-conscious of being thin and weak, consider taking Chinese medicine to regulate your body. “This is when I get angry, there is a disease treatment to go, no disease don’t mess with the medicine, where is the drug conditioning said.” Cai Haodong lamented. Her recent a hepatitis B patient had recovered well, suddenly appeared jaundice, transaminase elevation symptoms, some inquiries only to find that the patient privately take He Shouwu, expect to complement the liver and cure gray hair. “We heard on the emergency, He Shouwu liver injury cases have been seen. Liver disease patients how to take liver damage to the Chinese herbal medicine.” Cai Haodong said, understanding that the patient’s sister is also taking He Shouwu, they suggested to come to the hospital for diagnosis, the results of the same found liver damage. Yan Jie has been exposed to similar cases recently. A female patient who suffered from drug-related liver disease 2 years ago to Yan Jie consultation, after asking about the history of medication, Yan Jie did not identify the problem. Until the head nurse in a chat accidentally learned that the patient had eaten He Shouwu, “I later asked her, why not say this. She said, did not take it (He Shouwu) as medicine ah.” Yan Jie quite helpless, after careful examination of the causes, confirmed that the patient’s two liver damage and He Shouwu are related. “Like He Shouwu, soil panax ginseng, folk abuse of these drugs, purely no disease looking for disease.” Cai Haodong is quite helpless, He Shouwu in folklore can be rumored to black hair, soil panax ginseng is used to soak in medicinal wine, and these two drugs, there have been clear cases of liver damage. Du Xiaoxi, who majored in traditional Chinese medicine, believes that medicinal liver damage from traditional Chinese medicine is not a new topic in the clinic, but some medication problems should be attributed to purely man-made risks. “There are health programs that encourage the public to stew chicken with 10 grams of He Shouwu every day. But He Shouwu is a flavorful Chinese medicine, is it really appropriate for each person to eat so much per day?” Xiao Xiaohe, director of the All-Army Institute of Traditional Chinese Medicine at PLA 302 Hospital, has tallied that in the hospital’s database of drug liver damage cases, the number of liver damage cases caused by He Shouwu ranked No. 1 among all traditional Chinese medicines. He and Du Xiaoxi and others have jointly written that, “In recent years, the National Adverse Drug Reaction Monitoring Center has collected nearly 10,000 reports of adverse reactions to He Shouwu and its preparations, of which the serious adverse reactions are dominated by hepatic function damage. Only a small number of cases of liver damage from He Shou Wu were reported to the spontaneous adverse reaction reporting system of the National Adverse Drug Reaction Monitoring Center, and the potential number of undiscovered or undiagnosed cases of liver damage is even greater.” The problem of liver damage caused by He Shouwu has also been noted by the medical community in the U.S. In September 2012, the U.S. National Library of Medicine (USNLoM) released the LiverTox database of medicinal liver damage, in which He Shouwu was included as a separate topic. Xiao Xiaohe is concerned that studies have shown that anthraquinone components such as rhododendron (emodin) contained in He Shouwu can cause liver damage in experimental animals, and anthraquinone components are contained in many traditional Chinese medicines, such as rhubarb, huzhang, cassia, aloe vera, senna, etc., so the problem of hepatotoxicity of He Shouwu has a very wide ripple effect. “The side effects of Chinese herbs are being taken seriously all over the world. Many people in the country do not consider herbs as ‘medicines’ and have a deep-rooted idea that they are non-toxic and harmless. Our study found that many of the herbal medicines that cause liver damage are over-the-counter. The lack of clear instructions for the drugs and the lack of indication of toxicity have led to increased abuse of said drugs.” In their article, doctors at the Third Military Medical University’s Xinqiao Hospital bluntly stated that this litany of problems magnifies the dangers of herbal medicines exponentially. The killer is hard to find When investigating drug-induced liver disease, researchers have had a hard time categorizing the herbs that cause drug-induced liver disease as they do with chemical drugs, and they have invariably categorized all liver disease-causing herbs as “Chinese herbs”. In contrast, western medicines that cause liver disease are categorized in great detail, such as “anti-tuberculosis drugs”, “anti-tumor drugs”, “antibiotics”, and even down to a specific chemical composition, such as “Acetaminophen”. There are objective reasons why it is difficult to categorize Chinese medicine liver disease. Patients are either taking a single Chinese medicine, but more commonly, they are taking multiple Chinese medicines and their preparations, including powders, rushes, and soups. The lack of chemical composition analysis of the Chinese medicines themselves and the weakness of related toxicological studies, coupled with the fact that complex herbal treatments are common therapies and the types of medications taken and the dosages taken are complex and variable, make it difficult to pinpoint the cause of liver disease to a particular Chinese herbal medication. Only in a few cases, where the relationship between a single herbal drug and liver disease was very clear, was it easy to localize. For herbal liver disease, researchers can only do limited speculative analysis. Guo Hong of the Third Military Medical University did a statistical analysis in his thesis, “Of the 354 cases of herbal liver injury in which specific drugs were noted, 58 cases, or 16.4%, took elimination of nuclear tablets, 53 cases, or 15%, took Lei Gongteng, 15 cases, 15 cases, 15 cases, 15 cases of He Shouwu, 12 cases of smallpox pollen, and 8 cases, 8 cases, of Strong Bones and Joints Pill”. hepatologist at the 302nd Hospital Zhao Pan also took a similar note, “Among the nine people who took Chinese herbs to treat skin diseases that led to liver failure, five had taken Lei Gongteng ……” “In addition to the patients who took He Shouwu, Tuanshanqi, and other single-flavored prescriptions that led to medicinal liver injury , in most cases of herbal liver injury, hepatologists simply cannot find out or confirm, which flavor of the drug or ingredient is at fault.” Cai Haodong has a deep understanding of this, and during her tenure as a special expert at the Beijing Adverse Drug Reaction Monitoring Center, she often has to deal with the adverse reaction statements of Chinese herbal medicines submitted by hospitals below her. However, Chinese herbal medicine liver patients often take more than one large prescription of Chinese medicine, filled with a variety of Chinese medicines. Have no choice, Cai Haodong can only let the hospital to each prescription, each flavor of Chinese medicine one by one notes, to observe which several Chinese medicines appear high frequency. Combined with existing literature reports, analyze which or which Chinese medicine is most likely to cause liver injury. Xu Jinghang, deputy chief physician of Peking University First Hospital, has also come into contact with many of these herbal liver disease patients. On the day of the interview, she had just finished counseling a 51-year-old female patient. For the treatment of lumbar disc and lumbar leg pain, this patient has been taking Chinese medicine for a long time, and has a history of five or six years of medication. As a result, cirrhosis of the liver was found and liver failure. “The patient was taking a prescription from a Chinese medicine hospital doctor. For most of the year, she took pCms and prescription tonics (herbs) intermittently. Her prescriptions were complex, with perhaps a dozen or more flavors in a single formula, and varied from stage to stage. It was difficult for us to localize the cause of the liver damage to a particular herbal ingredient. We did liver biopsies, pathology tests, and screened for many other factors before we determined it was due to the herbs.” “This is the most difficult problem we have in dealing with liver damage from herbal medicines.” Xu Jinghang laments that adverse reactions to chemical drugs are much better determined, such as acetaminophen, which is well researched, the instructions are clear, and the etiology is easy to find, whereas herbal liver disease is difficult to determine which drug is responsible. Prescribing Worries The hepatologists interviewed claimed that the vast majority of proprietary Chinese medicines do not have adverse reactions labeled on their instructions, contributing to the risk of herbal liver disease. In their clinical contact with cases of herbal liver disease, most of the drugs were prescribed by doctors, who had not instructed patients to check their liver function when taking herbal medicines. In Cai Haodong’s opinion, it is difficult for non-hepatologists to familiarize themselves with the liver damage of herbal medicines, especially those in small and medium-sized hospitals. “Our Adverse Drug Reactions journal hosts conferences, and the attendees are basically doctors from large tertiary hospitals. Some doctors in large hospitals may also know that some herbs can have liver damage through this type of study. However, it is really difficult for non-hepatologists to realize the breadth and severity of liver damage from herbal medicines.” Zhou Chaofan, who was the director of the Chinese Medicine Specialty Committee of the National Pharmacopoeia Commission, also confirmed this. He also told the Phoenix Weekly reporter, “The development of Chinese medicine should keep pace with the times, taking the best and removing the dregs, but for some traditionally non-toxic cognition of the new exposure of Chinese medicine, many Chinese medicine practitioners have not done enough to pay attention to themselves. There are even professorial experts in Chinese medicine, even the toxicity of He Shouwu are denied.” Many hepatologists are quite vigilant about the use of Chinese herbs. During a physical examination at Ditan Hospital, a nurse was prescribed a Chinese medicine for a breast problem, and a hepatologist prescribed the same medicine. The nurse later developed jaundice (an indicator of liver damage), which alerted the hepatologist, who found on examination that she too had developed liver damage and hastened to stop the medicine. Hepatologist Xu Jinghang had a similar example. “We have a nurse colleague in our department, she because of the skin acne problem, in our hospital Chinese medicine department prescribed Chinese medicine to adjust. After taking it for a few weeks, the doctor in our department suggested that she check her liver function. The result was high transaminases. Transaminase is a particularly sensitive indicator of liver damage. It means the liver cells have lesions.” Xu Jinghang said, the good thing is that this is a relatively mild liver damage, the colleague in time to stop the drug after the return to normal. “Even in a big hospital such as Beida Hospital, looking for Chinese medicine doctor prescribed, or western medicine doctor prescribed proprietary Chinese medicine, there is also the possibility of liver injury. If you don’t go for liver function tests, it’s not always possible to find out.” Xu Jinghang example, He Shouwu this flavor of Chinese medicine caused by liver damage has been relatively clear, she has also been in the medical literature many times to see the relevant adverse reaction reports. However, contains He Shouwu ingredients of proprietary Chinese medicines but in the instruction manual labeled “adverse reactions are not clear”. This is indeed a special treatment for Chinese medicines. According to China’s State Food and Drug Administration’s regulations on Chinese medicine instructions, “Chinese medicine instructions should be factual and detailed list of adverse reactions to the drug. The adverse reactions should be listed according to their severity, frequency of occurrence or systematicity of symptoms. If it is not yet clear whether there are any adverse reactions, it can be expressed as ‘not yet clear’ under the item.” Cai Haodong has always insisted in her practice that she will refuse to prescribe any medication that she knows contains He Shouwu unless she is clear that the patient has a history of related medication and is resistant to it. “It is estimated that many doctors prescribe drugs, will not realize the risk of He Shouwu.” Cai Haodong recalled that she had encountered a pharmaceutical company to Ditan Hospital to promote a lipid-lowering drugs. Pharmaceutical company publicity did not mention which contains He Shouwu, she carefully read the instructions of the composition of the drug to know, however, the instructions did not say He Shouwu content. Cai can only be blocked back “there is He Shouwu also come to our hepatology recommendation?” In the international arena, Canada, Britain, Australia and other countries drug regulatory authorities have introduced for He Shouwu and its preparations to regulate or even limit the use of the policy. 2006, the UK Medicines and Healthcare products Regulatory Agency (MHRA) in the receipt of seven cases of liver damage caused by taking He Shouwu preparations after the report, released information on the He Shouwu adverse reactions and blocked the importation of this medicinal herb. In the same year, a Pharmacovigilance Alert issued by the State Food and Drug Administration reprinted the news. “This is unlikely to make much of a difference if it’s simply information about adverse drug reaction notices. Non-medical people won’t pay much attention to it, and even professionals, doctors or nurses are unlikely to make an active information search.” Xu Jinghang revealed that such notices from the drug regulatory authorities are more of a reminder and do not have mandatory significance. Industry insiders estimate that there should be hundreds of proprietary Chinese medicines containing He Shouwu on the mainland.In October 2013, He Shouwu-related proprietary Chinese medicines were ordered to make changes for the first time in China. For the first time, the State Food and Drug Administration issued a notice for He Shouwu, specifying that people with liver insufficiency are prohibited from using five kinds of He Shouwu-containing medicines: Nourishing Blood and Enlivening Hair Capsules, Shouwu Pills, Shouwu Tablets, Shouwu Yanshou Tablets, and Shouwu Yanshou Pellets; and at the same time, turning these five kinds of He Shouwu-containing medicines to be managed as prescription medicines and requesting companies to revise the instructions of their products. Wang Jiazhuo (a pseudonym), a researcher from an authoritative Chinese medicine research organization, was involved in the revision of He Shouwu, he revealed to the “Phoenix Weekly” reporter, the revision took two years before and after the demonstration of the current Chinese medicine to solve the problem of adverse reactions is indeed difficult. Lives lost drug liver In the People’s Liberation Army 302 Hospital Liver Failure Diagnosis and Research Center clinician Zhao Pan, ordinary drug liver injury is still difficult to constitute a serious liver disease problem. What’s really scary is drug-induced acute liver failure (ALF). Drug-induced ALF has an extremely high mortality rate in China. Even if a patient receives a liver transplant in time, the mortality rate can be as high as 20 to 40 percent, according to Zhao Pan. Unlike developed countries, China has not yet emphasized the investigation of the etiology of drug-induced liver failure. “When it comes to severe drug-induced liver disease, you may die before even getting a liver transplant.” Yan Jie is deeply touched by this. Two years ago, Yan Jie met a 20-year-old girl in the hospital had a liver transplant. And the reason, it is from a serious drug liver damage: the little girl taking Chinese herbal medicine Uva Ursi caused. At the doctoral stage in 2009, Zhao Pan had the idea of investigating the causes of drug-induced liver failure in China. He visited military hospitals in Beijing, Shanghai, Wuhan and Jinan, and spent four years investigating first-hand cases of acute liver failure, and in November 2013 and April 2014, his findings were published in two academic papers in the medical journals PLOSONE and CriticalCare Medicine. One of them noted that “the most important cause of acute liver failure in China is Chinese herbs.” Zhao Pan’s study looked at seven tertiary military hospitals in China and analyzed the causes of 177 patients with acute liver failure and found that 30 of them, or nearly one-fifth of the patients, had Chinese herbs as their cause. None of these 30 patients with acute liver failure had a history of liver disease, and all of them developed acute liver failure after taking Chinese herbal medicine. Ultimately, none of them received liver transplants, and 18 died as a result. These 30 people did not have to gamble with their lives by taking Chinese herbs. When Zhao Pan went through the patients’ medical records, he organized the purposes for which they took the herbs: nine were trying to treat skin diseases, six were treating upper respiratory tract infections. Others wanted to treat rheumatism, depression, and some even took the medicine just to lose weight. Herbs even accounted for half of the statistics of drug-induced liver failure cases in the 302nd Hospital of the People’s Liberation Army (PLA) itself. A document entitled “Clinical Analysis of 120 Cases of Pharmacological Liver Failure” published in a medical journal points out that from 2002 to 2012, 302 Hospital admitted more than 3,000 cases of patients with pharmacological liver damage, of which 120 patients developed pharmacological liver failure. Among the drugs causing drug-induced liver failure, Chinese herbal medicines accounted for 61 cases (50.83%), and the improvement rate of patient treatment was less than 30%. After initiating and completing the first phase of a nationwide study of acute drug-induced liver injury in 2005, Xu Jianming, a professor at Anhui Medical University, focused his attention on acute liver failure in 2006. Xu expanded his research to 16 provinces and cities in the second phase and screened 213 cases of acute liver failure through an international quantitative scoring standard. “Herbal medicines took the first place with 28 percent of the cases. Chinese herbs also ranked first in the classification of drugs that cause death in liver injury patients.” According to Xu, this basically shows that Chinese herbs have become the main cause of severe liver injury in China. In addition to acute liver failure, at the First Affiliated Hospital of Anhui Medical University, Xu was repeatedly exposed to another serious liver disease often caused by Chinese herbs: hepatic sinusoidal obstruction syndrome (SOS, formerly known as hepatic small vein occlusion (HVOD)). This liver disease has a hospitalization mortality rate of more than 10 percent. As chief physician, Xu has been taking over and confirming such cases for seven years. In June 2007, Xu first diagnosed a patient in Anhui province. Xu questioned the patient and found that he had taken a Chinese herb called Panax quinquefolium, which he used to make wine and drank for a long time. Xu then conducted a pathologic examination to screen for the cause of the disease, and ultimately confirmed that his hepatic sinusoidal obstruction syndrome was caused by Panax quinquefolii. In 2011, Xu and his doctoral students completed a nationwide survey on hepatic sinusoidal obstruction syndrome. They searched 19 large tertiary hospitals in 15 provinces and cities across the country and found 98 cases that met the study requirements. Deaths accounted for 11 of these cases. The results of the study showed that “the main cause of hepatic sinusoidal obstruction syndrome is herbal medicine, and 2/3 of the cases were caused by the herb called ‘Tu San Qi’.” In-depth toxicology studies conducted during the same period showed that this herb contained pyrrolizidine alkaloid monomer components. It was this type of ingredient that led to this serious liver disease. Beneath the Iceberg The liver is the site where the biological and chemical transformation and metabolism of drugs occurs; after entering the body, drugs are first transformed into highly water-soluble substances under the action of the liver, metabolized and then excreted by the kidneys, and is also the target organ for damage from drugs and their metabolites. Several hepatology clinicians believe that the general degree of liver injury is reversible and recoverable. Liver disease can be both severe and mild. From general and mild drug-related liver injury to severe liver lesions, even cirrhosis and liver failure, the process changes with individual physique, drug type, dosage, and course of medication. Modern medicine has an in-depth understanding of drug-related liver injury. Peking University School of Pharmacy professor, chief pharmacist Zhai Shodi said, history of the first case of liver injury documented in the 18th century. Someone due to phosphorus and arsenic poisoning, resulting in jaundice and fatal liver damage. With the development of the chemical industry in the 19th century, the use of chloroform anesthesia caused liver injury cases increased, drug liver damage gradually gained attention. Pharmacologic liver injury has become the most common cause of modern drug withdrawal. More than 900 chemical drugs are now known to cause drug-related liver disease. If a drug has excessive liver damage and there are other drugs with similar potency that can be substituted, it may face delisting after a thorough evaluation. From 1975 through 2007, the FDA withdrew 77 drugs from the market due to liver damage, with liver-damaging drugs accounting for the largest number of 11. This is a higher percentage than both hematologic and cardiotoxic drugs. “The incidence of pharmacologic liver injury is high, second only to cutaneous mucosal diseases and drug fever, which are the most commonly reported adverse reactions. Pharmacologic liver injury also tends to occur in the elderly. They themselves have poor liver function and take a lot of medications, and 40 percent of hepatitis in the elderly is drug-related liver damage.” Zhai Shodi said. With the in-depth study of toxicology, the adverse reactions of Chinese herbal medicines have also been gradually emphasized. 1992, there was a doctor in the Chinese Journal of Traditional Chinese Medicine statistics, from the results of more than half a century of domestic medicine journal, the 50s and before only 62 cases of adverse reactions to traditional Chinese medicines, there were 174 cases in the 60s, the 70s there were 398 cases, and in the 80s it has risen to 2,217 cases. The list of commonly used Chinese medicines clinically found to cause liver injury is also expanding. In China’s Measures for the Administration of Toxic Drugs for Medical Purposes, the 2010 edition of the Chinese Pharmacopoeia, the drug standards issued by the former Ministry of Health, and the local standards for medicinal herbs in Shandong, Guangdong, Liaoning, and Gansu Provinces, a total of 182 types of toxic Chinese herbs have been collected, among which there are 37 types of “big poisonous herbs,” 78 types of “toxic herbs,” and 1 type of “poisonous herbs,” and 2 types of “poisonous herbs. toxic herbs” 78 kinds, “small toxic herbs” 67 kinds. However, many toxic herbs are still being discovered. Some of the traditionally recognized non-toxic herbs also pose safety risks. “Even herbs that tonify the liver and kidneys have been found to be hepatotoxic in recent years.” Du Xiaoxi pointed out at the 2013 National Hospital Pharmacy Academic Annual Meeting that the literature reports that Ma Sang Ye, Four Seasons Green, Di Yu, Daylily Root, He Shou Wu, Nutmeg, and Clove can lead to liver injury; Chinese medicines containing glycosides (Diosgenin), toxic proteins (seeds), alkaloids (Qian Li Guang, Zi Cao), heavy metals (Lead, Arsenic), and animals (Centipede, Zebra Cordyceps) are all associated with liver injury. However, liver injury is only known to the person taking the medicine when it reaches a serious level. If the patient only has general symptoms of liver damage such as elevated aminotransferases, he or she can recover after stopping the medication in time. However, if the patient is unaware of the symptoms and does not go for checkups, he or she will not notice any changes in the liver. Cases of mild liver injury do not usually appear in the literature. Patients who are not hospitalized are not included in hospital statistics of drug-related liver injury cases. They also have difficulty appearing in the system of adverse drug reaction monitoring reports. Therefore, hepatologists believe that the actual number of people who have suffered liver injuries from taking Chinese herbs is much higher than the hundreds or tens of thousands reported in the literature. Ill-advised Chinese and Western medicine Wang Jiazhuo recognizes that pharmacogenetic liver damage from Chinese medicines has become a real-life proposition that seriously affects the safety of clinical use of Chinese medicines and urgently needs to be addressed. However, he also holds a grudge for some of the higher reported data on liver disease in Chinese herbal medicines. He believes that the current prevalence of Chinese and Western drug combinations, coupled with the fact that Chinese medicines are not as well researched as chemical medicines, makes it possible to misreport many drug-induced liver diseases as being caused by Chinese medicines. Wang Jiazhuo disclosed liver injury data from his hospital. From 2002 to 2010, the hospital admitted nearly 2,000 cases of clinical liver damage. Of these, nearly a quarter of the liver damage cases were determined to be likely caused by TCM, and in addition, nearly half of the liver damage cases were suspected to be related to the combined use of TCM and Western medicines. Wang Jiazhuo said that this situation makes the confirmation and in-depth study of liver damage of traditional Chinese medicine extremely complicated. In the opinion of some members of the Chinese medicine industry, the combined use of Chinese herbs and chemicals in China, which allows Western doctors to prescribe Chinese medicines, has precisely also exacerbated the risk of liver disease from Chinese herbs. An incomplete statistic shows that about 70% of the proprietary Chinese medicines in China are prescribed by Western physicians in general hospitals. However, according to the theories and traditions of Chinese medicine, doctors prescribing Chinese medicines must understand the relevant theories of Chinese medicine, such as recognizing and treating the symptoms and concocting to remove the poison. “Different methods of concocting a single medicine can have different effects on liver damage, as is the case with He Shou Wu. But Western medicine may not be clear about this.” Zhou Chaofan, an expert in traditional Chinese medicine, told Phoenix Weekly that there is a difference between raw and manufactured He Shouwu, with the former being unprocessed and concocted, and the latter being treated. Although the concoction does not have a unified process standard, but nine steamed nine sun He Shouwu concocted products liver damage may be smaller. Western doctors apparently have difficulty understanding this. This combination of Chinese and Western medicine leads to confusion not only in the process of use, but there are also serious problems in the production and manufacturing of proprietary Chinese medicines. According to Dr. Hsu, chemicals adulterated in Chinese medicines are another major risk leading to herbal liver disease. While researching herbal medicinal liver injury, Xu once had a report from the College of Pharmacy at Central South University in a private communication. “Of the herbal medicines examined, the vast majority of proprietary Chinese medicines and health products were adulterated with chemicals.” The report Xu showed showed: dozens of western drug ingredients were checked in pCms and health products, including hypoglycemic drugs, antiepileptic drugs, sedative-hypnotic drugs, anti-asthma drugs, and weight-loss pills. “At this point it is not possible to attribute liver disease caused by such herbal medicines to herbal liver disease. With a mixture of pCms and western medicines, it’s impossible to tell whether this is caused by Chinese medicines, western medicines, or a mixture. It’s also confusing for us to know exactly which drug to study.” Xu Jianming told this reporter, only completely ruled out the problem of chemicals, in order to carry out the toxicity of Chinese medicine research. But whether it is He Shouwu or other Chinese medicines, the traditional inertia of folk use of Chinese herbal medicine, Chinese medicine instructions on the green light of adverse reactions, Chinese and Western medicine confusing prescriptive authority, all make the Chinese herbal medicine liver disease is in a long time secret, but more and more intense situation.