The first time I saw this, I was able to get to the hospital. The data from three large specialty hospitals show that more than half of the drug liver cases are related to Chinese medicine. The most significant cause of acute liver failure, a liver disease severe enough to kill, is herbal medicine. “It is all too necessary to call the attention of the public and the government.” Numerous interviewed hepatologists 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 folk abuse and improper government regulation, have kept the liver damage of herbal medicines secret for a long time in the mainland. The Phoenix Weekly reporter spent half a year visiting many authoritative hepatologists on the mainland and tracking the most cutting-edge discussions in the pharmaceutical industry to investigate the serious drug safety issue of liver damage in Chinese herbal medicine. From the public and pharmaceutical companies to the academia and government, the problem of liver damage in Chinese herbal medicines 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 liver damage from Chinese herbal medicines that are widely used in China. Even Chinese and Western medical doctors, including those who prescribe herbal medicines, are often unaware of the risk of liver damage from herbal medicines. A growing body of medical research has found that a large class of traditional Chinese herbal medicines are damaging the liver of the nation. Long-term, high-dose use – including both proprietary Chinese medicines and herbal remedies – can cause fatal damage. Professor Xu Jianming of Anhui Medical University conducted a retrospective survey of medicated livers covering 16 large hospitals nationwide in 2005, which showed that herbal medicines accounted for 20.6 percent of the causative factors in more than 1,200 cases of drug-related liver injury.” In 2013, a paper from Xinqiao Hospital of the Third Military Medical University in Chongqing showed that “Chinese herbal medicine was the second leading cause of drug-related liver injury in China” at 18.6 percent of the 24,112 patients with drug-related liver injury from 1994 to 2011. The top of the list of drug liver is the western drug anti-tuberculosis drugs, accounting for nearly one-third of the cases. Guo Hong, the paper’s subject leader and deputy chief physician at Xinqiao Hospital of the Third Military Medical University, told Phoenix Weekly that the study did not take a primary case study, but reviewed cases reported in the domestic medical literature. Due to the lack of primary data, the paper has some limitations, and its main purpose is to call on physicians at home and abroad to pay attention to drug-related liver damage, especially that caused by Chinese herbal medicines. Some individual hospital data began to be disclosed and discussed in the industry. on May 23, 2014, at the 6th Forum on Drug-Induced Diseases and Safe Drug Use held by the Academic Journal of Adverse Drug Reactions, many experts highlighted the risk of liver disease from herbal medicines in their reports, and gave several individual hospital values. Du Xiaoxi, director of the National Adverse Drug Reaction Monitoring Center, introduced: the director of a specialist liver hospital in Beijing had previously told her that about 60 percent of the hospital’s drug-related liver cases were related to herbal medicine; the director of another western hospital estimated on a private occasion at this forum that the hospital’s herbal medicine related drug-related liver cases could account for half of the cases. Wei Lai, vice president of Peking University People’s Hospital, disclosed data on the proportion of herbal liver disease at the hospital. “The proportion of Chinese herbal medicine and chemical drugs (i.e., Western drugs) in drug-related liver disease is 51% for one and 49% for the other. The chemical drugs that cause liver disease are more concentrated, while which herbs cause drug liver? We haven’t figured it out yet.” In clinical practice, drug-induced liver disease is a diagnosis of exclusion, which is aided by hepatologists relying primarily on a database of adverse drug reactions, based on accumulated prior knowledge. More than 900 chemical drugs are available that are clearly known to cause drug-related liver disease. The risk of liver injury is clearly communicated in the instructions for many chemical drugs, such as anti-tuberculosis drugs, antibiotics and many chemotherapy drugs. Once the association between liver disease and the drug is identified and diagnosed by the physician during the course of drug administration, discontinuation and adjunctive hepatoprotective therapy may be an option. Internationally, drug-related liver disease is attracting increasing attention from the pharmacy community, pharmaceutical companies, drug regulatory authorities and the public. However, due to the widespread use of traditional Chinese medicine 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 determined, domestic and foreign data on liver damage of chemical drugs are complete, and the whole process of detection, diagnosis and discontinuation of treatment of chemical drug liver disease is relatively clear. “We are well aware of its efficacy and risks, and doctors and patients pay attention to liver function monitoring, are alert to possible liver disease caused by taking the drug, and make timely adjustments and treatment.” According to Yan Jie, deputy chief physician of the liver disease center at Beijing Ditan Hospital and associate professor at Peking University School of Medicine. Due to the complex composition of Chinese herbal medicines, no one abroad has studied the hepatotoxicity of Chinese herbal medicines, and there is a lack of safety research data in China, which has led to the fact that the general public, even including the Chinese and Western doctors who prescribe them, are not aware of the risk of liver damage from Chinese herbal medicines during their use. There is no shortage of people suffering from acute liver failure and other serious liver diseases, and even death. Dangerous He Shou Wu Some hepatologists have found that the claim that herbs are non-toxic has long circulated among the public, resulting in the misuse of herbs. Some extremely serious cases of liver disease and death were caused by herbal liver disease patients who believed in folk remedies, abused herbal medicines or took herbal medicines in excessive doses or over the course of treatment. Cai Haodong, director of the liver disease center at Beijing Ditan Hospital of the Capital Medical University (which mainly treats liver disease patients), works on adverse drug reactions and has long been concerned about drug safety. One type of email that appears with high frequency in one of her public mailboxes is: pregnant with a child or feeling thin and weak, considering taking Chinese medicine for regulation. “This is when I get angry, if you have a disease treatment to go, no disease do not take drugs, where to say the drug conditioning.” Cai Haodong lamented. She recently a hepatitis B patient was recovering well, suddenly jaundice, transaminases rise symptoms, some inquiries only to find that the patient privately take He Shou Wu, expecting to supplement the liver and cure gray hair. “We are anxious to hear that cases of liver damage from He Shou Wu have become commonplace. How can a patient with liver disease still take herbs that damage the liver.” Cai Haodong said, understanding that the patient’s sister is also taking He Shou Wu, they suggested to come to the hospital for diagnosis, the results of the same found liver damage. Yan Jie has recently been exposed to similar cases. A female patient who suffered from drug-related liver disease 2 years ago approached Yan Jie for a 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 this patient had eaten He Shou Wu, “then I asked her, why not say this. She said, did not take it (He Shou Wu) as medicine ah.” Yan Jie quite helpless, after carefully investigating the causes, confirmed that the patient’s two liver damage and He Shou Wu are related. “Like He Shou Wu, earth Panax notoginseng, folk abuse of these drugs, purely no disease to find disease.” Cai Haodong is quite helpless, He Shou Wu is rumored to be used in folklore to augment hair, and earth Panax notoginseng is used to make medicinal wine, and both of these drugs, there have been clear cases of liver damage. Du Xiaoxi, who has a degree in Chinese medicine, believes that pharmacological liver damage from Chinese medicine is not a new topic in the clinic, but some medication problems should be attributed to purely artificial risks. “There are health programs that encourage the public to stew chicken with 10 grams of He Shou Wu every day. But is He Shou Wu, a Chinese herb, really suitable for each person to eat so much every day?” Xiao Xiaohe, director of the PLA 302 Hospital’s All-Army Institute of Chinese Medicine, had counted that in the hospital’s database of drug liver damage cases, the number of liver damage cases caused by He Shou Wu ranked No. 1 among all traditional Chinese medicines. He and Du Xiaoxi 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 Shou Wu and its preparations, of which serious adverse reactions are dominated by liver function damage. Only a small percentage of cases of liver damage from He Shou Wu are reported to the National Adverse Drug Reaction Monitoring Center’s ADR spontaneous reporting system, and the potential number of undetected or undiagnosed cases of liver damage is even larger.” The problem of liver damage from He Shou Wu has also been noted by the U.S. medical community, and in September 2012, He Shou Wu was included as a separate topic in the LiverTox database of drug-related liver damage released by the U.S. National Library of Medicine (USNLoM). Xiao Xiaohe is concerned because studies have shown that anthraquinone components such as rhodopsin (emodin) contained in He Shou Wu can cause liver damage in experimental animals, and anthraquinone components are contained in many Chinese herbs such as rhubarb, thuja, cassia, aloe and senna, so the problem of He Shou Wu hepatotoxicity has a very wide ripple effect. “The side effects of herbal medicines are valued all over the world. Many people in the country do not consider herbs to be ‘drugs’ and the idea that they are non-toxic and harmless is deeply ingrained. Our research found that many of the herbs that cause liver damage are over-the-counter drugs. The lack of clear instructions for the drugs and the lack of indication of toxicity led to increased abuse of said drugs.” In their article, doctors at Xinqiao Hospital of the Third Military Medical University bluntly state that this litany of problems dramatically magnifies the dangers of herbal medicines. When investigating drug-induced liver disease, researchers have had difficulty classifying herbs that cause drug-induced liver disease in the same way as chemical drugs, and have invariably classified herbs that cause liver disease as “Chinese herbs. In contrast, Western drugs that cause liver disease are classified 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 Chinese herbal liver diseases are difficult to classify. Patients are taking a single herbal medicine, but more commonly, they are taking multiple herbal medicines and their preparations, including bulk, punch and tonics. The lack of chemical composition analysis of herbal medicines themselves and the weakness of related toxicological studies, coupled with the fact that compound herbal treatments are common therapies and the types of medicines taken and the doses taken are complex and variable, these make it difficult to identify the cause of liver disease to a particular herbal medicine. Only in a few cases, the relationship between a single herbal drug and liver disease is so clear that it is easy to locate. For herbal liver disease, researchers can only do limited speculative analysis. Guo Hong of the Third Military Medical University has done a statistical analysis in his paper, “Among 354 cases of herbal liver injury with specific drugs indicated, there were 58 cases (16.4%) of taking elimination tablets, 53 cases (15%) of Leigongteng, 15 cases of He Shou Wu, 12 cases of smallpox powder, and 8 cases of Strong Bone Joint Pill”. 302 Hospital hepatologist Zhao Pan also took a similar note, “of the nine people who took Chinese herbs for skin diseases that led to liver failure, five had taken Leigongteng ……” “In addition to patients who took single prescriptions such as He Shou Wu and Tu San Qi that led to liver injury from the medicine , in most cases of herbal liver injury, hepatologists simply cannot find out or confirm, which flavor of drug or ingredient is at fault.” Cai Haodong knows this, and during her tenure as a special expert at the Beijing Adverse Drug Reaction Monitoring Center, she often had to deal with adverse drug reaction reports submitted by the following hospitals. But herbal medicine liver patients often took more than one big prescription of Chinese medicine, filled with all kinds of Chinese medicines. Helplessly, Cai Haodong could only ask the hospital to indicate each prescription, each herbal medicine one by one, and observe which herbal medicines appeared with high frequency. Then, combined with the available literature reports, analyze which or which herbs are most likely to cause liver damage. Xu Jinghang, deputy chief physician at Peking University First Hospital, has also come into contact with many patients with liver disease from these herbs. On the day of the interview, she had just finished consulting with a 51-year-old female patient. This patient had been taking Chinese herbs for a long time, with a history of taking them for five or six years, in order to treat her lumbar disc and back pain. As a result, cirrhosis and liver failure were discovered. “The patient was taking what the doctor at the Chinese hospital had prescribed. For most of the year, she intermittently took proprietary Chinese medicines and prescription tonics (herbal medicines). Her prescriptions were complex; one prescription might have more than a dozen flavors, and they were different at different stages. It was difficult for us to pinpoint the cause of the liver damage to a particular herbal ingredient. We did a liver biopsy, pathology, and screened for many other factors before determining that it was due to the herbs.” “This is the most difficult problem we have in dealing with liver damage from herbal medicines.” Xu Jinghang lamented 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, while herbal liver disease is difficult to determine which drug is responsible. Prescription worries According to the interviewed hepatologists, the vast majority of proprietary Chinese medicines are not labeled with adverse reactions on their instructions, which contributes to the risk of herbal liver disease. In most of the herbal liver disease cases they encountered clinically, the drugs were prescribed by doctors, who did not instruct patients to check their liver function when taking herbal medicines. In Cai Haodong’s opinion, it is difficult for non-hepatologists to be familiar with which herbal medicines have liver damage, especially in small and medium-sized hospitals, “Our journal Adverse Drug Reactions hosts conferences, which are basically attended by doctors from large tertiary hospitals. Some doctors in large hospitals may also know that some herbal medicines can have liver damage through this type of study. But it is really difficult for non-hepatologists to realize the extensiveness and severity of liver damage from herbal medicines.” This was confirmed by Chaofan Zhou, who was the director of the National Pharmacopoeia Commission’s Professional Committee on Chinese Medicine. He also told Phoenix Weekly, “The development of Chinese medicine should keep pace with the times and take its essence to remove its dross, but many Chinese doctors themselves have not done enough to pay attention to the newly exposed problems of some traditional Chinese medicines that hold a non-toxic perception. There are even professorial experts in Chinese medicine who deny even the toxicity of He Shou Wu.” Many hepatologists maintain a fairly high level of vigilance over the use of herbal medicine. During a physical examination at Ditan Hospital, a nurse was prescribed a Chinese herbal 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 examined her and found that she also had liver damage, so she rushed to stop the medication. Hepatologist Xu Jinghang had a similar example. “We have a nurse colleague in our department who was prescribed Chinese herbal medicine to regulate her skin because of her acne problem in our hospital’s Chinese medicine department. After taking it for a few weeks, the doctor of our department advised her to check her liver function. It turned out that the transaminases were high. Aminotransferases are a particularly sensitive indicator of liver damage. It means there are lesions in the liver cells.” Xu Jinghang said that the good thing is that this is a relatively mild liver damage, and the colleague returned to normal after stopping the medication in time. “Even in a large hospital like Peking University Hospital, looking for a prescription from a Chinese medicine doctor, or a Chinese medicine prescribed by a Western doctor, there is the possibility of liver damage. If you don’t go for liver function tests, it is not always detected.” Xu Jinghang cited the example of liver damage caused by He Shou Wu, a Chinese herbal medicine that has been relatively clear, and she has seen reports of related adverse reactions in the medical literature many times. However, the Chinese patent medicines containing He Shou Wu ingredients are labeled “adverse reactions are not yet clear” on the drug instructions. This is indeed a special treatment for Chinese medicine. According to the Chinese State Food and Drug Administration on the instructions of Chinese medicine, “the instructions of Chinese medicine should be factual and detailed list of adverse reactions to the drug. And according to the severity of adverse reactions, the frequency of occurrence or the systemic nature of the symptoms listed. It is not clear whether there are adverse reactions, can be expressed under the item with ‘not clear’.” Cai Haodong has always insisted in her treatment that as long as she knows the drugs containing He Shou Wu, she will refuse to prescribe them unless she is clear that the patient has a history of related medication and is resistant to it. “I guess a lot of doctors don’t realize the risks associated with he shou wu when they prescribe it.” Cai Haodong recalled that she had encountered a pharmaceutical company to Ditan Hospital to promote a lipid-lowering drugs. The pharmaceutical company did not mention that it contained he shou wu, she carefully read the instructions of the drug ingredients to know, but the instructions also did not state the content of he shou wu. Cai can only block back “He Shou Wu still come to our liver disease department to recommend?” In 2006, the UK Medicines and Health Products Regulatory Agency (MHRA) received seven reports of liver damage caused by he shou wu preparations, issued information about adverse reactions to he shou wu and blocked the import of the herb. That 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 are not likely to pay attention to it, and even professionals, doctors or nurses are unlikely to make active information retrievals.” Xu Jinghang revealed that such notices from the drug regulatory authorities are more of a hint and do not have mandatory significance. The industry estimates that there should be hundreds of proprietary Chinese medicines containing he shou wu on the mainland. in October 2013, he shou wu-related proprietary Chinese medicines were ordered to make changes for the first time in China. The State Food and Drug Administration (SFDA) issued a notice for the first time for He Shou Wu, specifying that five types of drugs containing He Shou Wu were prohibited for people with liver insufficiency: Blood nourishing and hair growth capsule, Shou Wu pill, Shou Wu tablet, Shou Wu Yanshou tablet and Shou Wu Yanshou granule; at the same time, these five types of drugs containing He Shou Wu were transferred to prescription drug management, and companies were required to revise the product instructions. Wang Jiazhuo (a pseudonym), a researcher from an authoritative Chinese medicine research institute in China, was involved in the revision of He Shou Wu, he told the Phoenix Weekly reporter that the revision took two years to prove before and after, and it is indeed difficult for Chinese medicine to solve the problems related to adverse reactions. In the view of Zhao Pan, a clinician at the Liver Failure Treatment and Research Center of the PLA 302 Hospital, ordinary drug-related liver injury can hardly constitute a serious liver disease problem. What is really scary is the acute liver failure (ALF) caused by taking drugs. The mortality rate for drug-induced acute liver failure in China is extremely high. Even if a patient receives a liver transplant in time, it can still have a mortality rate of 20-40%, according to Zhao Pan. Unlike in developed countries, China has not paid much attention to the investigation of the causes of drug-induced liver failure. “When it comes to severe drug-related liver disease, one may die before even having a liver transplant.” Yan Jie has deep feelings about this. Two years ago, Yan Jie met a young girl in the hospital in her 20s had a liver transplant. And the reason, it is from a serious drug liver damage: the young girl taking Chinese herbal medicine wu hair caused. In 2009 PhD stage, Zhao Pan had the idea to investigate the causes of drug-related liver failure in China. He visited military hospitals in Beijing, Shanghai, Wuhan, and Jinan, and spent four years completing a first-hand case investigation of acute liver failure. in November 2013 and April 2014, his research results were published as two academic papers in two medical journals, PLOSONE and CriticalCare Medicine, respectively. One of them stated, “The most important etiology of acute liver failure in China is Chinese herbal medicine.” Zhao Pan’s study looked at seven tertiary military hospitals in China and analyzed the etiology of 177 patients with acute liver failure and found that herbal medicine was the etiology in 30 of them, accounting for nearly one-fifth of the cases. All of these 30 patients with acute liver failure had no history of liver disease and all developed acute liver failure after taking herbal medicines. Ultimately, none of them received liver transplants and 18 died as a result. These 30 people taking herbal medicines did not have to gamble their lives. When Zhao Pan went through the patients’ medical records, he compiled the purposes for which they took the herbs: nine wanted to treat skin diseases, and six wanted to treat upper respiratory tract infections. Others wanted to treat rheumatism and depression, and some even took the medicine just to lose weight. In the statistics of the People’s Liberation Army 302 Hospital on its own cases of drug-induced liver failure, Chinese herbs even accounted for half of the cases. A document “Clinical analysis of 120 cases of drug-related liver failure” published in a medical journal points out that from 2002 to 2012, 302 Hospital admitted more than 3,000 patients with drug-related liver damage, of which 120 patients had drug-related liver failure. Among the drugs causing drug-related 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 nationwide research on acute drug-induced liver injury in 2005, Anhui Medical University professor Xu focused on acute liver failure in 2006. Xu expanded the second phase of research to 16 provinces and cities and screened 213 cases of acute liver failure using international quantitative scoring criteria. “Chinese herbal medicine occupied 28 percent of the cases and ranked first. Chinese herbs also ranked first in the classification of drugs that cause death in patients with liver injury.” According to Xu, this basically shows that herbal medicines have become the main cause of serious 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 herbs: hepatic sinusoidal obstruction syndrome (SOS, formerly known as hepatic small vein occlusion disease (HVOD)). This liver disease has an in-hospital mortality rate of over 10%. As chief physician, Xu has been taking on and diagnosing such cases for seven years. In June 2007, Xu first diagnosed a patient with the disease in Anhui Province. Xu followed up with the patient and found that the patient had taken a Chinese herb called earth panax notoginseng, which he used to make wine and drank for a long time. Xu then performed pathological examinations to screen for the cause of the disease and eventually confirmed that his hepatic sinusoidal obstruction syndrome was caused by the earth panax pseudoginseng. In 2011, Xu and his doctoral students completed a nationwide investigation of hepatic sinusoidal obstruction syndrome. They searched 19 large tertiary hospitals in 15 provinces and cities across China and found 98 cases that met the study requirements. Among them, the number of deaths occupied 11 cases. The results of the study showed that “the main etiology of hepatic sinusoidal obstruction syndrome is herbal medicine, and 2/3 of the cases were caused by this herbal medicine called ‘Tu San Qi’.” In-depth toxicological studies conducted during the same period showed that this herb contained monomeric components of pyrrole-like alkaloids. It was this component that led to this serious liver disease. Beneath the iceberg The liver is the site of biological and chemical transformation and metabolism of drugs. After entering the body, drugs are first transformed into highly water-soluble substances by the liver, metabolized and then excreted by the kidneys, which are also the target organs for damage to drugs and their metabolites. Several hepatology clinicians believe that the average degree of liver injury is reversible and recoverable. Liver disease can be both severe and mild. From general, mild drug-related liver injury to serious liver lesions and even cirrhosis and liver failure, the process varies with the individual’s constitution, the type of drug, the dose taken, and the course of medication. Modern medicine has an in-depth understanding of drug-related liver injury. Zhai Shodi, professor and chief pharmacist of Peking University School of Pharmacy, said that the first documented case of liver injury in history appeared 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 more cases of liver damage, pharmacogenic liver damage gradually gained attention. Pharmacogenic liver injury has become the most common cause of modern drug withdrawals. More than 900 chemical drugs are now known to cause pharmacologic liver disease. If a drug has too much liver damage and there are other drugs with similar efficacy that can be substituted, it may face delisting after a full evaluation. From 1975 to 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 percentage is higher than both hematologic and cardiotoxic drugs. “The incidence of drug-related liver injury is high, second only to skin mucosal disease and drug fever, which are the most reported adverse reactions. Drug-related liver injury also tends to occur in the elderly. They have poor liver function themselves and take a lot of drugs, and 40 percent of hepatitis in the elderly is drug-related liver damage.” Zhai Shodi said. In 1992, a doctor in the Chinese Journal of Traditional Chinese Medicine statistics, from the results of more than half a century of domestic medical journal, only 62 cases of adverse reactions to traditional Chinese medicine in the 1950s and before, 174 cases in the 1960s, 398 cases in the 1970s, to the 1980s has risen to 2,217 cases. The list of commonly used herbs clinically found to cause liver damage is also expanding. In China’s Measures for the Administration of Toxic Medicines for Medical Use, the Chinese Pharmacopoeia, 2010 Edition I, the drug standards promulgated by the former Ministry of Health, and the local herbal standards of Shandong, Guangdong, Liaoning, Gansu and other provinces, a total of 182 kinds of toxic herbal medicines are collected, including 37 kinds of “major toxic herbal medicines” and 78 kinds of “toxic herbal medicines”. 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 have safety risks. “Even herbs for the liver and kidneys have been found to be hepatotoxic in recent years.” Du Xiaoxi pointed out at the 2013 National Hospital Pharmacy Academic Conference that the literature reports that horse mulberry leaves, seasonal green, ground elm, daylily root, heshouwu, nutmeg and clove can cause liver damage; herbs containing glycosides (diosgenin), toxic proteins (seeds), alkaloids (millipede, comfrey), heavy metals (lead, arsenic), and animals (centipede, zebracho) have been associated with liver damage. However, liver damage is only known to the person taking the medicine when it reaches a severe level. If the patient only has general symptoms of liver damage such as elevated transaminases, he or she can recover after timely discontinuation of the drug. However, if the patient is unaware and does not get tested, he or she will not notice any changes in the liver. Minor cases of liver injury do not usually appear in the literature. Patients who are not hospitalized will not be 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 suffer liver injury from taking herbal medicines is much higher than the hundreds or tens of thousands reported in the literature. Ill-advised Chinese and Western medicine Wang Jiazhuo acknowledges that pharmacogenic liver damage from Chinese herbs has become a realistic proposition that seriously affects the safety of clinical use of Chinese herbs and needs to be urgently addressed. But he also takes issue with some of the higher reported data on liver disease in Chinese herbal medicine. He believes that the prevailing combination of Chinese and Western drugs, coupled with the fact that herbal medicine is not as well studied as chemical drugs, makes it possible for many drug-induced liver diseases to be misreported as being caused by herbal medicine. Wang Jiazhuo disclosed the liver injury data of his hospital. From 2002 to 2010, the hospital admitted nearly 2,000 cases of clinical liver damage. Nearly a quarter of those liver damage cases were determined to be likely caused by Chinese medicine, and in addition, nearly half of the liver damage cases were suspected to be related to the combination of Chinese and Western medicines. Wang Jiazhuo said this situation makes the confirmation and in-depth study of liver damage from traditional Chinese medicine extremely complicated. In the view of some in the Chinese medicine industry, the combined application of herbal and chemical drugs in China allows Western doctors to prescribe Chinese medicine precisely and also exacerbates the risk of herbal liver disease. An incomplete statistics shows that about 70% of Chinese proprietary medicines are prescribed by Western medical practitioners in general hospitals. However, according to the theories and traditions of TCM, doctors who prescribe TCM must understand the relevant theories of TCM, such as evidence-based treatment and concoction to remove toxins. “Different concoctions of 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 on this point.” Chinese medicine expert Zhou Chaofan told the Phoenix Weekly that there is a difference between raw radix heshouwu and system radix heshouwu, with the former being unprocessed and concocted and the latter being processed. Although there is no unified process standard for concoction, but nine steamed and nine sun-dried He Shou Wu concoction products may be less liver damage. Western medical doctors obviously have difficulty understanding this. This combination of Chinese and Western medicine leads to confusion not only in the process of use, but also in the manufacture of proprietary Chinese medicines, where there are serious problems. According to Dr. Jianming Xu, chemicals adulterated in Chinese herbal medicine are another major risk for herbal liver disease. While researching herbal drug-induced liver injury, Xu once got a report from the College of Pharmacy of Central South University in a private communication. “In the herbal medicines examined, the vast majority of proprietary Chinese medicines and health products were adulterated with chemicals.” Xu showed the report: including hypoglycemic drugs, anti-epileptic drugs, sedative-hypnotic drugs, anti-asthmatic drugs, diet pills and other Chinese herbal medicines and health care products, dozens of Western pharmaceutical ingredients were checked. “This is when you can’t attribute liver disease caused by such herbal medicines to herbal liver disease. With a mix of proprietary Chinese and Western medicines, it’s not clear whether this is caused by Chinese herbs, Western medicines, or a mix. We are also confused as to which specific drug to study.” Xu Jianming told the journal that only when the chemical problem is completely ruled out can the toxicity study of Chinese medicine be carried out. But whether it is He Shou Wu or other Chinese medicines, the traditional inertia of folk using herbal medicines, the green light of adverse reactions on the instructions of Chinese medicines, and the confusing prescription rights of Chinese and Western doctors, all make herbal liver disease in a long-term secret, but growing situation.