Its natural, therefore it must be safe!OR

Do we really ask what people are ingesting?

Mark LittleEmergency Physician & Clinical

ToxicologistCairns Base Hospital

SMACC 2013 Sydney

In this talk I will attempt to link…

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SMACC 2013 Sydney

SMACC 2013 Sydney

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SMACC 2013 Sydney

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Take home messages

“We need to ask our patients what else are

they ingesting”

All things ‘natural’ may not be safeSMACC 2013 Sydney

So let me start with a case….

You are handed an ECG

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• 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

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• 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

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• He received IV K+

• A few days later an observant RMO notices a large full sports bag by his bed

• In it he discovers …

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SMACC 2013 Sydney

Boxes of• Ginko• Ginseng• Selenium• Zinc, copper, manganese• KI• Riboflavin• Vit C D3 B5• Human growth Hormone

• MgSO4• Rodium• Green lip mussels• Tumeric, cumin

ginger• Garlic oil• Melatonin• Gotu kola• Omega 3• Himalayan mountain

salt

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Boxes of

• Ginko• Ginseng• Selenium• Zinc, copper, manganese• KI• Riboflavin• Vit C D3 B5• Human growth Hormone

• MgSO4• Rodium• Green lip mussels• Tumeric, cummin ginger• Garlic oil• Melatonin• Gotu kola• Omega 3• Himalayan mountain salt

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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.

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SMACC 2013 Sydney

Turns out instead of having 1 teaspoon/d having 8g/d for

weeks

• So we did a test……

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Urine cesium

• Sample A: 656,000mcg/gm creatinine

• Sample B: 848,000mcg/gm creatinine

• (N: <7.7mcg/gm creatinine)

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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

We did not ask what else he was taking

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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

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Drug interactionsAustralian Prescriber Dec 10

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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.

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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

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Summary of cases

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Conclusion

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

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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

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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

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• 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

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Patient survives

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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

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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%)

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Adverse events

• Endocrine disorders 22% – (hypoglycaemia 228 cases, Cushings 17)

• CNS disorders 21%– (coma 114, drowsiness 80)

• Deaths 22– Hepatotoxcity 10, severe hypoglycaemia 9

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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)

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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

Conclusion

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

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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…

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Take home messages“We need to ask our

patients what else are they ingesting”

All things ‘natural’ may not be safe

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Questions?

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