Mark Little: Its natural therefore it must be safe

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

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

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  • 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
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  • 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
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  • 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
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  • 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
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  • 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