Letters

Remedies may contain cocktail of active drugs

A 75 year old Belgian woman with gonarthrosis had been treated for five years with sulindac. She had also been treated for hypertension for more than 10 years with hydrochlorothiazide, triamterene, amlodipine, and atenolol. On 5 May 1993 she stopped taking sulindac and took, on her own initiative, Chuifong Toukuwan (eight pills daily for one month), which she obtained by mail order. She had good relief of symptoms but began to look cushingoid, as confirmed by a low plasma cortisol concentration (table) and weight gain: administration of exogenous corticosteroid was suspected. Furthermore, the treatment of her hypertension seemed less effective and renal failure was considered. One month after she stopped the treatment her plasma cortisol concentration and renal function had recovered (table).

Serum urea, creatinine, and cortisol concentrations before
treatment with Chuifong Toukuwan pills (18 January 1993), one
month after treatment (8 and 16 June), and one month after end
of treatment (19 July).
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                18 January   8 June   16 June   19 July
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Urea (mmol/l)      8.17      10.50     11.83      8.00
Creatinine
  (mmol/l)         97.4      106.2     124.8     108.9
Cortisol
  (mmol/l)*                  33.11     33.15    621.55
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* Morning blood sampling.

Analysis identified six synthetic drugs illegally introduced in the plant matrix: each pill contained 0.6 mg of hydrochlorothiazide, 3.2 mg of indomethacin, 6.8 mg of diclofenac, 38 mg of mefenamic acid, 20 µg of dexamethasone, and 0.75 mg of diazepam. Therefore, two added drugs--diclofenac and mefenamic acid--that had never been detected in such preparations were found. In addition, the recommended dose affords usual doses of each of the three non-steroidal anti-inflammatory drugs and the benzodiazepine.

Use of several non-steroidal anti-inflammatory drugs is well known for its adverse effects (nephrotoxicity, retention of salt and water, gastrointestinal disorders), which are increased by the addition of corticosteroid. Moreover, the use of non-steroidal anti-inflammatory drugs with antihypertensive agents (diuretics or ß blocking agents, or both) decreases the efficacy of the hypertensive treatment.

Finally, as licorice, one constituent of the plant matrix, could be considered to be an additional hazard (aggravating the electrolyte imbalances) many unexpected adverse effects may occur.

Berengere I Vander Stricht, Olivier E Parvais, Renee J Vanhaelen-Fastre, Maurice H Vanhaelen 

Lecturer, Lecturer, Senior lecturer, Professor Laboratory of Pharmacognosy and Bromatology, Institute of Pharmacy, Free University of Brussels (ULB), Campus de la Plaine CP 205-4, B-1050 Brussels, Belgium.

1. Atherton DJ. Towards the safer use of traditional remedies. BMJ 1994;308:673-4. (12 March.) [Free Full Text]
2. Ries CA, Sahud MA. Agranulocytosis caused by Chinese herbal medicines. JAMA 1975;231:352-5. [Abstract]
3. Forster PJG, Calverley M, Hubball S, McConkey B. Chuei-Fong-Tou-Geu-Wan in rheumatoid arthritis. BMJ 1979;ii: 308.
4. Offerhaus L, Dukes MNG, Smits HM. "Herbal" medicines and rheumatoid arthritis. BMJ 1979:ii:668.
5. Goldman JA. Chinese herbal medicine: camouflaged prescription anti-inflammatory drugs, corticosteroids and lead. Arthritis Rheum 1991;34:1207.