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Rapid Responses: Rapid Responses published:
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Chinese herbal creams
- David Church (3 March 1999)
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Yes But
- Ned Hoke (5 March 1999)
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Validity of study?
- Helene Sorkin (20 March 1999)
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RISK TO THE PUBLICS HEALTH OF UNLICENSED MEDICINES
- Sarah Anderson (2 September 1999)
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Ethics of duplicate publication
- Mark D Kennedy (27 September 1999)
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The problem with redundant publication is failure to disclose it
- Richard Smith (27 September 1999)
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David Church
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Dear Editor Keane et al, BMJ 1999, 318; 563 (Analysis of Chinese herbal creams prescribed for dermatological conditions) have submitted further evidence that some of the widely-touted so-called 'herbal' and 'natural' products contain potent prescription-only drugs. This serves to remind us that although such preparations are often aggressively advertised as harmless "it is 'natural'/'herbal' so it has no drug interactions or side effects" ) directly to the unsuspecting patient (and sometimes sold to them by non-medically qualified practitioners), many of them are in fact definitely NOT harmless. Many of these preparations do not carry adequate labelling of the contents. POM ingredients are included with no indication of their presence. Interactions are highly likely with both prescribed medication, and other non-prescribed drugs. Even allergies occur to such off-label constituents, such as for lactose-intolerant patients to the lactose in many 'homoeopathic' preparations. Let us not forget that both warfarin (clover) and Digoxin (foxglove) are herbal drugs, but both can be fatal if improperly used. Even aspirin, a completely safe, 'herbal' variety of which can be obtained from some herbalists (as claimed on TV this week) is subject to side effects and allergic reactions in susceptible people. It is about time we as a Profession took responsibility for ensuring Government applies controls to the production and distribution of ALL drugs, and stop the loophole that allows 'natural', 'herbal', and 'homoeopathic' remedies to be marketed with no guarantees of efficacy, safety, stable dosage, and product quality. After all, it is the health and safety of our patients that is at risk. David Church locum GP mid-Wales |
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Ned Hoke, private practice
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Doctors in the orient have practiced for thousands of years mixing their own prescriptions. With the advent of highly refined chemical medicines and botanical extractions this Chinese practice goes on and one finds herbal and prescription medicines mixed together in some cases..in preparations made in the orient or dispensed by one of that culture. The physician who paints all herbal therapy with a blackened brush and insists on strict government controls for all such things is simply being hysterical based on evidence of a discrete situation that does need better management. Holding all herbal and naturopathic pharmaceuticals to accurate labeling standards is not only a worthy principle it is an essential ingredient of medico-legal public policy. Holding learned and honorable natural methods health care hostage to principles and practices appropiate to conventional modern medicine is to disenfranchise fundamental personal authority and rational opportunity for self-care. Let's correct the inappropiate and work the genuine problem in the size that it is. |
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Helene Sorkin, acupuncturist Saguaro Clinic
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I question the basic validity of the study as it was done based on materials brought in by patients. These products could have been adulterated before the study began. To me, it would be preferable to purchase the product "off the shelf". This is in no way to deny that there can be problems from imported products; that is always a possibility. Thankk you. |
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Sarah Anderson
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EDITOR, Keane et al reported the analysis of Chinese herbal creams prescibed for dermatological conditions and the finding that many contain dexamethasone at concentrations inappropriate for their site of use. All patients treated with these creams were unaware of their ingredients. Keane et al concluded that "greater regulation & restriction needs to be imposed on herbalists" to prevent illegal and inappropriate prescribing. We support Keane et al in their call for greater regulation not only of alternative practitioners but also of their unlicensed products. On the 28/7/99 Prof. Breckenridge, Chairman of the Committee on Safety of Medicines sent an urgent message to medical professionals via the Chief Medical Officer and the Public Health link / EPINET system (a dedicated electronic network linking the CMO to Health Authorities, Trusts and GP's). The message warned medical professionals about renal failure associated with 'aristolochoia,' found in some Chinese Herbal Medicines. Recently a patient was investigated following complaints of fatigue, loss of appetite, constipation and myalgia. She was found to have severe anaemia caused by lead poisoning. For several weeks she had been taking various "remedies" given to her by an Ayurvedic Practitioner. These remedies were analysed at the Medical Toxicology Unit, Guy's & St. Thomas' Hospital, and two were found to contain high levels of lead, arsenic and mercury. These were Mahayograj-Guggul (lead: 28,900ppm; mercury: 4,970ppm) and Pulsineuron (lead: 10,200ppm; mercury: 5,840ppm; arsenic: 45,900ppm). The cases documented here raise a number of issues concerning the safety of alternative medicines. The use and expenditure on alternative medicine has increased substantially in the last decade, to an estimated $21.2 billion in the USA in 1997. The fact that 'traditional' and 'herbal' remedies, particularly from the Indian subcontinent, can lead to heavy metal poisoning is not new. It is worrying that with increasing use of alternative medicines in the UK, there is no established national mechanism for ensuring the safety of these products, and also there is no rapid system to warn the public against taking those remedies identified as dangerous. Alternative medicines are not licensed, and therefore are not regulated or tested as stringently as prescribed medicines. The public tend to regard 'traditional' and 'herbal' remedies as safe due to the fact that they are natural plant-derived products. They pose a threat to health that many people are unaware of. Dr Sarah R. Anderson Dr Claude Seng Brent and Harrow Health Authority, Bessborough Road, Harrow, Middlesex. HA1 3EX. 1. Keane FM, Munn SE, Du Vivier AWP, Taylor NF, Higgins EM. Analysis of Chinese herbal creams prescribed for dermatological conditions. BMJ 1999;318:563-4. 2. Breckenridge A. Renal Failure associated with Aristolochia in some Chinese herbal medicines. CEM/CMO/99/8 3. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280(18):1569- 75. 4. Shaw D, Leon C, Kolev S, Murray V. Traditional remedies and food supplements. A 5-year toxicological study (1991-1995). Drug Safety 1997;17(5):342-56. 5. Prpic-Majic D, Pizent A, Jurasovic J, Pongracic J, Restek- Samarzija N. Lead poisoning associated with the use of Ayurvedic metal- mineral tonics. J Toxicol Clin Toxicol 1996;34(4):417-23. |
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Mark D Kennedy, Head, Information Svcs W. Virginia U. Health Sci Library
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I wonder how you justified publishing the same article in BMJ and also in the May 1999 issue of WJM (Western Journal of Medicine? I thought everyone know this was strictly forebade by all journals? Please respond to the readership of both journals. (I have no competing interests.) |
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Richard Smith, Editor BMJ
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The problem with redundant publication is not publishing the same material twice, which happens all the time, but rather doing so without full disclosure. It is the intent to deceive which is the problem. For example, the Committee on Publication Ethics report, which was published earlier this month, defines redundant publication thus: "Redundant publication occurs when two or more papers, without full cross reference, share the same hypothesis, data, discussion points, or conclusions." (1) In other words, publishing material in the WJM that has appeared in the BMJ is not redundant publication--because it is disclosed. We have for nearly 20 years taken material that was published in the BMJ and republished it in our local editions. The Student BMJ contains material published in the weekly BMJ. Our ABC books, which again go back 20 years, republish material that is published in the BMJ. Our regret is not that we do this but that we don't do it more. Publishers meet the needs of different groups and audiences by republishing material. We sometimes publish material that has appeared in other publications in the BMJ--usually when we know that very few of our audience will have seen the material. There is currently little overlap between the readers of the WJM (most of whom at the moment are in New Mexico) and the readers of the BMJ. Richard Smith 1 Committee on Publication Ethics. The COPE Report 1999. London: BMJ Publishing Group, 1999. (www.publicationethics.org.uk) |
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