Question and Answer Session

March 14, 2006 Presentation: Traditional and Herbal Remedies: Toxicology and Laboratory Concerns

This month's expert is Catherine A. Hammett-Stabler, PhD. View the presentation and direct your questions to our online expert. AACC would like to thank Bayer HealthCare Diagnostics for making this program possible.

I understand there is a (HHS?)draft guideline looking at federal regulation of traditional medicines. Can you point me to this document?

Catherine A. Hammett-Stabler, PhD: I haven't seen such a draft guideline from DHHS. You may be thinking of discussions originating in the FDA. In late 2004 they announced plans to strengthen their regulation of alternative medicines.

Do you have any information on Chiles? For treatment of the common cold and fevers in general among the Mano people of Liberia, the root of suo longo (Ethulia conysoides) is chopped into small pieces, three hot chile peppers are added, and the mixture is boiled in a few cups of water. The concoction is removed from the heat and is allowed to steep all night. In the morning, a half a teaspoon of salt is added, and one cup is consumed.
Washington, DC

Catherine A. Hammett-Stabler, PhD: I'm not familiar with this particular use, but chili peppers are used for a variety of purposes in many cultures. Capsaicin and vanillylamine are thought to be two of the "active" compounds. Studies of their use in treating conditions from cancers to colds have shown very mixed results with little solid evidence of benefit. One of the most common uses of capsaicin is in management of chronic pain associated with neuropathies.

I'm wondering if you're seeing the same trend we are - namely younger and younger patients with toxicological effects from herbals and supplements? Caffeine, kava, and yohimbe seem to be the current favorites of the ultracompetitive teenage (and younger!) students and athletes who sometimes find themselves in the ED.
Nashville, TN

Catherine A. Hammett-Stabler, PhD: We see a wide range of patients using herbal and supplements. As in your institution, the younger ones are using caffeine and kava, but we have plenty in the >65 age range as well! You might find the surveys I list in the slides interesting.

Mother brings 14 y.o. female to emergency room. Initial exam is exceptional for elevated respiration and BP, nausea, moderate perspiration, and child complaining of colorful hallucinations. A typical LSD case, or maybe an exotic hallucinogen? Nope. Kids made a concoction out of the following ingredients: Nutmeg, almonds, raw pistachios, cinnamon, cumin, tarragon, oregano, basil, turmeric, cayenne pepper, black pepper, and Maple Syrup, mixed into a vanilla milkshake. Nice coating for pork chops, but is there anything here that would explain the patient’s condition?
Houston, TX

Catherine A. Hammett-Stabler, PhD: Yes! nutmeg is a possibility. I've found these two references to be useful: Forrester MB. Nutmeg intoxication in Texas, 1998-2004. Hum Exp Toxicol. 2005; 24(11):563-6. Sangalli BC, Chaing W Toxicology of nutmeg abuse. J Toxicol Clin Toxicol. 2000;38(6):671-8.

Have you or any of your colleagues integrated a database of "Traditional" medicines into your LIS? Does such a product even exist?
Jacksonville, FL

Catherine A. Hammett-Stabler, PhD: Most lists of toxicities and or interferences on lab tests found in review articles and books are based on assumptions or traditional lore; rarely are these accompanied by references demonstrating the actual mechanism. There is an alternative med PDR that provides the typical pharmacological discussions of the cited products. Although for some entries it describes test interferences, I rarely find references that actually document the interference or its mechanism. There are some alternative medicines listed on the On-line version of Young's Effects of ...series. I find this to be the best current source since it provides references. Our Integrative Medicine Program has talked about developing something for pharmacy but hasn't done so.

In reviewing your presentation I notice you mention homeopathy. Is there any evidence to show that there are any benefits or side effects from homeopathic preparations as there are with herbal tinctures, infusions, poultices, teas, etc.?
Dallas, TX

Catherine A. Hammett-Stabler, PhD: No evidence of benefit. Amitava Dasgupta gave a wonderful presentation at last year's annual meeting that you might interesting. We have it posted on the TDM/toxicology Division web site: It's really quite a thorough discussion of the topic!

As a tech in an outpatient program for young drug offenders, I hear numerous urban myths about beating drug tests. One of the more popular recipes for beating the THC (marijuana) test is golden seal root and niacin (I’m now seeing a dramatic increase in kids with a telltale flush from recent niacin use). Right now we just send them home and reschedule, although I’m petitioning the judge to consider these episodes “failed” testing attempts. Can golden seal and niacin be used to successfully mask recent marijuana use?
Rockville, MD

Catherine A. Hammett-Stabler, PhD: The reference is Schwarzhoff R, Cody JT. The effects of adultering agents on FPIA analysis of urine for drugs of abuse. Journal of analytical toxicology. 1993; 17:14-17. In this paper the authors adulterated drug positive urine samples using a variety of things (bleach, cleaners, hand soap, vinegar, etc). One tested was golden seal at a final concentration of 0.9%. Now typically, golden seal is not added to urine as are things like bleach, vinegar, etc, but is ingested. Still when they did their experiment, they found some interesting results that appear to be an analytical interference. One of my graduate students at UF did a study of golden seal teas that suggested the way the teas thwarted drug use detection was more from dilution than anything else.

What studies are being done by NCCAM to determine the efficacy of these substances for disease treatament or prevention? and Will laboratories be testing for presence of active ingredients or metabolites?

Catherine A. Hammett-Stabler, PhD: NCCAM's web site has a listing of available grants. One of the biggest problems in conducting research with both commercially available products and home prepared products is the lack of standardization. There are a few labs that offer such testing - I hope more methods will be developed and published - we need methods to identify toxic components as well.

I would like to know more about the Goldenseal effects on urine drug screens by FPIA. Is anything published? Is it known what ingredients cause the interference? Are other immunoassays affected?
Hamilton, Ontario, Canada

Catherine A. Hammett-Stabler, PhD: See the previous answer for the reference. I have not found any other papers reporting similar studies of other immunoassays.

I have numerous patients requesting to continue their use of echinacea during pregnancy to ward off flu and colds (I try to dissuade them, but am not always successful). Are you aware of any maternal/fetal tests that may experience interference from echinacea?
Columbus, OH

Catherine A. Hammett-Stabler, PhD: You’ve probably seen Dr. Ernst’s recent publication: Huntley AL, Thompson-Coon J, Ernst E. The safety of herbal medicinal products derived from Echinacea species: a systematic review. Drug Saf. 2005;28(5):387-400. In this, he cautions against echinacea’s use during pregnancy. Before this was published, however, there were several studies that found no benefit from the herb’s use. There’s a recent article you can get via PubMed in the Cochrane Database System Review 2006 Jan 25; (1) Echinacea for preventing and treating the common cold.

The world Conservation Union's Medicinal Plants Specialist Group says that, the increased use of herbal remedies and the fact that two-thirds of all plants used are harvested from the wild, will not only destroy these plants, but affect the health and economy of the third-world countries where they are harvested. What steps are being taken by the US to prevent the depletion of this natural resource which is often the only source of health care for that countries people?
Chicago, IL

Catherine A. Hammett-Stabler, PhD: I'd suggest this is not a responsibility of the US alone but of all countries including those where such plants are found. But be assured that this is an issue that has gotten attention. There have been news reports and editorials in Science, Nature Biotechnology and other publications trying to raise even more interest. Take a look at J Ethnopharmacology. Ethnobotany/ethnopharmacology and mass bioprospecting: issues on intellectual property and benefit-sharing. 2005; 100:15-22 for a good discussion – you can get it thru PubMed.

Aloe vera capsules are touted as great for numerous ailments, including arthritis. Limited internet search indicates they may have Vitamin K effect such as other plants, so could be a problem for anyone on coumadin. Also warnings about severe diarrhea. True? Any other drug interactions?
Houston, Texas

Catherine A. Hammett-Stabler, PhD: Have not seen any studies reporting an interaction with coumadin - but remember there are a lot of interactions that go unreported or documented. As for warnings about causing diarrhea, a traditional use of aloe is as a laxative.

Is OTC polycosanol effective for cholesterol management? If so, does it have side effects similar to statins?
Houston, Texas

Catherine A. Hammett-Stabler, PhD: Octacosanol is the primary active constituent of a natural wax found in fruits, leaves and seeds – it’s available as a wheat-germ oil extract, and as you indicate there are studies that suggest it is effective in lowering cholesterol. Most of the studies are small, short term, and the changes in the lipid levels are moderate. (They don’t report the analytical variability, etc or multiple measurements on the subjects to consider the biological variability seen with lipids.) But some did compare the supplement to statins. The subjects on the octacosanol supplements did not report the side effects reported by those on statins. There’s a good review in Nutrition 19: 192-195 (2003) that gives a summery of some of the studies reported. The reviewers (and several since) suggest more studies are needed before concluding if the supplement does effectively reduce lipids.

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