Trick or Treatment (30 page)

The second important point about Table 1 is that it is not comprehensive. Although the table includes more than thirty herbal medicines, we were forced to omit many remedies simply because they have not been properly tested. And without decent trials it is impossible to give an indication of whether or not a particular treatment is effective for a particular condition. If a herbal remedy does not appear in the table, then it is probably safe to assume that there is no convincing evidence to support its use.

The third point also relates to an omission, because the table makes no reference to the efficacy of so-called
individualized herbal medicines
. These special herbal mixtures are not bought over the counter, but rather they are concocted by a traditional herbalist after a detailed personal consultation. Traditional Chinese healers, Ayurvedic healers and European traditional herbalists usually practise this form of individualized herbal medicine, combining several herbs in order to find the mixture that is most suitable for the characteristics of an individual patient. It may depend on the patient’s history, background, personality and environment, as well as on the current symptoms. This means that two patients presenting the same symptoms may receive very different herbal mixtures. It is harder to test this form of herbal medicine because of its individualized nature, but it is certainly not impossible. Indeed, there have been several high-quality randomized clinical trials.

Typically these trials involved dividing a group of patients with a particular condition, such as irritable bowel syndrome, into three subgroups. Group A would receive a standard herbal treatment appropriate to the condition, such as peppermint, while groups B and C would be seen by a highly experienced herbalist who created an individualized remedy for each patient. Patients in group B would then receive their own personal remedy, while group C would receive a placebo remedy that looked and tasted similar to the individualized remedies, but which was inactive. Although patients in group A realized that they were receiving a standard herbal remedy, those in groups B and C were not aware of whether they were receiving an individualized remedy or the placebo. In general, the results of these studies are disappointing, because individualized herbal remedies either failed to perform better than placebo, or failed to perform better than the standard herbal remedy. Hence, our advice would be to avoid individualized herbal remedies – at worst they are an expensive placebo and at best an expensive option compared to straightforward herbal medicines, such as peppermint bought over the counter.

The fourth and final issue about herbal medicine – both those that appear in Table 1 and those that do not – is safety. As discussed in the previous chapter, patients need to know if an alternative medicine is both effective and safe. Arguably, safety is even more important than effectiveness.

First, do no harm

‘First, do no harm’ is not, as many people assume, part of the Hippocratic Oath. Nevertheless, Hippocrates did ascribe to this belief, and expressed very similar advice to doctors in his text
Of the Epidemics
: ‘As to diseases, make a habit of two things—to help, or at least to do no harm.’

Modern medicine interprets this edict in terms of benefit versus risk, because we now accept that almost every medical intervention carries a risk of side-effects. Hence, before embarking on any treatment regime the doctor and patient should agree that the likelihood and extent of the potential benefit outweigh the risk and severity of adverse side-effects. So far, we have looked only at the possible benefits associated with some herbal medicines, but now it is time to examine the possible risks.

It is important to remember that the majority of powerful chemicals found in plants, those that may help deal with human disease, have evolved to serve a very different purpose. For example, some of these chemicals will have evolved in order to protect the plant from insects, and if these natural insecticides can poison bugs then it is highly likely that they will, in sufficiently high doses, harm humans too.

We will begin by discussing the drawbacks of St John’s wort, because, as we have seen, it is one of the most popular and effective herbal remedies currently on the market. The main concern with St John’s wort is that it contains chemicals that can interfere with other drugs that a patient might be taking. In fact, St John’s wort can inhibit the impact of over half of prescribed medicines, including some anti-HIV and anti-cancer drugs. This is because St John’s wort stimulates enzymes in the liver that destroy other drugs before they can do their job. Moreover, St John’s wort reduces the activity of a transport mechanism that would otherwise carry drugs from the gut into the bloodstream. Essentially, this herbal remedy can serve a double whammy to other drugs, either by destroying them or by blocking their delivery.

Authorities in both Sweden and the UK have advised women using oral contraceptives not to take St John’s wort, as there are several cases which indicate that the herb inhibits the normal action of contraceptives and thereby could lead to pregnancy. Similarly, concerns have been raised over kidney transplant patients, because St John’s wort interferes with the action of
cyclosporine
, an immunosuppressant drug that helps prevent organ rejection. In one case, a twenty-nine-year-old woman in Arkansas began taking St John’s wort for depression while also taking cyclosporine in the wake of a kidney and pancreas transplant. Her transplant had been successful, but the cyclosporine levels in her blood fell and both her kidney and pancreas function began to decline. Her doctors remained perplexed for several weeks, because the patient did not bother to tell them that she was taking St John’s wort. When this issue came to light, she was asked to halt her intake of St John’s wort and the doctors tried to boost her cyclosporine levels. Unfortunately, it was too late – the kidney was rejected and the patient had to return to a programme of dialysis.

The problems caused by herbal remedies interfering with conventional medicines are partly due to a lack of awareness among the general public that herbal medicines carry risks. A large proportion of the public assumes that herbal remedies are inherently safe because they are natural. An Israeli survey, for instance, revealed that 56 per cent of people using herbal remedies believed that ‘they caused no side-effects’. This helps to explain the results of a survey of 318 out-patients being treated for cancer at the Royal Marsden Hospital in London – 52 per cent of them were using alternative supplements, but less than half of these patients had bothered to inform the doctors and nurses who were treating them.

Even if a patient is not taking any other medication, St John’s wort can still cause problems. A 1998 review linked the remedy to several types of adverse reactions, such as gastrointestinal symptoms, dizziness, confusion, tiredness, sedation and dryness of the mouth. However, it is important to stress that these sorts of adverse reactions are only possibilities, and the risk might be considered acceptable if a patient receives sufficient benefit from using St John’s wort. Indeed, it is generally accepted that this particular remedy has fewer and less serious adverse effects than some conventional antidepressant drugs. Hence, St John’s wort can be a useful herbal remedy, as long as the patient is aware of its inherent problems, as long as there is no interference with any conventional drugs being taken, and as long as the patient’s GP is kept informed.

Unfortunately, with some other herbal remedies, the adverse effects are more serious and certainly outweigh any benefit. In the early 1990s, a Belgian doctor called Jean-Louis Vanherweghem was puzzled by the appearance of two young women at his clinic; both had suffered sudden and unexplained kidney damage, otherwise known as
nephropathy
. After a bit of questioning, he learned that both women had been following the same slimming regimen, which involved the use of various Chinese herbs. The link between the herbs and the kidney failure was only a hunch at this stage, but it was confirmed when local records showed that seven other women under fifty years of age had suffered similar kidney failure in 1991 and 1992 and all of them had followed the same herbal slimming programme.

Vanherweghem published his observations in the
Lancet
in 1993, and within a year he published a follow-up paper which identified seventy cases of what was becoming known as Chinese herb nephropathy. Thirty of these cases had been fatal. Eventually, after examining and testing the mixture of herbs that was common to all the cases of kidney failure, it became apparent that the culprit was a herb known as
aristolochia
.

Further concerns were raised in the late 1990s when the herb was also linked to cancer. Belgian doctors discovered that 40 per cent of patients diagnosed with Chinese herb nephropathy also showed signs of multiple tumours. Although this was enough evidence for several countries around the world to ban the sale of products containing aristolochia, some herbal practitioners and manufacturers still maintained that it was a safe plant and that something else must be responsible for the kidney failure and tumours. After all, aristolochia had been used for centuries and there had never been any previous indications that it might be toxic.

Indeed, the ancient Greeks, Romans, Chinese and Native Americans have all relied on aristolochia to treat everything from snake bites to headaches. Because the curved shape of the plant resembled the birth canal, European herbalists particularly encouraged its use to ease labour and induce menstruation – hence its other name, ‘birthwort’. We now know, however, that all these patients were being gradually poisoned. The reason that traditional healers would not have noticed the link between the herb and subsequent kidney failure would have been because the onset of nephropathy would have been several months or years later.

The dangers of aristolochia are discussed by the investigative journalist Dan Hurley in his book
Natural Causes
, which also reveals the dangers of many other herbal medicines. One of the most recent examples in his catalogue of horrors is
ephedra
, a remedy extracted from the Chinese plant ma huang (
ephedra sinica
). Scientists had long been concerned about the side-effects of ephedra, so they developed a safer version called
pseudoephedrine
, which acts as an effective decongestant and which can still be bought today as a component in many cold remedies. Nevertheless, the original herbal extract has continued to be used by millions of people, particularly athletes and slimmers, to improve physique and lose weight. However, by 2005 there was strong evidence that 19,000 people had suffered severe reactions and at least 164 had died as a result of using ephedra. The most prominent case was Steve Bechler, a pitcher for the Baltimore Orioles, who died in 2003 during training as a result of heatstroke. Ephedra increases perspiration and dehydration, which is why the medical examiner concluded that ephedra had played a ‘significant role’ in Bechler’s sudden death. The sale of ephedra is now banned in most countries, although it is still readily available via the internet.

As well as the dangerous adverse effects associated with several herbal remedies, there is also another serious risk, namely the problem of contamination. In 1999 Jerry Oliveras, a food and medicines quality inspector, testified in front of an American Federal Drug Administration panel:

Ayurvedic herbal medicines are equally prone to heavy metal contamination. In 2003, a group of Boston medical researchers trawled their local shops and purchased seventy distinct Ayurvedic herbal medicine products. One in ten contained more arsenic than the standard safety level, with the worst case having an arsenic content 200 times greater than the allowed level. One in ten products also contained excess mercury, with the worst case having over 1,000 times more mercury than the recommended safety level. Most worrying of all, one in five products also contained excess lead, with the worst case having over 10,000 times more lead than the recommended safety level.

Sometimes the contaminants in herbal medicines are not toxic metals, but rather conventional pharmaceuticals, deliberately introduced in order to obtain the desired effect. For example, in 1998 the herbal sedative Sleeping Buddha was found to contain the conventional sedative drug
estazolam
, and five Chinese herbal diabetes products were tested in 2000 and found to contain the diabetes drugs
glyburide
and
phenformin
. Perhaps the most common contaminants are corticosteroids, which are added to herbal eczema creams, and Viagra, which is introduced into some herbal aphrodisiacs to give the desired effect.

We already know from Table 1 that there is a lack of evidence to support the claims made for several herbal products, which means that many of them may be ineffective. But concealing pharma ceuticals within these ineffective herbal products leads to a dream scenario for the manufacturers and retailers. The product is still viewed as natural and at the same time it is very likely to be effective. There are, however, serious problems with this deceitful practice and the dream scenario can easily turn into a nightmare. Apart from the legal and ethical issues, the patients are unwittingly consuming a drug, thereby exposing themselves to an unknown hazard. The drug might interfere with other medicines being taken, causing adverse reactions. Alternatively, a patient might turn to a herbal remedy because he or she is allergic to a particular pharmaceutical, but if the herbal remedy is contaminated with that selfsame pharmaceutical, then the patient is duped into taking the very thing that he or she is trying to avoid.