By Andrew Gaeddert
In the United States, about 100,000 persons die each year from side effects developed from taking prescription drugs, and about 300 per year from over the counter medications (Citizens for Health Report, Vol. 2, No. 1,1994). There are over 695,000 hospitalizations per year of older Americans due to adverse drug reactions (Worst Pills, Best Pills II). According to a study published in the Journal of the American Geriatrics Society (37: 323-326; 1989), 9.4% of hospital admissions were due to a drug-induced illness. The admitted patients were taking an average of 5.7 medications at the same time.
In contrast, pure herbs taken appropriately are quite safe. By pure herbs, I am referring to products that contain only traditional materia medica, and not, for example, products such as Black Pearls or Jin Bu Huan Anodine Tablets which contain various amounts of chemical drugs.
Korean constitutional medicine holds that about 5% of the population are unable to tolerate herbs. Based on my experience of working with chronically ill patients (i.e., chronic fatigue syndrome with multiple allergies), I believe that in the United States less than 1% of the population cannot take Chinese herbs. Side effect reactions can vary from mild body discomfort to gastrointestinal symptoms to allergic reactions. Thus, practitioners should be aware of such side effects and should institute immediate counter measures. However, the development of side effects does not necessarily mean that the patient cannot take herbs at all. Rather, in many cases, a modification of the herbal formula will circumvent potential adverse effects.
SPURIOUS SIDE EFFECTS
A common adverse reaction is actually not a side effect of taking herbs. Instead, the patient develops a cold or the flu, or eats inappropriately, and informs the practitioner that “the herbs made me sick.” Often, these are individuals who take herbs for the first time and are somewhat apprehensive, and are unaware of what in reality is occurring in their body (i.e., reaction from developing a cold, the flu, etc.).
An adverse effect can also result from pharmaceuticals and vitamins. Additionally, emotional stress and changes in diet or environment should not be overlooked as causes to bodily reactions. And, for many patients who have put off treatment until their systems are completely in disarray, their bodies may react uncomfortably when treatment is begun, although the reaction is not an outright side effect.
Therefore, when patients present such symptoms, practitioners should question them carefully: Did the patient eat or drink inappropriately? Was the patient fatigued? Did family or coworkers come down with similar symptoms? Is the patient taking any pharmaceuticals, vitamins, or the like? This line of questioning is necessary so that patients who are not accustomed to herbs do not blame them unjustly.
ALLERGIC REACTIONS
Some persons who take Chinese herbs will develop an allergic, or hypersensitivity, reaction. The gamut of responses ranges from skin outbreaks (see case history) to other kinds of reactions. Even if the herbal remedy is not the suspected culprit, it should be discontinued pending a thorough evaluation of the actual cause. Again, the same line of questioning as above should be used.
Materia medica that are commonly linked to allergic reactions include Borneol (Bing Pian), Rhubarb (Da Huang), Schisandra (Wu Wei Zi), Eupolyphaga (Tu Bie Chong), Siler (Fang Feng), Centipede (Wu Gong), among others. Traditional formulas that have been implicated include Yunnan White Medicine (Yunnan Bai Yao), Minor Invigorate the Collaterals Special Pill (Xiao Huo Luo Dan), Six- Miracle Pill (Liu Shen Wan), and others.
In most cases, the best measure of countering hypersensitivity reactions due to herbs is to have the patient stop taking the remedy; usually the reaction symptoms will resolve spontaneously. For more severe reactions, conventional treatment with antihistamines, or if necessary, epinephrine, may be required. To ascertain whether a specific herb or remedy is responsible, a rechallenge with the same remedy can be done if the original allergic response was mild.
After the allergic response has completely subsided, herbal treatment can be continued with the offending herb(s) eliminated or substituted, or with an alternate formula. If the allergic reaction was mild, in many cases future reactions can be avoided by reducing the dosage of the herb(s) and/or formula.
Persons who are of deficiency constitutions (have multiple allergies or sensitive systems) seem more susceptible to allergic responses. These individuals tolerate herbal tablets better than teas, and can thus be started on herbs at one-third the regular dosage, then increasing to three tablets three times a day over a two to three week period. Another suggestion is to take the herbs with meals so that their absorption is slower, arid the chance of instigating adverse reactions is reduced.
Above all, every effort should be made to avoid allergic reactions. Patients with an allergic constitution should be questioned carefully about their allergy history. (Allergic constitution refers to persons who have allergic reactions that are serious, who are allergic to substances that usually do not provoke reactions in the general population, and/or are hypersensitive to loud noises, are withdrawn, etc.) Practitioners should he especially aware of those with reactions to plants since much of Chinese materia medica are of botanical origin. For example, persons allergic to oranges may want to avoid Citrus (Chen Pi), or those who are sensitive to ragweed may need to stay away from chrysanthemum or chamomile since all three belong to the same botanical family.
GASTROINTESTINAL REACTIONS
Many American have weak digestive systems. When a patient is suspected to have such problems, they should be questioned carefully: Do they have digestive problems after meals? Do they use antacids? Do they suffer constipation or loose stools? Men should be probed more tactfully, since they have been taught to “shrug off” physical pain and discomfort.
The most common digestive side effect from taking herbs is stomach upset. In particular, some herbs such as Yin tonics including cooked Rehmannia (Shu Di Huang), are by nature difficult to digest. Symptoms that may result are nausea, queasiness, fullness, or stomach cramps. When such symptoms develop, the herbal remedy should be stopped. Then, by reducing their dosage, or by substituting another herb or formula, by taking digestants such as Quiet Digestion, which contains Malt (Mai Ya) and Citrus (Chen Pi), untoward reactions can be avoided. Altering the form of administration may be helpful as well since tablets are generally better tolerated than teas.
REACTIONS DUE TO MISDIAGNOSIS
An incorrect diagnosis can lead to an incorrect treatment, which can result in adverse reactions. For instance, administering tonifying herbs when a patient has a cold or the flu can exacerbate the symptoms since such herbs can cause the Excess to remain harbored in the body. Careful questioning of the patient is imperative, especially in cases that are more complex and are presenting a myriad of symptoms. For example, a patient may present a Cold pattern in the morning followed by Heat signs in the afternoon. Thus, a warming formula appropriate for the morning pattern could potentially cause an adverse reaction, if the afternoon Heat signs are not taken into account. To obtain a complete picture of the syndrome pattern, patients can be scheduled at alternating times of the day, rather than at about the same time at each appointment.
In practicing Chinese medicine, one should constantly bear in mind the importance of combining the results from the Four Diagnoses to arrive at an overall conclusion. Practitioners who are not obtaining good results may be attempting to speed through their diagnosis process by basing treatment on only one or two of the Four Diagnoses. An historical example of misdiagnosis and its consequences is recorded in the Grand Materia Medica (1578): “An elderly woman over 60 years of age had been suffering watery stools for five years. After eating greasy, raw, or cold foods, the condition would recur painfully. The previous doctor observed that she was elderly and had protracted recurrent diarrhea accompanied by abdominal pain, and mistakenly diagnosed her as having Spleen deficiency, causing sinking of Qi and intractable loose bowels. He administered Spleen regulating, upward raising, and securing and binding medicines. After taking this remedy, the woman’s condition immediately worsened. Later, a second doctor felt that her pulse was submerged and slippery, and upon combining the four diagnoses, concluded that her condition was instead due to long-term injury of the Spleen and Stomach, with accumulated Cold. The method of treatment was to administer Hot medicines to drive out the Cold. Within two days of taking this new medicine, the woman’s diarrhea stopped.”
INAPPROPRIATE TIME OF ADMINISTRATION
A correct diagnosis and formula are not necessarily enough to effect successful treatment. Untoward reactions can also develop because a formula was not taken at the appropriate time of day. Chinese medicine is based on the principle that the human body is in harmony with the universe. The cycle of seasons and of day and night produce corresponding physiologic cycles in the body. The goal of treatment is to rebalance Yin and Yang. Therefore, when administering herbal medicines, the most appropriate time of day must be chosen; this is based on the body’s physiologic cycle and the dynamics of the disease.
For patients who are not responding, practitioners can have them try taking herbs in accord with the general rule as given in the Chinese classics: upward raising and exterior relieving medicines should be taken before noon, and downward sinking and evacuating medicines in the afternoon; Yang warming and Qi tonifying herbs should be taken between early morning and noon, and Yin enriching and Blood nourishing herbs at nightfall; herbs that expel excesses from the Yang and/or Qi levels should be taken in the early morning, and herbs that clear and drain Fire from the Yin at nightfall. Of course, individual variation may require experimentation before the right time of day is found for taking herbs.
DIE OFF REACTIONS
Die off reaction (Jarisch-Herxheimer reaction) is usually seen in patients who are being treated for parasites, especially protozoans such as giardia. These symptoms can be mitigated by starting patients on a reduced dosage such as one-third the recommended dosage for the first week, then slowly increasing over the next couple of weeks. Occasionally, persons with candidiasis may experience die off reactions; they, too, can undergo the reduced dosage regimen.
MISCELLANEOUS REACTIONS
Other types of reactions include those that result from prohibited combinations (nineteen antagonisms, eighteen incompatibilities) and dietary incompatibilities. A more serious type of side effect is a toxicity (overdose) reaction since it can be potentially life threatening. Thus, it behooves practitioners to know the prohibited combinations, dietary incompatibilities, as well as the recommended dosages of materia medica they use, especially those that are considered to be toxic in small amounts.
One recent incident worth mentioning is that of four persons who after taking Chapparal developed hepatitis. Shortly thereafter, American herb manufacturers withdrew products containing Chapparal. Toxicological studies will determine whether the hepatitis was due to the herb, or to alcohol or other drugs that these patients were taking. Hopefully, Chapparal was not responsible, and will be returned to the market, since it has been safely used in America for hundreds of years.
CONCLUSION
By the time many patients visit TCM practitioners, their systems are seriously out of balance. Their purpose in trying alternative medicine is to seek a simpler and gentler way of treatment. While most herbs are gentler than pharmaceutical drugs, the former are certainly not without side effects. Patients and practitioners should not be under the impression of “it’s natural, so it doesn’t have any side effects.”
While this article has discussed herbal side effects, the beauty of herbal medicine is its flexibility. When an herb or formula is not achieving the desired effect, other herbs or formulas may be substituted. In western medicine, the range of options is often quite limited.
Finally, it is important that herbs be administered by trained and knowledgeable individuals. Herbs are not so hazardous as to require them to be prescribed by an MD. Indeed, the vast majority of American MDs are not even trained in herbs.
CASE HISTORY
Skin reactions are not uncommon. While the desired routes of elimination are through the bowel and bladder, toxins can leave the body through the skin, since it, too, is an organ of elimination. I consulted on one case where the patient was suffering severe herpes simplex. In addition, she was under a great deal of emotional stress, was taking the amino acid, L-Lysine, and was exposed to lead in her occupation.
Her practitioner administered acupuncture and herbal remedies to aim at draining Heat. One week after starting treatment, the patient reported to a hospital emergency room and was later diagnosed as having Stevens-Johnson syndrome, an inflammatory skin eruption, usually caused by allergy to drugs, infections, among other factors.
Can this case be considered a side effect from taking herbs? Perhaps, or perhaps not. Since the skin outbreak occurred after herbs were taken, then it is possible that the reaction was caused by the herbs. However, Stevens-Johnson syndrome can also be caused by infections. Thus, the skin outbreak could also have been due to the herpes simplex.
From a Chinese medicine perspective, this patient had a tremendous amount of accumulated Heat in her system. The initial efforts to resolve the Heat were unsuccessful. And then, the Heat left all at once. The skin was affected, since the normal routes of elimination – the bowel and bladder – were not eliminating the Heat quickly enough.