The Clinical Spectrum of Jin Bu Huan Toxicity

Abstract

Herbal medications and other nontraditional medical therapies are becoming increasingly popular in the United States. We describe three children and three adults in whom severe toxic effects developed after ingestion of a Chinese herbal medication, jin bu huan, which is sold as Jin Bu Huan Anodyne Tablets. Jin bu huan produced distinct clinical syndromes after acute ingestion in children and long-term use in adults. A single, acute ingestion in children rapidly produced life-threatening neurologic and cardiovascular manifestations, while long-term jin bu huan use in adults was associated with hepatitis. Jin bu huan contains levo-tetrahydropalmatine, a potent neuroactive substance. The constituents of jin bu huan are misidentified on the package, resulting in significant delay in identifying the plant alkaloid responsible for its toxicity. Although perceived as innocuous, jin bu huan may produce major health effects. The highly concentrated formulation, the lack of childproof packaging, and the product insert listing indications for the treatment of serious medical conditions may all contribute to the development of toxic reactions.

Emerging Trends of Herbal Care in Dentistry

“…[table/ fig-2]: Herbal Medicines which are associated with toxicity [18][19][20][21][22][23][24][25] …”

Herbalife hepatotoxicity: Evaluation of cases with positive reexposure tests

“…Retrospective assessment of unintentional reexposure tests is cumbersome, because clinical conditions are variable, as shown in the present report (Tables 1 and 4) [1][2][3][4][5] and in previous case analyses [14,[36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] . Specific criteria for reexposure tests are available since 1988 (Table 3) [31] and have been incorporated in the CIOMS scale (Table 4) [16,32,34] following successful use for validation purposes [33] .…”

“…Data problems of reexposure cases are not confined to Herbalife products (Table 4) but represent a general problem extending to liver injury by all herbal drugs, dietary supplements and herbal products [14,[36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] . Analysis of 30 cases within the last three decades claiming a positive reexposure test revealed that in many cases detailed descriptions of the reexposure test and actual ALT values were lacking.…”

“…In retrospect, a positive reexposure test has been confirmed in only 13/30 cases (43%) [16] , as ascertained by established criteria published previously [31] . Of note, none of these reports communicated criteria for the evaluation of the observed reexposure test [14,16,[36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] . The use of inappropriate causality assessment methods in the analyzed case reports is difficult to reconcile [1][2][3][4][5] .…”

Herbal hepatotoxicity: Challenges and pitfalls of causality assessment methods

“…For reexposure assessments of the cholestatic (± hepatocellular) type of liver injury, ALT has to be replaced by ALP. Criteria for positive reexposure tests are included in the updated CIOMS scale (Tables 5 and 6) and were not previously applied in cases with reported positive reexposure tests [40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57]59,91] . When these cases were submitted to retrospective analysis using the reexposure test criteria, a positive reexposure test could be confirmed in only 13/30 cases, the test was negative in 5/30 cases and uninterpretable in 12/30 cases [91] .…”