The use of herbal medicines, dietary supplements, and other alternative products has risen sharply since passage of the Dietary Supplement Health and Education Act (DSHEA) in 1994. In contrast to prescription or nonprescription drugs, these products do not require U.S. FDA pre-approval before marketing (except for new dietary ingredients that were not in the marketplace prior to 1994). Premarketing evaluation of safety and efficacy is not mandated. However, both foreign and domestic manufacturers are required to comply with good manufacturing practices and quality control standards. Consumers often mistakenly believe that these “natural” products are free of harm and may unknowingly be at risk for illness from the products and herb-drug and herb-disease interactions, particularly with “polysupplement” use. Table II-31 lists common selected products that are available as herbal remedies or dietary supplements or that have alternative uses, along with their potential toxicities.

1.FDA Office of Food Safety and Nutrition: Consumer alerts and health professional advisories about safety concerns related to botanical products and other dietary supplements. https://www.fda.gov/food/recalls-outbreaks-emergencies/alerts-advisories-safety-information

2.The Poisonous Plant database provides access to references in the scientific literature (primarily print literature through about 2007) describing studies and reports of the toxic properties and effects of plants and plant parts. https://www.fda.gov/food/science-research-food/fda-poisonous-plant-database

3.National Institutes of Health Dietary Supplement Label Database. https://dsld.od.nih.gov/dsld/

4.National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) LiverTox® Database. https://www.ncbi.nlm.nih.gov/books/NBK547852/

1. Adulterants. A number of poisonings related to herbal preparations have been caused by heavy metals such as cadmium, lead, arsenic, and mercury, or pharmaceuticals such as sildenafil, fluoxetine, sibutramine, phenolphthalein, dapoxetine, and designer steroids. Many of these products are marketed for sexual enhancement, weight loss, muscle building, or treatment of diabetes. As a general rule, if the product results in an immediate effect, it may mean that the product contains pharmaceutical rather than natural herbal ingredients.
2. Misidentification. Some herbs are intrinsically toxic, and poisoning may occur as a result of misidentification or mislabeling of plant materials, as occurred with a Belgian slimming formulation contaminated with the herb Stephania fangchi containing the nephrotoxin aristolochic acid.
3. Improper or nontraditional processing. Many herbs must be processed to remove the toxins before they are consumed. One example is aconite root, which contains cardiotoxic and neurotoxic alkaloids. Green tea extract (concentrated through processing, different from regular green tea) has been linked to a number of hepatitis cases and should not be taken on an empty stomach.
4. Herb-drug interactions. Dietary supplements may potentiate or diminish the effects of drugs with a narrow therapeutic index. Ginseng (Panax ginseng), Salvia miltiorrhiza (Danshen), nattokinase, and Ginkgo biloba appear to have anticoagulant effects and should not be used concomitantly with warfarin, aspirin, or other anticoagulant or antiplatelet therapies. St. John's wort has been shown to have several clinically significant pharmacokinetic interactions with substrates for p-glycoprotein and the cytochrome P450 system. Green tea interacts with a number of drugs including statins, nadolol, sildenafil, tacrolimus, and warfarin via inhibition of metabolism and absorption.
5. Allergic reactions. Raw botanical herbs may cause allergic reactions. Many herbs are treated with sulfur as a preservative and should be used with caution in consumers who have known sulfur allergy.
6. Pesticides are commonly used on botanical products, and consumers may be unknowingly exposed to these chemicals resulting in acute or chronic poisoning.

Depends on the toxic constituent of the herbal product and may be acute in onset (eg, with the cardiac-stimulant effects of ephedra or guarana) or delayed (as with Chinese herbal nephropathy caused by Aristolochia). Allergic reactions to botanical products may manifest with skin rash (including urticaria), bronchospasm, and even anaphylaxis.

Is based on a history of use of alternative products and exclusion of other medical/toxicologic causes. Identification of an unknown herb may be facilitated by consulting with a local Chinese herbalist, acupuncturist, or naturopathic practitioner. In some cases, chemical analysis of the product may confirm the presence of the suspected causative constituent or contaminant.

1. Specific levels. Quantitative levels are not available for most alternative medicine toxins. Ephedrine can be measured in the blood and urine of people taking Ma huang. Some immunoassays for amphetamines are sensitive to ephedrine.
2. Laboratory studies. Serum electrolytes including glucose, BUN, creatinine, liver aminotransferases, and prothrombin time are useful in cases of suspected organ toxicity resulting from alternative therapies. Heavy metals screening is recommended if consistent with poisoning.

1. Emergency and supportive measures. Toxic effects of herbal medicines should be managed with the same approach taken with other ingestions.
   1. Replace fluid losses caused by diarrhea or vomiting with IV crystalloid fluids.
   2. Treat hypertension, tachycardia, and arrhythmias if they occur.
   3. Treat anxiety, agitation, or seizures caused by stimulant herbs with IV benzodiazepines.
   4. Maintain an open airway and assist ventilation if necessary in cases of CNS depression or coma related to sedative herb use.
2. Specific drugs and antidotes. There are no specific antidotes for toxicity related to herbal and alternative products.
3. Decontamination. Administer activated charcoal orally if conditions are appropriate (see Table I-37). Gastric lavage is not necessary after small-to-moderate ingestions if activated charcoal can be given promptly.
4. Enhanced elimination. The effectiveness of these procedures in removing herbal and alternative medicine toxins has not been studied.