Herbal medicines
significantly from 34% in 1990 to 42% in 1997. Herbal
GENERAL INFORMATION
Members of the individual plant genera listed in Table 1,
based on the lists given in the Kew Herbarium Catalogue
[1], are covered in separate monographs. Each of the
monographs has the following structure:

Family: each monograph is organized under a family of
plants (for example Asparagaceae).

Genera: the various genera that are included under the
family name are tabulated (for example the family
Asparagaceae contains 36 genera).

Species: in each monograph adverse reactions to some
species are described. For example, in the monograph
on Asparagaceae, four species are included: Agave
americana, Agave sisalana, Asparagus officinalis, and
Ruscus aculeatus.
The families of plants and their species that are the sub-
jects of monographs are listed in Table 1 by alphabetical
order of family. The same data are listed in Table 2 by
alphabetical order of species and in Table 3 by alphabet-
ical order of some common names.
Other monographs cover the Basidiomycetes (Lentinus
edodes, shiitake) and algae.
Definitions
There is no internationally recognized definition of a
herbal medicine. The European Scientific Co-operative
on Phytotherapy (ESCOP) has defined herbal medicinal
products as “medicinal products containing as active
ingredients only plants, parts of plants or plant materials,
or combinations thereof, whether in the crude or pro-
cessed state”. Definitions provided in a European Union
(EU) directive on Traditional Herbal Medicinal Products
[2] are given in Table 4, along with some other terms used
in relation to herbal medicines [3].
Usage
In the UK, retail sales of complementary medicines
(licensed herbal medicines, homeopathic remedies, essen-
tial oils used in aromatherapy) were estimated to be £72
million in 1996, an increase of 36% in real terms since 1991
[5]. This, however, was likely to be a gross underestimate,
as popular products sold as food supplements, including
Ginkgo biloba and garlic, were not included. According to
a detailed analysis of the herbal medicines marketed in
Germany and France, total sales of herbal products in
those countries in 1997 were US$1.8 billion and US$1.1
billion respectively [6]. In 1994, annual retail sales of
botanical medicines in the USA were estimated to be
around US$1.6 billion; in 1998, the figure was closer to
US$4 billion [7]. In the period from 2007 to 2009 the
market in complementary medicines in the UK grew by
18% and was estimated to be worth about £213 million.
Two surveys of US adults carried out in 1991 and 1997/98
involved over 1500 and over 2000 individuals respectively
[8,9]. The use of at least one form of complementary
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therapy in the 12 months preceding the survey increased
medicine was one of the therapies showing the most
increase over this time: there was a statistically significant
increase in self-medication with herbal medicine from 2.5%
of the sample in 1990 to 13% in 1997 [8]. Disclosure rates to
physicians of complementary medicine use were below 40%
in both surveys [9]. Furthermore, 18% of prescription med-
icine users took prescription medicines concurrently with
herbal remedies and/or high-dose vitamins. These aspects
of user behavior clearly have implications for safety.
The reasons for the popularity of herbal medicine are
many and diverse. It appears that complementary medi-
cine is not usually used because of an outright rejection of
conventional medicine, but more because users desire to
control their own health and because they find comple-
mentary medicine to be more congruent with their own
values, beliefs, and philosophical orientations toward
health and life [10]. Also, users may consult different
practitioners for different reasons. An important reason
for the continuing increase in use is that consumers (often
motivated by the lay press) consider herbal medicines to
be “natural” and assume that they are free from harms.
However, this notion is dangerously misleading; adverse
reactions have often been associated with the use of com-
plementary therapies [11]. Furthermore, complementary
therapies may not only be directly harmful (for example
adverse reactions to a herbal preparation), but like other
medical treatments have the potential to be indirectly
harmful (for example through being applied incompe-
tently, by delaying appropriate effective treatment, or by
causing needless expense) [12].
In a study of how 13 patients defined adverse events
associated with manual therapy techniques in Canada,
they defined mild, moderate and major adverse events
according to pain and other symptoms, taking into account
their intensity, functional impact, and duration, and by
ruling out alternative causes, in ways that differed from
those of clinicians [13].
In a questionnaire survey of 800 subjects living or work-
ing in suburban Kuala Lumpur, Malaysia, 610 replied;
they had misconceptions regarding the safety of comple-
mentary and alternative medicines and over-the-counter
medications, and usually underestimated the risks [14].
Medication history and previous experience of adverse
reactions had significant effects on their behavior.
General adverse effects and
adverse reactions
In principle, herbal medicines have the potential to elicit the
same types of adverse reactions as synthetic drugs; the body
has no way of distinguishing between naturally occurring
compounds and synthetic or semisynthetic compounds.
Herbal medicines consist of whole extracts of plant
parts (for example roots, leaves) and contain numerous
potentially active molecules. Synergy is normally assumed
to play a part in the medicinal effects of plant extracts, and
medical herbalists have always claimed that whole plant
extracts have superior effects over single isolated constit-
uents. Similarly, it is also claimed that combinations of
herbs have synergistic effects. There is in vitro and/or
 708 Herbal medicines

Table 1 Families of plants and their species that are the sub- Table 1 Continued
jects of monographs in this encyclopedia (by alphabetical order
of family) Some common
Family Species names
Some common
Family Species names Asparagus Asparagus
officinalis
Acanthaceae Andrographis Indian Echinacea, Ruscus aculeatus Butcher’s broom
paniculata king of bitters Asteraceae Achillea Yarrow
Acoraceae Acorus calamus Sweet flag, calamus millefolium
Aloeaceae Aloe species Aloe Anthemis species Chamomile
Amaranthaceae Acryanthes Prickly chaff flower, Arnica montana Arnica
aspera devil’s horsewhip Artemisia Wormwood
Pfaffia paniculata Brazilian ginseng absinthium
Amaryllidaceae Allium sativum Garlic Artemisia annua Qinghaosu
Anacardiaceae Anacardium Cashew Artemisia cina Wormseed
occidentale Artemisia vulgaris Common
Mangifera indica Mango wormwood
Pistacia vera Pistachio Calendula Marigold
Pistacia lentiscus Mastic officinalis
Semecarpus Marking nut Callilepis laureola Impila, ox-eye daisy
anacardium Chrysanthemum Common tansy
Toxicodendron Sumac vulgaris
(Rhus) species Cynara scolymus Artichoke
Apiaceae Ammi majus Bishop’s weed Echinacea Coneflower
Ammi visnaga Toothpick weed species
Angelica sinensis Dong quai Eupatorium Thoroughwort
Centella asiatica Centella, gotu kola species
Conium Hemlock Inula helenium Elecampane
maculatum Matricaria recutita Chamomile
Coriandrum Coriander Petasites species Butterbur
sativum Senecio species Ragwort
Ferula Asafetida Silybum Milk thistle
assafoetida marianum
Apocynaceae Catharanthus Madagascar Stevia species Sweet herb
species periwinkle Tanacetum Feverfew
Dyera costulata Jelutong parthenium
Holarrhena Coral swirl Tussilago farfara Coltsfoot
antidysenterica Berberidaceae Berberis vulgaris European barberry
Nerium oleander Oleander Caulophyllum Blue cohosh
Rauwolfia Snakeroot thalictroides
serpentina Dysosma Bajiaolian
Strophanthus Kombé pleianthum
species Mahonia species Barberry
Thevetia Yellow oleander Boraginaceae Cynoglossum Hound’s tongue
peruviana officinale
Vinca species Periwinkle Symphytum Black wort
Araliaceae Dendropanax Tree ivy officinale
trifidus Heliotropium Heliotrope
Hedera helix Ivy species
Panax species Asian ginseng Brassicaceae Armoracia Horseradish
Schefflera Dwarf umbrella tree rusticana
arboricola Brassica nigra Black mustard
Arecaceae Areca catechu Areca, betel Raphanus sativus Black radish
Serenoa repens Saw palmetto var. niger
Aristolochiaceae Aristolochia Dutchman’s pipe Sinapis species Mustard
species Burseraceae Boswellia serrata Indian frankincense
Asarum Xu xin Comiphora Myrrh
heterotropoides species
Asclepiadaceae Asclepias species Milkweed Campanulaceae Codonopsis Deodeok
Calotropis Milkweed lanceolata
species Lobelia inflata Indian tobacco
Xysmalobium Uzara Trachelium Blue throatwort
undulatum caeruleum
Asparagaceae Agave americana American aloe, Cannabaceae Humulus lupulus Hop
century plant, Capparaceae Capparis spinosa Caper plant
maguey
Agave sisalana Sisal (Continued)

(Continued)

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 Herbal medicines 709

Table 1 Continued Table 1 Continued

Some common Some common

Family Species names Family Species names

Celastraceae Catha edulis Khat, qat Thuja plicata Western or Pacific

Euonymus European spindle red cedar, giant or
europaeus tree Western
Euonymus Wahoo bark arborvitae, giant
atropurpureus cedar,
Tripterygium Lei gong teng, shinglewood
wilfordii thunder god vine Cycadaceae Cycas circinalis False sago palm
Chenopodiaceae Chenopodium American wormseed Droseraceae Dionaea Venus flytrap
ambrosioides muscipula
Clusiaceae Garcinia Brindleberry, Dryopteraceae Arachniodes Leatherleaf fern
gambogia gamboge adiantiformis
Hypericum St John’s wort Dryopteris filix- Male fern
perforatum mas
Colchicaceae Colchicum Autumn crocus Ericaceae Arctostaphylos Bearberry
autumnale uva-ursi
Gloriosa superba Glory lily, flame lily, Gaultheria Wintergreen
climbing lily, procumbens
creeping lily Ledum palustre Marsh Labrador tea
Convolvulaceae Argyreia nervosa Hawaiian baby Rhododendron Rhododendron
woodrose species
Convolvulus Mexican scammony Vaccinium Cranberry
scammonia macrocarpon
Erycibe henryi Ting kung teng Euphorbiaceae Breynia officinalis Chi R Yun
Prain Croton tiglium Croton
Ipomoea Ginger-leaf Ricinus Castor oil plant
asarifolia morning-glory communis
Ipomoea batatas Sweet potato Fabaceae Arachis Peanut
Ipomoea purga Jalap Cassia senna Senna
Coriariaceae Coriaria arborea Tutu Crotalaria species Rattlebox
Coriaria myrtifolia Redoul Cyamopsis Cluster bean
Cucurbitaceae Bryonia alba White bryony tetragonoloba
Citrullus Colocynth Cytisus scoparius Scotch broom
colocynthis Dipteryx odorata Dutch tonka bean
Ecballium Squirting cucumber Dipteryx English tonka bean
elaterium oppositofolia
Momordica Karela fruit, bitter Genista tinctoria Dyer’s broom
charantia melon Glycyrrhiza Liquorice
Sechium edule Chayote glabra
Cupressaceae Calocedrus California incense Lupinus species Lupin
decurrens cedar Medicago sativa Alfalfa
Cryptomeria Japanese cedar Melilotus Sweet clover
japonica officinalis
Cupressus Arizona cypress Myroxylon Balsam of Peru
arizonica species
Cupressus Mediterranean Pithecollobium Jering fruit
sempervirens cypress jiringa
Cupressus Leyland cypress Sophora Ku shen
leylandii falvescens
Juniperus ashei Ashe juniper, post Trifolium pratense Red clover
cedar, mountain Gentianaceae Gentiana species Gentian
cedar, blueberry Swertia species Felwort
juniper Ginkgoaceae Ginkgo biloba Maidenhair tree,
Juniperus Common juniper silver apricot
communis Hippocastanaceae Aesculus Horse chestnut
Juniperus Prickly juniper, hippocastanum
oxycedrus prickly cedar, Illiciaceae Illicium anisatum Star anise
cade juniper, Illicium religiosum Japanese star anise
sharp cedar Illicium verum Chinese star anise
Juniperus rigida Japanese juniper Iridaceae Crocus sativus Indian saffron
Juniperus Mountain cedar Juglandaceae Carya illinoensis Pecan
sabinoides Juglans regia English walnut
(Continued)
(Continued)

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 710 Herbal medicines

Table 1 Continued Table 1 Continued

Some common Some common

Family Species names Family Species names

Krameriaceae Krameria species Ratany Onagraceae Oenothera Evening primrose,

Lamiaceae Hedeoma American biennis fever plant, king’s
pulegoides pennyroyal, false cure-all, night
pennyroyal willow herb,
Lavandula Lavender scabish, sundrop,
angustifolia tree primrose
Mentha piperita Peppermint Papaveraceae Chelidonium Celandine
Mentha pulegium European majus
pennyroyal, Papaver Opium poppy
squaw mint, somniferum
mosquito plant, Passifloraceae Passiflora Apricot vine,
pudding grass incarnata grenadille,
Salvia miltiorrhiza Danshen passion flower,
Salvia officinalis Sage passion vine
Scutellaria Skullcap Pedaliaceae Harpagophytum Devil’s claw, grapple
species procumbens plant, wood spider
Teucrium species Germander Phytolaccaceae Phytolacca Pokeweed
Lauraceae Cinnamonum Camphor tree americana
camphora Piperaceae Piper Kava
Laurus nobilis Laurel methysticum
Sassafras Sassafras Plantaginaceae Plantago species Plantain
albidum Poaceae Anthoxanthum Sweet vernal grass
Liliaceae Lilium species Lily odoratum
Loganiaceae Gelsemium Heartbreak grass Avena Oats
elegans Oryza Rice
Gelsemium Carolina jasmine or Polygonaceae Polygonum Knotweed
sempervirens jessamine, species
evening trumpet Polygonum Witch hazel
flower, woodbine, multiflorum
yellow jasmine or Rheum palmatum Rhubarb
jessamine Ranunculaceae Aconitum Monkshood
Strychnos nux- Nux vomica napellus
vomica Cimicifuga Black bugbane,
Lycopodiaceae Lycopodium Clubmoss, Jin bu racemosa black cohosh,
serratum huan black snakeroot,
Mackinlayaceae Centella asiatica Asiatic or Indian rattleroot,
pennywort rattletop,
Malvaceae Gossypium Cotton rattleweed
species Delphinium Larkspur
Psoralea Bakuchi consolida
corylifolia Hydrastis Golden seal
Melanthiaceae Veratrum species Hellebore canadensis
Zigadenus Foothill Pulsatilla species Pasque flower
paniculatus deathcamas, Pulsatilla vulgaris Meadow windflower
sand-corn Ranunculus Buttercup
Meliaceae Azadirachta Bead tree, pride of damascenus
indica China, margosa, Rhamnaceae Rhamnus Cascara sagrada
neem or nim tree, purshianus
holy tree, indiar, Ziziphus jujuba Dazao
lilac tree Rosaceae Crataegus Hawthorn,
Menispermaceae Chondrodendron Curare vine species maybush,
tomentosum whitethorn
Stephania Jin bu huan, Shan Prunus species Apricot, bitter
species dou gen almond, choke
Myristicaceae Myristica fragrans Nutmeg cherry, peach,
Myrtaceae Eucalyptus Eucalyptus plum
species Prunus serotina Wild black cherry
Eugenia Clove tree Rubiaceae Asperula odorata Sweet woodruff
caryophyllus Cephaelis Ipecacuanha
(Syzygium ipecacuanha
aromaticum) Hintonia latiflora Copalchi bark
Melaleuca Tea tree Morinda citrifolia Noni
alternifolia
(Continued)
(Continued)

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 Herbal medicines 711

Table 1 Continued Table 1 Continued

Some common Some common

Family Species names Family Species names

Rubia tinctorum Madder Zygophyllaceae Larrea tridentate Chaparral, creosote

Uncaria Cat’s claw bush
tomentosa Peganum Wild rue, Syrian rue,
Rutaceae Agathosma Buchu harmala African rue
betulina Tribulus terrestris Bullhead, cat’s
Citrus aurantium Seville orange, head, devil’s
marmalade eyelashes, devil’s
orange thorn, devil’s
Citrus paradisi Grapefruit weed, goathead,
Dictamnus Dense-fruit pittany puncture vine,
dasycarpus tackweed
Pilocarpus Jaborandi
jaborandi
Pilocarpus Aceitillo
racemosus
Table 2 Families of plants and their species that are the sub-
Ruta graveolens Rue
jects of monographs in this encyclopedia (by alphabetical order
Salicaceae Salix species Willow
of species)
Sapindaceae Blighia sapida Akee
Paullinia cupana Guaraná Some common
Selaginellaceae Selaginella Spike moss Species names Family
doederleinii
Solanaceae Anisodus Zangqie Achillea Yarrow Asteraceae
tanguticus millefolium
Capsicum annum Chili pepper Aconitum napellus Monkshood Ranunculaceae
Brugmansia Angel’s trumpet Acorus calamus Sweet flag, calamus Acoraceae
candida Acryanthes Prickly chaff flower, Amaranthaceae
Brugmansia Angel’s tears aspera devil’s horsewhip
suaveolens Aesculus Horse chestnut Hippocastanaceae
Datura Jimson weed hippocastanum
stramonium Agathosma Buchu Rutaceae
Daturae flos Yangjinhua betulina
Lycium barbarum Chinese wolfberry Agave americana American aloe, Asparagaceae
Mandragora Mandrake century plant,
species maguey
Nicotiana Tobacco Agave sisalana Sisal Asparagaceae
tabacum Allium sativum Garlic Amaryllidaceae
Scopolia species Scopola Aloe species Aloe Aloeaceae
Sterculiaceae Sterculia species Sterculia Alpinia galanga Galangal Zingiberaceae
Taxaceae Taxus species Yew Ammi majus Bishop’s weed Apiaceae
Theaceae Camellia sinensis Green tea Ammi visnaga Toothpick weed Apiaceae
Urticaceae Parietaria judaica Asthma weed Anacardium Cashew Anacardiaceae
Urtica dioica Stinging nettle occidentale
Valerianaceae Valeriana species All-heal, amantilla, Andrographis Indian Echinacea, Acanthaceae
heliotrope, paniculata king of bitters
valerian Angelica sinensis Dong quai Apiaceae
Verbenaceae Lantana camarra Lantana Anisodus Zangqie Solanaceae
Verbena species Vervain tanguticus
Vitex agnus- Chaste tree, hemp Anthemis species Chamomile Asteraceae
castus tree, monk’s Anthoxanthum Sweet vernal grass Poaceae
pepper odoratum
Viscaceae Phoradendron American mistletoe Arachis Peanut Fabaceae
flavescens Arachniodes Leatherleaf fern Dryopteraceae
Viscum album Mistletoe adiantiformis
Zingiberaceae Alpinia galanga Galangal Arctostaphylos Bearberry Ericaceae
Boesenbergia Chinese ginger, uva-ursi
pandurata finger-root Areca catechu Areca, betel Arecaceae
Curcuma longa Turmeric Argyreia nervosa Hawaiian baby Convolvulaceae
Elettaria Cardamum woodrose
cardamomum Aristolochia Dutchman’s pipe Aristolochiaceae
Zingiber officinale Ginger species

(Continued) (Continued)

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 712 Herbal medicines

Table 2 Continued Table 2 Continued

Some common Some common

Species names Family Species names Family

Armoracia Horseradish Brassicaceae Cimicifuga Black bugbane, Ranunculaceae

rusticana racemosa black cohosh,
Arnica montana Arnica Asteraceae black snakeroot,
Artemisia Wormwood Asteraceae rattleroot,
absinthium rattletop,
Artemisia annua Qinghaosu Asteraceae rattleweed
Artemisia cina Wormseed Asteraceae Cinnamonum Camphor tree Lauraceae
Artemisia vulgaris Common Asteraceae camphora
wormwood Citrullus Colocynth Cucurbitaceae
Asarum Xu xin Aristolochiaceae colocynthis
heterotropoides Citrus aurantium Seville orange, Rutaceae
Asclepias species Milkweed Asclepiadaceae marmalade
Asparagus Asparagus Asparagaceae orange
officinalis Citrus paradisi Grapefruit Rutaceae
Asperula odorata Sweet woodruff Rubiaceae Codonopsis Deodeok Campanulaceae
Avena Oats Poaceae lanceolata
Azadirachta indica Bead tree, pride of Meliaceae Colchicum Autumn crocus Colchicaceae
China, margosa, autumnale
neem or nim tree, Comiphora Myrrh Burseraceae
holy tree, indiar, species
lilac tree Conium Hemlock Apiaceae
Berberis vulgaris European barberry Berberidaceae maculatum
Blighia sapida Akee Sapindaceae Convolvulus Mexican scammony Convolvulaceae
Boesenbergia Chinese ginger, Zingiberaceae scammonia
pandurata finger-root Coriandrum Coriander Apiaceae
Boswellia serrata Indian frankincense Burseraceae sativum
Brassica nigra Black mustard Brassicaceae Coriaria arborea Tutu Coriariaceae
Breynia officinalis Chi R Yun Euphorbiaceae Coriaria myrtifolia Redoul Coriariaceae
Brugmansia Angel’s trumpet Solanaceae Crataegus Hawthorn, Rosaceae
candida species maybush,
Brugmansia Angel’s tears Solanaceae whitethorn
suaveolens Crocus sativus Indian saffron Iridaceae
Bryonia alba White bryony Cucurbitaceae Crotalaria species Rattlebox Fabaceae
Calendula Marigold Asteraceae Croton tiglium Croton Euphorbiaceae
officinalis Cryptomeria Japanese cedar Cupressaceae
Callilepis laureola Impila, ox-eye daisy Asteraceae japonica
Calocedrus California incense Cupressaceae Cupressus Arizona cypress Cupressaceae
decurrens cedar arizonica
Calotropis species Milkweed Asclepiadaceae Cupressus Leyland cypress Cupressaceae
Camellia sinensis Green tea Theaceae leylandii
Capparis spinosa Caper plant Capparaceae Cupressus Mediterranean Cupressaceae
Capsicum annum Chili pepper Solanaceae sempervirens cypress
Carya illinoensis Pecan Juglandaceae Curcuma longa Turmeric Zingiberaceae
Cassia senna Senna Fabaceae Cyamopsis Cluster bean Fabaceae
Catha edulis Khat, qat Celastraceae tetragonoloba
Catharanthus Madagascar Apocynaceae Cycas circinalis False sago palm Cycadaceae
species periwinkle Cynara scolymus Artichoke Asteraceae
Caulophyllum Blue cohosh Berberidaceae Cynoglossum Hound’s tongue Boraginaceae
thalictroides officinale
Centella asiatica Centella, gotu kola Apiaceae Cytisus scoparius Scotch broom Fabaceae
Centella asiatica Asiatic or Indian Mackinlayaceae Datura Jimson weed Solanaceae
pennywort stramonium
Cephaelis Ipecacuanha Rubiaceae Daturae flos Yangjinhua Solanaceae
ipecacuanha Delphinium Larkspur Ranunculaceae
Chelidonium Celandine Papaveraceae consolida
majus Dendropanax Tree ivy Araliaceae
Chenopodium American Chenopodiaceae trifidus
ambrosioides wormseed Dictamnus Dense-fruit pittany Rutaceae
Chondrodendron Curare vine Menispermaceae dasycarpus
tomentosum Dionaea Venus flytrap Droseraceae
Chrysanthemum Common tansy Asteraceae muscipula
vulgaris Dipteryx odorata Dutch tonka bean Fabaceae

(Continued) (Continued)

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 Herbal medicines 713

Table 2 Continued Table 2 Continued

Some common Some common

Species names Family Species names Family

Dipteryx English tonka bean Fabaceae Hydrastis Golden seal Ranunculaceae

oppositofolia canadensis
Dryopteris filix- Male fern Dryopteraceae Hypericum St John’s wort Clusiaceae
mas perforatum
Dyera costulata Jelutong Apocynaceae Illicium anisatum Star anise Illiciaceae
Dysosma Bajiaolian Berberidaceae Illicium religiosum Japanese star anise Illiciaceae
pleianthum Illicium verum Chinese star anise Illiciaceae
Ecballium Squirting cucumber Cucurbitaceae Inula helenium Elecampane Asteraceae
elaterium Ipomoea asarifolia Ginger-leaf Convolvulaceae
Echinacea Coneflower Asteraceae morning-glory
species Ipomoea batatas Sweet potato Convolvulaceae
Elettaria Cardamum Zingiberaceae Ipomoea purga Jalap Convolvulaceae
cardamomum Juglans regia English walnut Juglandaceae
Erycibe henryi Ting kung teng Convolvulaceae Juniperus ashei Ashe juniper, post Cupressaceae
Prain cedar, mountain
Eucalyptus Eucalyptus Myrtaceae cedar, blueberry
species juniper
Eugenia Clove tree Myrtaceae Juniperus Common juniper Cupressaceae
caryophyllus communis
(Syzygium Juniperus Prickly juniper, Cupressaceae
aromaticum) oxycedrus prickly cedar,
Euonymus Wahoo bark Celastraceae cade juniper,
atropurpureus sharp cedar
Euonymus European spindle Celastraceae Juniperus rigida Japanese juniper Cupressaceae
europaeus tree Juniperus Mountain cedar Cupressaceae
Eupatorium Thoroughwort Asteraceae sabinoides
species Krameria species Ratany Krameriaceae
Ferula assafoetida Asafetida Apiaceae Lantana camarra Lantana Verbenaceae
Garcinia Brindleberry, Clusiaceae Larrea tridentate Chaparral, creosote Zygophyllaceae
gambogia gamboge bush
Gaultheria Wintergreen Ericaceae Laurus nobilis Laurel Lauraceae
procumbens Lavandula Lavender Lamiaceae
Gelsemium Heartbreak grass Loganiaceae angustifolia
elegans Ledum palustre Marsh Labrador tea Ericaceae
Gelsemium Carolina jasmine or Loganiaceae Lilium species Lily Liliaceae
sempervirens jessamine, Lobelia inflata Indian tobacco Campanulaceae
evening trumpet Lupinus species Lupin Fabaceae
flower, woodbine, Lycium barbarum Chinese wolfberry Solanaceae
yellow jasmine or Lycopodium Clubmoss, Jin bu Lycopodiaceae
jessamine serratum huan
Genista tinctoria Dyer’s broom Fabaceae Mahonia species Barberry Berberidaceae
Gentiana species Gentian Gentianaceae Mandragora Mandrake Solanaceae
Ginkgo biloba Maidenhair tree, Ginkgoaceae species
silver apricot Mangifera indica Mango Anacardiaceae
Gloriosa superba Glory lily, flame lily, Colchicaceae Matricaria recutita Chamomile Asteraceae
climbing lily, Medicago sativa Alfalfa Fabaceae
creeping lily Melaleuca Tea tree Myrtaceae
Glycyrrhiza glabra Liquorice Fabaceae alternifolia
Gossypium Cotton Malvaceae Melilotus Sweet clover Fabaceae
species officinalis
Harpagophytum Devil’s claw, Pedaliaceae Mentha piperita Peppermint Lamiaceae
procumbens grapple plant, Mentha pulegium European Lamiaceae
wood spider pennyroyal,
Hedeoma American Lamiaceae squaw mint,
pulegoides pennyroyal, false mosquito plant,
pennyroyal pudding grass
Hedera helix Ivy Araliaceae Momordica Karela fruit, bitter Cucurbitaceae
Heliotropium Heliotrope Boraginaceae charantia melon
species Morinda citrifolia Noni Rubiaceae
Hintonia latiflora Copalchi bark Rubiaceae Myristica fragrans Nutmeg Myristicaceae
Holarrhena Coral swirl Apocynaceae Myroxylon species Balsam of Peru Fabaceae
antidysenterica Nerium oleander Oleander Apocynaceae
Humulus lupulus Hop Cannabaceae Nicotiana Tobacco Solanaceae
tabacum
(Continued)
(Continued)
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 714 Herbal medicines

Table 2 Continued Table 2 Continued

Some common Some common

Species names Family Species names Family

Oenothera biennis Evening primrose, Onagraceae Salvia miltiorrhiza Danshen Lamiaceae

fever plant, king’s Salvia officinalis Sage Lamiaceae
cure-all, night Sassafras albidum Sassafras Lauraceae
willow herb, Schefflera Dwarf umbrella tree Araliaceae
scabish, sundrop, arboricola
tree primrose Scopolia species Scopola Solanaceae
Oryza Rice Poaceae Scutellaria Skullcap Lamiaceae
Panax species Asian ginseng Araliaceae species
Papaver Opium poppy Papaveraceae Sechium edule Chayote Cucurbitaceae
somniferum Selaginella Spike moss Selaginellaceae
Parietaria judaica Asthma weed Urticaceae doederleinii
Passiflora Apricot vine, Passifloraceae Semecarpus Marking nut Anacardiaceae
incarnata grenadille, anacardium
passion flower, Senecio species Ragwort Asteraceae
passion vine Serenoa repens Saw palmetto Arecaceae
Paullinia cupana Guaraná Sapindaceae Silybum Milk thistle Asteraceae
Peganum harmala Wild rue, Syrian Zygophyllaceae marianum
rue, African rue Sinapis species Mustard Brassicaceae
Petasites species Butterbur Asteraceae Sophora Ku shen Fabaceae
Pfaffia paniculata Brazilian ginseng Amaranthaceae falvescens
Phoradendron American mistletoe Viscaceae Stephania species Jin bu huan, Shan Menispermaceae
flavescens dou gen
Phytolacca Pokeweed Phytolaccaceae Sterculia species Sterculia Sterculiaceae
americana Stevia species Sweet herb Asteraceae
Pilocarpus Jaborandi Rutaceae Strophanthus Kombé Apocynaceae
jaborandi species
Pilocarpus Aceitillo Rutaceae Strychnos nux- Nux vomica Loganiaceae
racemosus vomica
Piper methysticum Kava Piperaceae Swertia species Felwort Gentianaceae
Pistacia lentiscus Mastic Anacardiaceae Symphytum Black wort Boraginaceae
Pistacia vera Pistachio Anacardiaceae officinale
Pithecollobium Jering fruit Fabaceae Tanacetum Feverfew Asteraceae
jiringa parthenium
Plantago species Plantain Plantaginaceae Taxus species Yew Taxaceae
Polygonum Witch hazel Polygonaceae Teucrium species Germander Lamiaceae
multiflorum Thevetia Yellow oleander Apocynaceae
Polygonum Knotweed Polygonaceae peruviana
species Thuja plicata Western or Pacific Cupressaceae
Prunus serotina Wild black cherry Rosaceae red cedar, giant
Prunus species Apricot, bitter Rosaceae or Western
almond, choke arborvitae, giant
cherry, peach, cedar,
plum shinglewood
Psoralea Bakuchi Malvaceae Toxicodendron Sumac Anacardiaceae
corylifolia (Rhus) species
Pulsatilla species Pasque flower Ranunculaceae Trachelium Blue throatwort Campanulaceae
Pulsatilla vulgaris Meadow windflower Ranunculaceae caeruleum
Ranunculus Buttercup Ranunculaceae Tribulus terrestris Bullhead, cat’s Zygophyllaceae
damascenus head, devil’s
Raphanus sativus Black radish Brassicaceae eyelashes, devil’s
var. niger thorn, devil’s
Rauwolfia Snakeroot Apocynaceae weed, goathead,
serpentina puncture vine,
Rhamnus Cascara sagradao Rhamnaceae tackweed
purshianus Trifolium pratense Red clover Fabaceae
Rheum palmatum Rhubarb Polygonaceae Tripterygium Lei gong teng, Celastraceae
Rhododendron Rhododendron Ericaceae wilfordii thunder god vine
species Tussilago farfara Coltsfoot Asteraceae
Ricinus communis Castor oil plant Euphorbiaceae Uncaria Cat’s claw Rubiaceae
Rubia tinctorum Madder Rubiaceae tomentosa
Ruscus aculeatus Butcher’s broom Asparagaceae Urtica dioica Stinging nettle Urticaceae
Ruta graveolens Rue Rutaceae Vaccinium Cranberry Ericaceae
Salix species Willow Salicaceae macrocarpon

(Continued) (Continued)

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 Herbal medicines 715

Table 2 Continued Table 3 Continued

Some common Common

Species names Family name Species Family

Valeriana species All-heal, amantilla, Valerianaceae Barberry Mahonia species Berberidaceae

heliotrope, Bead tree Azadirachta indica Meliaceae
valerian Bearberry Arctostaphylos uva- Ericaceae
Veratrum species Hellebore Melanthiaceae ursi
Verbena species Vervain Verbenaceae Betel Areca catechu Arecaceae
Vinca species Periwinkle Apocynaceae Bishop’s weed Ammi majus Apiaceae
Viscum album Mistletoe Viscaceae Bitter almond Prunus species Rosaceae
Vitex agnus- Chaste tree, hemp Verbenaceae Bitter melon Momordica charantia Cucurbitaceae
castus tree, monk’s Black bugbane Cimicifuga racemosa Ranunculaceae
pepper Black cohosh Cimicifuga racemosa Ranunculaceae
Xysmalobium Uzara Asclepiadaceae Black mustard Brassica nigra Brassicaceae
undulatum Black radish Raphanus sativus var. Brassicaceae
Zigadenus Foothill Melanthiaceae niger
paniculatus deathcamas, Black Cimicifuga racemosa Ranunculaceae
sand-corn snakeroot
Zingiber officinale Ginger Zingiberaceae Black wort Symphytum officinale Boraginaceae
Ziziphus jujuba Dazao Rhamnaceae Blue cohosh Caulophyllum Berberidaceae
thalictroides
Blue throatwort Trachelium caeruleum Campanulaceae
Blueberry Juniperus ashei Cupressaceae
Table 3 Families of plants and their species that are the sub- juniper
jects of monographs in this encyclopedia (by alphabetical order Brazilian Pfaffia paniculata Amaranthaceae
of common names) ginseng
Brindleberry Garcinia gambogia Clusiaceae
Common Buchu Agathosma betulina Rutaceae
name Species Family Bullhead Tribulus terrestris Zygophyllaceae
Butcher’s Ruscus aculeatus Asparagaceae
Aceitillo Pilocarpus racemosus Rutaceae broom
African rue Peganum harmala Zygophyllaceae Butterbur Petasites species Asteraceae
Akee Blighia sapida Sapindaceae Buttercup Ranunculus Ranunculaceae
Alfalfa Medicago sativa Fabaceae damascenus
All-heal Valeriana species Valerianaceae Cade juniper Juniperus oxycedrus Cupressaceae
Aloe Aloe species Aloeaceae Calamus Acorus calamus Acoraceae
Amantilla Valeriana species Valerianaceae California Calocedrus decurrens Cupressaceae
American aloe Agave americana Asparagaceae incense
American Phoradendron Viscaceae cedar
mistletoe flavescens Camphor tree Cinnamonum Lauraceae
American Hedeoma pulegoides Lamiaceae camphora
pennyroyal Caper plant Capparis spinosa Capparaceae
American Chenopodium Chenopodiaceae Cardamum Elettaria cardamomum Zingiberaceae
wormseed ambrosioides Carolina Gelsemium Loganiaceae
Angel’s tears Brugmansia Solanaceae jasmine or sempervirens
suaveolens jessamine
Angel’s Brugmansia candida Solanaceae Cascara Rhamnus purshianus Rhamnaceae
trumpet sagradao
Apricot Prunus species Rosaceae Cashew Anacardium Anacardiaceae
Apricot vine Passiflora incarnata Passifloraceae occidentale
Areca Areca catechu Arecaceae Castor oil plant Ricinus communis Euphorbiaceae
Arizona Cupressus arizonica Cupressaceae Cat’s claw Uncaria tomentosa Rubiaceae
cypress Cat’s head Tribulus terrestris Zygophyllaceae
Arnica Arnica montana Asteraceae Ccreeping lily Gloriosa superba Colchicaceae
Artichoke Cynara scolymus Asteraceae Celandine Chelidonium majus Papaveraceae
Asafetida Ferula assafoetida Apiaceae Centella Centella asiatica Apiaceae
Ashe juniper Juniperus ashei Cupressaceae Century plant Agave americana Asparagaceae
Asian ginseng Panax species Araliaceae Chamomile Anthemis species Asteraceae
Asiatic Centella asiatica Mackinlayaceae Chamomile Matricaria recutita Asteraceae
pennywort Chaparral Larrea tridentate Zygophyllaceae
Asparagus Asparagus officinalis Asparagaceae Chaste tree Vitex agnus-castus Verbenaceae
Asthma weed Parietaria judaica Urticaceae Chayote Sechium edule Cucurbitaceae
Autumn crocus Colchicum autumnale Colchicaceae Chi R Yun Breynia officinalis Euphorbiaceae
Bajiaolian Dysosma pleianthum Berberidaceae Chili pepper Capsicum annum Solanaceae
Bakuchi Psoralea corylifolia Malvaceae Chinese ginger Boesenbergia Zingiberaceae
Balsam of Peru Myroxylon species Fabaceae pandurata
(Continued) (Continued)

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 716 Herbal medicines

Table 3 Continued Table 3 Continued

Common Common
name Species Family name Species Family

Chinese star Illicium verum Illiciaceae European Euonymus europaeus Celastraceae

anise spindle tree
Chinese Lycium barbarum Solanaceae Evening Oenothera biennis Onagraceae
wolfberry primrose
Choke cherry Prunus species Rosaceae Evening Gelsemium Loganiaceae
Climbing lily Gloriosa superba Colchicaceae trumpet sempervirens
Clove tree Eugenia caryophyllus Myrtaceae flower
(Syzygium False Hedeoma pulegoides Lamiaceae
aromaticum) pennyroyal
Clubmoss Lycopodium serratum Lycopodiaceae False sago Cycas circinalis Cycadaceae
Cluster bean Cyamopsis Fabaceae palm
tetragonoloba Felwort Swertia species Gentianaceae
Colocynth Citrullus colocynthis Cucurbitaceae Fever plant Oenothera biennis Onagraceae
Coltsfoot Tussilago farfara Asteraceae Feverfew Tanacetum parthenium Asteraceae
Common Juniperus communis Cupressaceae Finger-root Boesenbergia Zingiberaceae
juniper pandurata
Common tansy Chrysanthemum Asteraceae Flame lily Gloriosa superba Colchicaceae
vulgaris Foothill Zigadenus paniculatus Melanthiaceae
Common Artemisia vulgaris Asteraceae deathcamas
wormwood Galangal Alpinia galanga Zingiberaceae
Coneflower Echinacea species Asteraceae Gamboge Garcinia gambogia Clusiaceae
Copalchi bark Hintonia latiflora Rubiaceae Garlic Allium sativum Amaryllidaceae
Coral swirl Holarrhena Apocynaceae Gentian Gentiana species Gentianaceae
antidysenterica Germander Teucrium species Lamiaceae
Coriander Coriandrum sativum Apiaceae Giant Thuja plicata Cupressaceae
Cotton Gossypium species Malvaceae arborvitae
Cranberry Vaccinium Ericaceae Giant cedar Thuja plicata Cupressaceae
macrocarpon Ginger Zingiber officinale Zingiberaceae
Creosote bush Larrea tridentate Zygophyllaceae Ginger-leaf Ipomoea asarifolia Convolvulaceae
Croton Croton tiglium Euphorbiaceae morning-
Curare vine Chondrodendron Menispermaceae glory
tomentosum Glory lily Gloriosa superba Colchicaceae
Danshen Salvia miltiorrhiza Lamiaceae Goathead Tribulus terrestris Zygophyllaceae
Dazao Ziziphus jujuba Rhamnaceae Golden seal Hydrastis canadensis Ranunculaceae
Dense-fruit Dictamnus dasycarpus Rutaceae Gotu kola Centella asiatica Apiaceae
pittany Grapefruit Citrus paradisi Rutaceae
Deodeok Codonopsis lanceolata Campanulaceae Grapple plant Harpagophytum Pedaliaceae
Devil’s claw Harpagophytum Pedaliaceae procumbens
procumbens Green tea Camellia sinensis Theaceae
Devil’s Tribulus terrestris Zygophyllaceae Grenadille Passiflora incarnata Passifloraceae
eyelashes Guaraná Paullinia cupana Sapindaceae
Devil’s Acryanthes aspera Amaranthaceae Hawaiian baby Argyreia nervosa Convolvulaceae
horsewhip woodrose
Devil’s thorn Tribulus terrestris Zygophyllaceae Hawthorn Crataegus species Rosaceae
Devil’s weed Tribulus terrestris Zygophyllaceae Heartbreak Gelsemium elegans Loganiaceae
Dong quai Angelica sinensis Apiaceae grass
Dutch tonka Dipteryx odorata Fabaceae Heliotrope Heliotropium species Boraginaceae
bean Heliotrope Valeriana species Valerianaceae
Dutchman’s Aristolochia species Aristolochiaceae Hellebore Veratrum species Melanthiaceae
pipe Hemlock Conium maculatum Apiaceae
Dwarf umbrella Schefflera arboricola Araliaceae Hemp tree Vitex agnus-castus Verbenaceae
tree Holy tree Azadirachta indica Meliaceae
Dyer’s broom Genista tinctoria Fabaceae Hop Humulus lupulus Cannabaceae
Elecampane Inula helenium Asteraceae Horse chestnut Aesculus Hippocastanaceae
English tonka Dipteryx oppositofolia Fabaceae hippocastanum
bean Horseradish Armoracia rusticana Brassicaceae
English walnut Juglans regia Juglandaceae Hound’s Cynoglossum officinale Boraginaceae
Eucalyptus Eucalyptus species Myrtaceae tongue
European Berberis vulgaris Berberidaceae Impila Callilepis laureola Asteraceae
barberry Indian Andrographis Acanthaceae
European Mentha pulegium Lamiaceae Echinacea paniculata
pennyroyal Indian Boswellia serrata Burseraceae
frankincense
(Continued)
(Continued)

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 Herbal medicines 717

Table 3 Continued Table 3 Continued

Common Common
name Species Family name Species Family

Indian Centella asiatica Mackinlayaceae Meadow Pulsatilla vulgaris Ranunculaceae

pennywort windflower
Indian saffron Crocus sativus Iridaceae Mediterranean Cupressus Cupressaceae
Indian tobacco Lobelia inflata Campanulaceae cypress sempervirens
Indiar Azadirachta indica Meliaceae Mexican Convolvulus Convolvulaceae
Ipecacuanha Cephaelis Rubiaceae scammony scammonia
ipecacuanha Milk thistle Silybum marianum Asteraceae
Ivy Hedera helix Araliaceae Milkweed Asclepias species Asclepiadaceae
Jaborandi Pilocarpus jaborandi Rutaceae Milkweed Calotropis species Asclepiadaceae
Jalap Ipomoea purga Convolvulaceae Mistletoe Viscum album Viscaceae
Japanese Cryptomeria japonica Cupressaceae Monk’s pepper Vitex agnus-castus Verbenaceae
cedar Monkshood Aconitum napellus Ranunculaceae
Japanese Juniperus rigida Cupressaceae Mosquito plant Mentha pulegium Lamiaceae
juniper Mountain Juniperus ashei Cupressaceae
Japanese star Illicium religiosum Illiciaceae cedar
anise Mountain Juniperus sabinoides Cupressaceae
Jelutong Dyera costulata Apocynaceae cedar
Jering fruit Pithecollobium jiringa Fabaceae Mustard Sinapis species Brassicaceae
Jimson weed Datura stramonium Solanaceae Myrrh Comiphora species Burseraceae
Jin bu huan Lycopodium serratum Lycopodiaceae Neem or nim Azadirachta indica Meliaceae
Jin bu huan Stephania species Menispermaceae tree
Karela fruit Momordica charantia Cucurbitaceae Night willow Oenothera biennis Onagraceae
Kava Piper methysticum Piperaceae herb
Khat Catha edulis Celastraceae Noni Morinda citrifolia Rubiaceae
King of bitters Andrographis Acanthaceae Nutmeg Myristica fragrans Myristicaceae
paniculata Nux vomica Strychnos nux-vomica Loganiaceae
King’s cure-all Oenothera biennis Onagraceae Oats Avena Poaceae
Knotweed Polygonum species Polygonaceae Oleander Nerium oleander Apocynaceae
Kombé Strophanthus species Apocynaceae Opium poppy Papaver somniferum Papaveraceae
Ku shen Sophora falvescens Fabaceae Ox-eye daisy Callilepis laureola Asteraceae
Lantana Lantana camarra Verbenaceae Pacific red Thuja plicata Cupressaceae
Larkspur Delphinium consolida Ranunculaceae cedar
Laurel Laurus nobilis Lauraceae Pasque flower Pulsatilla species Ranunculaceae
Lavender Lavandula angustifolia Lamiaceae Passion flower Passiflora incarnata Passifloraceae
Leatherleaf Arachniodes Dryopteraceae Passion vine Passiflora incarnata Passifloraceae
fern adiantiformis Peach Prunus species Rosaceae
Lei gong teng Tripterygium wilfordii Celastraceae Peanut Arachis Fabaceae
Leyland Cupressus leylandii Cupressaceae Pecan Carya illinoensis Juglandaceae
cypress Peppermint Mentha piperita Lamiaceae
Lilac tree Azadirachta indica Meliaceae Periwinkle Vinca species Apocynaceae
Lily Lilium species Liliaceae Pistachio Pistacia vera Anacardiaceae
Liquorice Glycyrrhiza glabra Fabaceae Plantain Plantago species Plantaginaceae
Lupin Lupinus species Fabaceae Plum Prunus species Rosaceae
Madagascar Catharanthus species Apocynaceae Pokeweed Phytolacca americana Phytolaccaceae
periwinkle Post cedar Juniperus ashei Cupressaceae
Madder Rubia tinctorum Rubiaceae Prickly cedar Juniperus oxycedrus Cupressaceae
Maguey Agave americana Asparagaceae Prickly chaff Acryanthes aspera Amaranthaceae
Maidenhair Ginkgo biloba Ginkgoaceae flower
tree Prickly juniper Juniperus oxycedrus Cupressaceae
Male fern Dryopteris filix-mas Dryopteraceae Pride of China Azadirachta indica Meliaceae
Mandrake Mandragora species Solanaceae Pudding grass Mentha pulegium Lamiaceae
Mango Mangifera indica Anacardiaceae Puncture vine, Tribulus terrestris Zygophyllaceae
Margosa Azadirachta indica Meliaceae Qat Catha edulis Celastraceae
Marigold Calendula officinalis Asteraceae Qinghaosu Artemisia annua Asteraceae
Marking nut Semecarpus Anacardiaceae Ragwort Senecio species Asteraceae
anacardium Ratany Krameria species Krameriaceae
Marmalade Citrus aurantium Rutaceae Rattlebox Crotalaria species Fabaceae
orange Rattleroot Cimicifuga racemosa Ranunculaceae
Marsh Ledum palustre Ericaceae Rattletop Cimicifuga racemosa Ranunculaceae
Labrador tea Rattleweed Cimicifuga racemosa Ranunculaceae
Mastic Pistacia lentiscus Anacardiaceae Red clover Trifolium pratense Fabaceae
Maybush Crataegus species Rosaceae Redoul Coriaria myrtifolia Coriariaceae
Rhododendron Rhododendron species Ericaceae
(Continued)
(Continued)

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 718 Herbal medicines

Table 3 Continued Table 3 Continued

Common Common
name Species Family name Species Family

Rhubarb Rheum palmatum Polygonaceae White bryony Bryonia alba Cucurbitaceae

Rice Oryza Poaceae Whitethorn Crataegus species Rosaceae
Rue Ruta graveolens Rutaceae Wild black Prunus serotina Rosaceae
Sage Salvia officinalis Lamiaceae cherry
Sand-corn Zigadenus paniculatus Melanthiaceae Wild rue Peganum harmala Zygophyllaceae
Sassafras Sassafras albidum Lauraceae Willow Salix species Salicaceae
Saw palmetto Serenoa repens Arecaceae Wintergreen Gaultheria Ericaceae
Scabish Oenothera biennis Onagraceae procumbens
Scopola Scopolia species Solanaceae Witch hazel Polygonum multiflorum Polygonaceae
Scotch broom Cytisus scoparius Fabaceae Wood spider Harpagophytum Pedaliaceae
Senna Cassia senna Fabaceae procumbens
Seville orange Citrus aurantium Rutaceae Woodbine Gelsemium Loganiaceae
Shan dou gen Stephania species Menispermaceae sempervirens
Sharp cedar Juniperus oxycedrus Cupressaceae Wormseed Artemisia cina Asteraceae
Shinglewood Thuja plicata Cupressaceae Wormwood Artemisia absinthium Asteraceae
Silver apricot Ginkgo biloba Ginkgoaceae Xu xin Asarum Aristolochiaceae
Sisal Agave sisalana Asparagaceae heterotropoides
Skullcap Scutellaria species Lamiaceae Yangjinhua Daturae flos Solanaceae
Snakeroot Rauwolfia serpentina Apocynaceae Yarrow Achillea millefolium Asteraceae
Spike moss Selaginella doederleinii Selaginellaceae Yellow jasmine Gelsemium Loganiaceae
Squirting Ecballium elaterium Cucurbitaceae or jessamine sempervirens
cucumber Yellow Thevetia peruviana Apocynaceae
St John’s wort Hypericum perforatum Clusiaceae oleander
Star anise Illicium anisatum Illiciaceae Yew Taxus species Taxaceae
Sterculia Sterculia species Sterculiaceae Zangqie Anisodus tanguticus Solanaceae
Stinging nettle Urtica dioica Urticaceae
Suaw mint Mentha pulegium Lamiaceae
Sumac Toxicodendron (Rhus) Anacardiaceae
Table 4 Definitions and descriptions used in relation to herbal
species
medicines
Sundrop Oenothera biennis Onagraceae
Sweet clover Melilotus officinalis Fabaceae Term Definition or description
Sweet flag, Acorus calamus Acoraceae
Sweet herb Stevia species Asteraceae Herbal substance “All mainly whole, fragmented or cut
Sweet potato Ipomoea batatas Convolvulaceae (herbal drug) plants, plant parts, algae, fungi,
Sweet vernal Anthoxanthum Poaceae lichen in an unprocessed, usually
grass odoratum dried form, but sometimes fresh.
Sweet Asperula odorata Rubiaceae Certain exudates that have not
woodruff been subjected to a specific
Syrian rue Peganum harmala Zygophyllaceae treatment are also considered to
Tackweed Tribulus terrestris Zygophyllaceae be herbal substances. Herbal
Tea tree Melaleuca alternifolia Myrtaceae substances are precisely defined
Thoroughwort Eupatorium species Asteraceae by the plant part used and the
Thunder god Tripterygium wilfordii Celastraceae botanical name according to the
vine binomial system (genus, species,
Ting kung teng Erycibe henryi Prain Convolvulaceae variety and author).” [2]
Tobacco Nicotiana tabacum Solanaceae Herbal preparation “Preparations obtained by
Toothpick Ammi visnaga Apiaceae (herbal drug subjecting herbal substances to
weed preparation) treatments such as extraction,
Tree ivy Dendropanax trifidus Araliaceae distillation, expression,
Tree primrose Oenothera biennis Onagraceae fractionation, purification,
Turmeric Curcuma longa Zingiberaceae concentration or fermentation.
Tutu Coriaria arborea Coriariaceae These include comminuted or
Uzara Xysmalobium Asclepiadaceae powdered herbal substances,
undulatum tinctures, extracts, essential oils,
Valerian Valeriana species Valerianaceae expressed juices and processed
Venus flytrap Dionaea muscipula Droseraceae exudates.” [3]
Vervain Verbena species Verbenaceae Herbal medicinal product “Any medicinal product, exclusively
Wahoo bark Euonymus Celastraceae containing as active ingredients
atropurpureus one or more herbal substances or
Western Thuja plicata Cupressaceae one or more herbal preparations,
arborvitae or one or more such herbal
Western red Thuja plicata Cupressaceae substances in combination with
cedar one or more such herbal
(Continued) (Continued)

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 Herbal medicines 719

Table 4 Continued lactation [24]. Several investigators have pointed out the
potential of herbal medicines to harm certain organs, for
Term Definition or description
example the liver [25] or the skin [26]. Laxatives are often
preparations”; “the product may based on herbal extracts, and the risks of herbal laxatives
contain vitamins or minerals for have been emphasized [27].
which there is well-documented Direct effects associated with herbal medicines can
evidence for safety, provided that occur in several ways:
the action of the vitamins or

hypersusceptibility reactions;
minerals is ancillary to that of the

collateral reactions;
herbal active ingredients
regarding the specific claimed
toxic reactions;
indications.”[3]
drug interactions;
Herbal remedy “A medicinal product consisting of a
impurities (contamination and adulteration);
substance produced by
false authentication;
subjecting a plant or plants to
lack of quality control.
drying, crushing or any other
process, or of a mixture whose
Some of these relate to product quality. While there are
sole ingredients are two or more some data on certain of these aspects, information on other
substances so produced, or of a aspects is almost entirely lacking. For example, there are
mixture whose sole ingredients case reports of interactions between conventional medi-
are one or more substances so cines and complementary (usually herbal) remedies
produced and water or some [12,28], but further information is largely theoretical [29].
other inert substances.” [4] Even a perfectly safe remedy (mainstream or unorthodox)
Herbal constituent A specific chemical compound can become unsafe when used incompetently. Medical com-
found in a herbal ingredient; for petence can be defined as doing everything in the best inter-
example, hyperforin found in the
est of the patient according to the best available evidence.
aerial parts (herb) of St John’s
wort
There are numerous circumstances, both in orthodox and
Herbal ingredient A specific individual medicinal plant complementary medicine, when competence is jeopardized:
and the plant part, present in a
missed diagnosis;
herbal medicine; for example, St
misdiagnosis;
John’s wort herb present in St
disregarding contraindications;
John’s wort tablets

preventing/delaying more effective treatments (for
example misinformation about effective therapies; loss
of herd immunity through a negative attitude toward
in vivo evidence to support the occurrence of synergism immunization);
between constituents in certain herbal extracts [15,16], but
clinical deterioration not diagnosed;
clinical evidence is lacking, and it is in any case uncertain
adverse reaction not diagnosed;
how far the principle extends. Synergy is also taken to
discontinuation of prescribed drugs;
mean an attenuation of undesirable effects, another key
self-medication.
tenet of herbalism being that the toxicity of plant extracts
is less than that of a single isolated constituent. However, The attitude of consumers toward herbal medicines can also
theoretically, plant constituents could also interact to ren- constitute a risk. When 515 users of herbal remedies were
der a herbal preparation more toxic than a single chemical interviewed about their behavior vis a vis adverse effects of
constituent. Virtually no evidence is available to substan- herbal versus synthetic over-the-counter drugs, a clear dif-
tiate either hypothesis. It is also important to determine ference emerged. While 26% would consult their doctor for
whether herbal treatments that have been shown to be as a serious adverse reaction to a synthetic medication, only
effective as conventional drugs have a better safety pro- 0.8% would do the same in relation to herbal remedies [30].
file. Contrary to the belief of many herbalists, long- The only way to minimize incompetence is by proper
standing experience is by no means a reliable yardstick education and training, combined with responsible regula-
when it comes to judging the risk of adverse reactions [17]. tory control. While training and control are self-evident
A hospital-based study from Oman suggested that 15% features of mainstream medicine they are often not fully
of all cases of self-poisoning seen in this setting are with incorporated in complementary medicine. Thus the issue of
traditional medicines [18]. In a case series from Thailand indirect health risk is particularly pertinent to complemen-
in patients with oral squamous cell carcinoma, the use of tary medicine. Whenever complementary practitioners
herbal medicines before the first consultation with a take full responsibility for a patient, this should be matched
health-care professional increased the risk of an advanced with full medical competence; if on the other hand, compe-
stage almost six-fold [19] and survey data from the USA tence is not demonstrably complete, the practitioner in
suggested that herb–drug interactions may be a significant question should not assume full responsibility [31].
problem in a sizeable proportion of patients [20].
Several herbal medicines pose serious problems for sur- Incidence of adverse effects
gical patients, for example through an increased bleeding and adverse reactions
tendency [21,22]. Vulnerable populations also include
children [23], and too few safety data are available to Much of the information on adverse reactions associated
recommend herbal medicines during pregnancy or with herbal medicines is anecdotal, and assessment and

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 720 Herbal medicines
classification of causality is often not possible. Likewise,
there have been few attempts to determine systematically
the incidence of adverse reactions to non-orthodox therapies.
Of 1701 patients admitted to two general wards of a
Hong Kong hospital, 3 (0.2%) had adverse reactions to
Chinese herbal drugs; two of the three were serious [32].
In a retrospective study of all 2695 patients admitted to a
Taiwan department of medicine during 10 months 4%
were admitted because of drug-related problems, and
herbal remedies ranked third amongst the categories of
medicines responsible [33]. In an active surveillance
adverse drug reaction reporting program conducted in a
family medicine ward of the National Taiwan University
Hospital, Chinese crude drugs were responsible for five
hospital admissions (22% of the total) or 12% of all
adverse reactions observed in the study [34]. This is a
part of the world where the herbal tradition is particularly
strong; the figures may not apply elsewhere.
The incidence of contact sensitization associated with top-
ical formulations containing plant extracts was significant
when evaluated in 1032 consecutive or randomly selected
patients visiting patch test clinics in The Netherlands [35].
In a 5-year toxicological study of traditional remedies
and food supplements carried out by the Medical Toxicol-
ogy Unit at Guy’s and St Thomas’ Hospital, London, 1297
symptomatic enquiries by medical professionals were
evaluated [36]. Of these, an association was considered
to have been confirmed, probable, or possible in 12, 35,
and 738 cases respectively. Ten of the confirmed cases
were related to Chinese or Indian herbal remedies. As a
result of these findings, in October 1996 the UK Commit-
tee on Safety of Medicines extended its yellow card
scheme for adverse drug reactions reporting to include
unlicensed herbal remedies, which are marketed mostly
as food supplements in the UK (the scheme had always
applied to licensed herbal medicines) [37,38]. This was an
important milestone in herbal pharmacovigilance.
A report from the Uppsala Monitoring Centre of the
WHO has summarized all suspected adverse reactions to
herbal medicaments reported from 55 countries worldwide
over 20 years [39]. A total of 8985 case reports were on
record. Most originated from Germany (20%), followed by
France (17%), the USA (17%), and the UK (12%). Aller-
gic reactions were the most frequent serious adverse events
and there were 21 deaths. The authors pointed out that
adverse reactions to herbal medicaments constitute only
about 0.5% of all adverse reactions on record.
In an audit of 100 patients admitted to a UK hospital for
acute medical emergencies, 24 were taking herbal reme-
dies (a total of 40 products); the most popular product was
garlic [40]. Twenty of these 24 patients were also taking
prescription medications and 11 were taking herbal reme-
dies that have either documented toxicity or known inter-
actions with prescription drugs. However, the use of a
herbal preparation was documented in the case notes in
only one case.
In a 5-month survey on the use of phytomedicines by
1063 patients, based on a pre-structured questionnaire, in
the outpatient department of an urban university general
hospital in Italy, of the1044 women who completed the
interview 491 (47%) reported taking at least one herbal
compound [41]. Of these 491 patients, 272 (55%) con-
sumed only one phytomedicine, while 219 (45%) also
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took traditional drugs. Adverse reactions were reported
by 47 (9.6%), including: gastrointestinal (due to dande-
lion, propolis, and fennel); cardiovascular (after liquorice,
ginseng, and green tea); dermatological (after propolis,
thyme, arnica, and passion-flower); and neurological
(after guaraná and liquorice). Conventional medicines
that were taken simultaneously and were potentially
involved in adverse reactions were antihypertensive
drugs, benzodiazepines, non-steroidal anti-inflammatory
drugs, antibiotics, and oral contraceptives. In five cases
adverse reactions were sufficiently serious to justify
admission to hospital. In 29/47 cases the adverse reaction
was not communicated to the doctor. The authors con-
firmed previous observations that consumers of herbal
remedies act differently with regard to reporting an
adverse reaction (serious or minor) to their physician,
and that many adverse manifestations to herbal remedies
are not monitored.
Perioperative events in 601 patients undergoing major
elective surgery who had taken traditional Chinese herbal
medicines presurgically have been studied in a teaching
hospital in Hong Kong [42]. Of these patients, 483 (80%)
had taken self-prescribed herbal medicines and 47 (8%)
had taken herbal medicines prescribed by practitioners of
traditional Chinese medicine in the 2 weeks before surgery.
The crude incidences of any combined end-points of pre-
operative, intraoperative, and postoperative events were
23% (19–26%), 74% (71–78%), and 63% (59–66%) respec-
tively. Compared with non-users, patients who took tradi-
tional Chinese herbal medicines by prescription were more
likely to have a preoperative event. The authors presented
four case reports to highlight the effect of traditional
Chinese herbal medicines by prescription on preoperative
prolongation of the activated partial thromboplastin time
and hypokalemia. In contrast, there was no significant asso-
ciation between the use of any type of traditional Chinese
herbal medicines and the occurrence of either intraopera-
tive or postoperative events. They emphasized that the use
of traditional Chinese herbal medicines by prescription
near the time of surgery should be discouraged, because
of the increased risk of adverse events in the preoperative
period.
Awareness of the need for surveillance of adverse reac-
tions to natural health products has stimulated the imple-
mentation of a reporting system for suspected adverse
reaction in Italy [43]. From April 2002 to March 2007,
233 spontaneous reports of suspected adverse reactions
to natural health products were collected. A large propor-
tion of the suspected adverse reactions were serious: hos-
pitalization was reported in 35% of cases; 6% reported
life-threatening clinical events, and there were two fatal
events. Most of the reported cases involved herbal prod-
ucts (66%); 21 reports were associated with 27 homeo-
pathic preparations, most of which contained a mixture of
substances; 14 reports attributed the suspected reactions
to products containing propolis.
Pharmacovigilance of herbal
products
Measures to improve the report standardization and
detection of suspected adverse reactions to complemen-
tary and alternative medicines have been prompted in

many regions. In a review of all suspected adverse reac-
tions spontaneously reported to the Swedish Medical
Products Agency between 1987 and 2006 (64 493 reports),
778 reports concerned with 967 suspected adverse reac-
tions were related to 175 different products [44]. The main
suspected adverse reactions were urticaria (8.3%), rashes
(7.4%), and contact dermatitis (5.7%). The substances
that were most commonly implicated were purple cone-
flower (Echinacea purpurea) (8.1%), purple coneflo-
wer þ Siberian ginseng (Eleutherococcus senticosus) þ
malabar nut (Adhatoda vasica) (7.3%) and ginkgo leaf
(Ginkgo biloba) (6.7%). In 221 reports, at least one reac-
tion was categorized as serious, the most frequent being
pulmonary embolism (1.7%), mixed liver reactions
(2.8%), and anaphylactic reactions (2.0%). Eleven of the
serious suspected adverse reactions had a fatal outcome.
Considering the limitations of spontaneous reporting of
suspected adverse reactions by health-care professionals,
it has been suggested that the signal detection power of
spontaneous reporting systems should increase, that new
monitoring systems are needed, and that consumers and
CAM providers should have the ability to report adverse
events during such therapy [44–46].
A review in China showed that traditional Chinese
medicine (TCM) had led to several adverse drug reactions
that pharmacovigilance in TCM was problematic,
although great efforts have been made to improve it [47].
In order to report adverse reactions to interventions in
randomized controlled trials transparently, it has been
suggested that Consolidated Standards of Reporting Tri-
als (CONSORT) for TCM should include background
information on adverse reactions to each intervention,
specific outcome assessments of adverse reactions, and
interpretation of the occurrence of adverse reactions in a
structural report [48]. To improve reporting related to
traditional Chinese medicine, recommendations have
been given on constructing a title and basic principles of
writing an abstract and the text of reports [49,50]. Frame-
works for reporting adverse drug reactions anecdotally
have also been suggested [51,52].
Indian Ayurveda and Unani medicines and Sri Lankan
Siddha medicines have been monitored by a pharmacov-
igilance program in India since 2008 [53]. In South India, a
pharmacist-coordinated program has been initiated to
improve the reporting of adverse reactions to complemen-
tary and alternative medicines [54].
Adverse events related to medicinal plants and their
derivatives (herbal medicines) have also been documen-
ted by the Brazilian Pharmacovigilance System since Jan-
uary 1999 [55].
Asian herbalism
Most reports of adverse reactions to herbal remedies, of
which there have been many reports [56–76], relate to
Chinese herbal medicines [77]. This is a matter of growing
concern, particularly because in many Western countries
the popularity of Chinese herbalism is increasing. This is
happening in the almost complete absence of governmen-
tal control [78] or of systematic research into the potential
hazards of Chinese herbal formulations [79]. Chinese
herbal decoctions are usually composed of a mixture of
up to 20 different kinds of herbs. Although they are
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Herbal medicines 721
traditionally thought to cause fewer adverse reactions
than conventional medicines, a review of the Chinese
literature has shown that of 31 cases reported in 25 articles
which dealt with adverse reactions, 10 were severe [80].
The main adverse reactions were allergic reactions and
gastrointestinal, nervous system, and hematological disor-
ders. All the patients recovered after withdrawal of the
decoction and symptomatic treatment.
Most serious adverse reactions to Chinese herbal rem-
edies are associated with formulations containing aconi-
tine, anticholinergic compounds, aristolochic acid,
podophyllin, or contaminating substances [81]. Problems
with Chinese herbal formulations are intensified because
of nomenclature, since common, botanical, and Chinese
names exist side by side, making confusion likely.
In a German hospital specializing in Chinese herbalism,
of 145 patients who had been treated within 1 year 53%
reported having had at least one adverse event attribut-
able to Chinese herbal medicines [82]. Nausea, vomiting,
and diarrhea were the most common complaints. In the
same institution about 1% of 1507 consecutive patients
treated with Chinese herbal mixtures had clinically rele-
vant rises in liver enzymes [83,84]. Glycyrrhiza radix and
Atractylodis macrocephalae rhizome were most consis-
tently associated with such problems. In most of these
cases there were no associated clinical signs and the abnor-
malities tended to normalize without specific therapy and
in spite of continued treatment with the Chinese herbal
mixtures.
When 1100 Australian practitioners of traditional
Chinese medicine were asked to complete questionnaires
about adverse reactions to Chinese herbal mixtures, they
reported 860 adverse events, including 19 deaths [85].
Each practitioner had encountered an average of 1.4
adverse events during each year of full-time practice.
A physician prospectively monitored all 1265 patients
taking traditional Chinese medicines at his clinic during 33
months [86]. Liver enzymes were measured before the
start of therapy and 3 and 10 weeks later. Alanine amino-
transferase activity was raised in 107 patients (8.5%) who
initially had normal values; of these, about 25% reported
symptoms such as abdominal discomfort, looseness of
bowels, loss of appetite, or fatigue.
A retrospective analysis of all adverse events related to
herbal medicines and dietary supplements reported to the
California Poison Control System has given data on the
risks of the adverse effects of herbal medicines [87].
Between January 1997 and June 1998, 918 calls relating
to such supplements were received. Exposures resulting in
adverse reactions occurred most often at recommended
doses. There were 233 adverse events, of which 29%
occurred in children. The products most frequently impli-
cated were zinc (38%), Echinacea (8%), witch hazel (6%),
and chromium picolinate (6%). Most of the adverse
events were not severe and required no treatment; hospi-
talization was required in only three cases.
Ayurvedic medicine
Ayurvedic medicine is a form of Hindu traditional medi-
cine in the Vedic tradition. It relies greatly on the use of
plant-derived medicines, to which heavy metals are often
added in a supposedly detoxified state, because of their
 722 Herbal medicines
reputed therapeutic properties. However, if the detoxifi-
cation process is not strictly followed during manufacture,
it is possible for the resulting product to contain large
amounts of heavy metals [88] (see below).
“Legal highs”
Plants that contain hallucinogenic drugs may be marketed
online as “legal highs”. In a study of 39 websites, 1308
products were found and evaluated [89]. The products
took the form of “pills” (47%), smoking materials (30%),
and single plant materials/extracts (18%). Most of the
products were claimed to be stimulants (42%), sedatives
(32%), or hallucinogens (13%). Ingredients were not listed
in 40% of products, contraindications in 82%, adverse
reactions in 92%, and drug interactions in 86%. The five
most common products were Salvia divinorum (salivinorin
A), Kratom (mitragynine), Hawaiian baby woodrose seeds
(lysergic acid amide), fly agaric (ibotenic acid, muscimol),
and Genie (JWH018, CP47497).
In another study of 28 websites 119 products were eval-
uated. Some of the products (47%) were likened to illicit
drugs, typically marijuana (48%) or ecstasy (23%) [90].
The most common product ingredients were Ephedra alka-
loids (27%), Salvia divinorum (17%), kava (10%), guaraná
(10%), Acorus calamus (10%), and damiana (10%). Effect
claims often involved use of the product as a hallucinogen
(51%) or stimulant (39%). Adverse reactions were men-
tioned by 64% of the sites and drug interactions by 54%.
Reviews
Many authors have reviewed the risks of herbal medicines
in general terms [91,92] and several reviews have covered
specific topics, including:

the toxicity of medicinal plants [93–95];

adverse reactions to herbal products in general [96–107];

adverse reactions in specific countries, for example the
USA [108] and Malaysia [109];

adverse effects on specific organs [110], such as the
cardiovascular system [111], the liver [112,113], and the
skin [114,115];

adverse reactions to herbal medicines in vulnerable
populations: elderly patients [116], pregnant women
[117], and surgical patients [118,119];

carcinogenicity [120];

tion of antiasthmatic and antianaphylactic medications and she
adverse reactions to herbal antidepressants [121];

adverse reactions to Chinese herbal medicaments
[122,123];

adverse reactions to Ayurvedic medicines [124];

herb–drug interactions [125–136];

pharmacovigilance of herbal medicines [137].
ORGANS AND SYSTEMS
Cardiovascular
Ligustrazine injection
Ligustrazine is purified from Radix chuanxiong. Ligustra-
zine injection is widely used in China for coronary heart
disease and stroke, but has been associated with attacks of
angina [138].
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A 61-year-old woman with renal insufficiency was given ligus-
trazine injection 0.1 g in 200 ml of saline by intravenous infu-
sion. After 100 ml had been given she suddenly developed chest
distress, palpitation, and headache. The symptoms resolved
after oxygen inhalation and sublingual isosorbide dinitrate.
She had a similar adverse reaction on a second occasion when
she was given ligustrazine.

A 55-year-old woman was given ligustrazine injection 0.2 g by
intravenous infusion for vertigo and hypertension and suddenly
developed chest distress and palpitation. The symptoms were
relieved by reducing the speed of infusion. A similar phenom-
enon occurred on the next day, when ligustrazine was given
intravenously.
The authors of the report believed that these adverse
events were not allergic reactions but were due to the
calcium channel-blocking property of ligustrazine, which
could increase heart rate and oxygen consumption. How-
ever, the clinical descriptions suggested the possibility of
non-IgE-mediated anaphylactic reactions.
Respiratory
Huoxiang Zhengqi Oral Liquid
Huoxiang Zhengqi Oral Liquid (“Agastache Oral Liquid to
Rectify the Qi”), a compound Chinese medicine formula,
consists of Herba Agastaches seu pogostemi (huo xiang),
Cortex Magnoliae officinalis (hou po), Pericarpium Citri
reticulatae (chen pi), Folium Perillae frutescentis (zi su ye),
Radix Angelicae dahuricae (bai zhi), Tuber Pinelliae ternatae
(ban xia), Pericarpium Arecae catechu (da fu pi), Rhizoma
Atractylodis macrocephalae (bai zhu), Sclerotium Poriae
cocos (fu ling), Radix Platycodi grandiflori (jie geng), and
Honey-fried Radix Glycyrrhizae uralensis (zhi gan cao), It is
a very commonly used over-the-counter product in China
for household medication, especially for symptoms such as
fever and chills, headache, heaviness of the head, abdominal
pain and distension, vomiting, and diarrhea during the
summer months. This formula is generally considered to
cause few adverse reactions, but it has been associated
with asthma [139].

A 73-year-old woman became asthmatic, with a pale complex-
ion and profuse sweating within 10 minutes of a dose of
Huoxiang Zhengqi Oral Liquid 10 ml for abdominal pain, dis-
tension, and diarrhea. There were moist crackles on ausculta-
tion and her heart rate was 140/minute. The asthmatic
symptoms and signs resolved within 10 minutes of administra-
made an uneventful recovery.

A 82-year-old man became asthmatic 10 minutes after taking 10 ml
of Huoxiang Zhengqi Oral Liquid for abdominal pain, vomiting,
and diarrhea. There were moist crackles on auscultation. The
asthma was effectively managed with conventional antiasthmatic
and antiallergic medications and he recovered fully within 2 days.
The cause of the asthmatic reaction caused by Huoxiang
Zhengqi Oral Liquid was unknown; however, it was
believed to be associated with the complex chemical com-
ponents present in the product, especially those in huo
xiang, such as patchouli, alcohol, and patchoulenone.
Sho-saiko-to
Sho-saiko-to is a kampo medicine, a mixture of herbs,
including Chinese date, ginger root, and licorice root. It

is reportedly contraindicated in patients taking inter-
ferons, patients with liver cirrhosis or hepatoma, and
patients with chronic hepatitis and a platelet count of
100  109/l. Sho-saiko-to has repeatedly been implicated
in interstitial or eosinophilic pneumonias.

A 45-year-old woman developed a high fever, a nonproductive
cough, and severe dyspnea [140]. Her chest X-ray showed bilat-
eral alveolar infiltrates. Treatment with antibiotics was not
successful and her condition deteriorated. She was finally put
on mechanical ventilation and subsequently improved dramat-
ically. It turned out that she had previously taken sho-saiko-to
for liver dysfunction of unknown cause.
Based on a positive lymphocyte stimulation test, the
authors were confident that this herbal remedy had caused
pulmonary edema.
Nervous system
Ting kung teng
Cholinergic poisoning has been attributed to a Chinese
herbal mixture, Ting kung teng.

A 73-year-old man developed a cholinergic syndrome, with
dizziness, sweating, chills, lacrimation, salivation, rhinorrhea,
nausea, and vomiting after taking the Chinese patent medicine
Ting kung teng for arthritis [141]. The herbal mixture contained
tropane alkaloids with cholinergic activity. After withdrawal of
the remedy he made a swift and complete recovery.
Sensory systems
Kampo medicines
Corneal opacities causing photophobia have been attrib-
uted to a Kampo medicine [142].

A 30-year-old Japanese woman developed bilateral photopho-
bia. There were dust-like opacities in both corneae. She had a
superficial keratectomy, and electron microscopy identified the
opacities as lipid-like particles. She had intermittently taken a
Kampo medicine composed of 18 different herbal ingredients.
Her photophobia coincided with episodes of taking this medi-
cine. The remedy was withdrawn and her symptoms subse-
quently subsided. She then abstained from the Kampo
medicine without recurrence.
Psychiatric
Herbalife
Herbalife is a complex herbal formula that is promoted for
weight loss. Acute mania has been attributed to it [143].

A 39-year-old man developed classic symptoms of mania within
4–72 hours of taking Herbalife. He continued to take it and
after several days became psychotic, paranoid, and out of con-
trol, culminating in a high-speed car chase with the police.
Bipolar disorder was diagnosed and treated, including with-
drawal of the Herbalife, and he remained free of symptoms 3
months later.
The author thought it likely that the herbal mixture had
caused the psychotic illness in a man who had no previous
history of mental disturbance.
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Herbal medicines 723
Gastrointestinal
Number Ten
Number Ten is a dietary supplement that contains rhu-
barb, ginger, astragalus, red sage. and turmeric. It has
been used to reduce food intake and cause weight loss in
a pilot study in 24 healthy women aged 18–60 years, body
mass index 25–35 kg/m2, who were taking no long-term
medications, but was ineffective [144]. Dose-related loose
stools was the main adverse reaction, which was not sur-
prising, as Number Ten was found to contain sennosides,
known laxatives, and gallic acid, which causes weight loss
in rodents.
Liver
Herbal medicines can be hepatotoxic, even those that are
claimed to have hepatoprotective effects. The possible
hepatotoxic effects of herbal medicines should be moni-
tored, even though they are often regarded as “natural”,
mild, and non-toxic.
Hepatotoxicity has been attributed to traditional medi-
cines in patients with hepatitis B infection [145]. In a pilot
study to review the clinical course of drug-induced liver
damage in a Singapore tertiary hospital 29 patients were
identified, of whom 15 had consumed traditional Chinese
medicines and four had taken antituberculosis drugs [146].
In a 26-month prospective study at an Asian tertiary
hospital to test whether drug-induced liver injury in 31
patients caused by traditional complementary and alter-
native medicines was related to adulterants, 23 had hepa-
tocelluar damage, six had cholestasis, and two had a mixed
pattern of injury [147]. Chinese medicines were implicated
in 17 cases, followed by Malay medicines in five. Adulter-
ants were found in nine of the 31 traditional medicines
that were available for chemical analysis. The authors
concluded that drug-induced liver injury in Asia has a
different pattern of causes from that in the West.
Chai-Ling-Tang
Chai-Ling-Tang (Sairei-to in Japanese), a compound
herbal formula, consists of 11 herbs, including the compo-
nents of Shosaikoto (Xiaochaihu Tang in Chinese, mean-
ing Minor Bupleurum Decoction) and Goreisan
(Wulingsan in Chinese, meaning Five-Ingredient Powder
with Poria): Radix Bupleuri (chai hu), Radix Scutellariae
(huang qin), Tuber Pinelliae ternatae (ban xia), Rhizoma
Zingiberis recens (sheng jiang), Radix Ginseng (ren shen),
Radix Glycyrrhizae (gan cao), Fructus Jujubae (da zao),
Rhizoma Alismatis (ze xie), Poria (fu ling), Polyporus
(zhu ling), and Rhizoma Atractylodis macrocephalae (bai
zhu). It has been reported to cause acute liver damage.

A 37-year-old man developed fatiguability, jaundice, and an
enlarged liver after taking the oral Japanese herbal medicine
Sairei-to for infertility for several weeks [148]. He had mark-
edly raised aspartate aminotransferase and alanine transami-
nase activities, but tests for hepatitis virus markers did not
suggest active viral infection. A liver biopsy strongly suggested
an allergic reaction. Pinellia tuber (tuber of Pinellia ternate
Breit), one of the 11 components of Sairei-to, was later deter-
mined to be the most probable causative component, based on
 724 Herbal medicines
a lymphocyte migration inhibition test. He made a full recovery
1 month after withdrawal of the preparation.

A 70-year-old woman with Sjögren’s syndrome took
Shosaikoto extract granules 7.5 g/day for about 1 month, and
subsequently switched to Saireito extract granules 9.0 g/day
[149]. After 10 weeks, her liver enzymes increased. The Saireito
was withdrawn, and the liver enzymes returned to normal the
following month.
In the second case, the component of Goreisan in Saireito
was believed to have caused the liver damage.
Copaltra
Copaltra is a herbal tea sold in France as an adjuvant
therapy for diabetes. It contains Coutarea latiflora (50 g)
and Centaurium erythreae (50 g).

A 49-year-old black woman was admitted with jaundice and
raised liver enzymes 4 months after starting to take Copaltra
[150]. She also took fenofibrate, polyunsaturated fatty acids,
metformin, benfluorex, and veralipride. Liver biopsy confirmed
the diagnosis of acute, severe, cytolytic hepatitis, most likely
drug-induced. She made a full recovery after withdrawal of
Copaltra.
The authors mentioned that five similar cases of hepatitis
attributed to Copaltra have been reported to the French
authorities.
Haematitium
Haematitium, a component of some herbal preparations,
which contains zinc, tin, iron, magnesium, and diferric
acid, has been implicated in liver damage.

A 4-year-old boy was given a herbal mixture containing 20 g of
burnt clay, ginger, licorice, mandarin skin, Chinese date, Inula
britannica, bitter orange, Codonopsis root, and “haematitium”
10 ml tds for 3 days for vomiting [151]. The vomiting stopped
for a few days but then recurred. He had jaundice and cervical
lymphadenopathy. Investigations showed the pattern of acute
hepatitis. Liver biopsy showed a severe acute hepatitis with
portal-to-portal bridging necrosis and a significant number of
eosinophils, raising the possibility of drug-induced hepatitis. He
had signs of increasing liver dysfunction, with a worsening
coagulopathy and an encephalopathy after 10 days. He under-
went orthoptic liver transplant 19 days after the first onset of
jaundice.
The authors reported a probable association between the
hepatic failure and the herbal preparation, based on the
World Health Organization definition of causality
assessment.
Isabgol
Isabgol is an Italian herbal mixture that is promoted for
constipation.

Syncytial giant cell hepatitis occurred in a 26-year-old woman
who used Isabgol [152]. Autoimmune disease and viral infec-
tions were excluded.
The authors felt that the causative role of the Isabgol was
supported by the spontaneous and dramatic clinical, bio-
chemical, and histological improvement that followed the
withdrawal of Isabgol without any further therapy.
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Kampo medicines
All admission records of patients suspected of having liver
problems related to Kampo medicines between 1979 and
1999 in a Japanese Department of Oriental Medicine were
reviewed [153]. There were 30 cases that were suspected
of being caused by Kampo medicines. On closer examina-
tion, nine seemed to be definitely unrelated, six were
probably unrelated, nine were possibly related, and six
were definitely or probably related to Kampo medicines.
There were no deaths on record.
Severe liver damage has been attributed to a Kampo
medicine [154].

A 50-year-old Japanese woman with a 20-year history of
asthma was taking steroids and bronchodilators when she
started self-medicating with a Kampo mixture called Saiko-
Keishi-Kankyo-To. Two months later, she developed acute
severe liver damage. The Kampo mixture was withdrawn and
she promptly recovered.
The authors attributed the liver damage to one ingredient
of the mixture, Trichosanthes radix, a Chinese medica-
ment that is prepared from the root of Trichosanthes
kirilowii maxim (Tian-hua-fen).
Lipokinetix
The slimming aid “LipoKinetix” contains norephedrine
hydrochloride, sodium usinate, 3,5-diiodothyronine,
yohimbine hydrochloride, and caffeine. Seven patients
all had the signs and symptoms of acute toxic hepatitis
after taking this dietary supplement [155]. Three patients
had taken no other concomitant medications. All recov-
ered spontaneously after “LipoKinetix” was withdrawn.
Tsumura
Tsumura, a Japanese herbal mixture has been associated
with hepatotoxicity [156].

A 49-year-old Japanese woman had taken oral Tsumura for
about 6 weeks to treat internal hemorrhoids when she felt
unwell. Her liver enzymes were raised and a diagnosis of
drug-induced hepatic damage caused by Angelica radix and
Bupleuri radix contained in the mixture was made. The liver
function tests normalized 4 months after withdrawal.
Xiao-chai-hu-tang
Xiao-chai-hu-tang (syo-saiko-to in Japanese), a herbal
remedy (consisting of bupleurum root, pinellia tuber, scu-
tellaria root, jubube fruit, ginseng root, glycyrrhiza root,
and ginger root), widely used in China for treatment of
respiratory, hepatobiliary, and gastrointestinal diseases,
particularly among patients with chronic liver disease,
has been reported to cause acute hepatitis [157].

A 52-year-old woman developed weakness, fatigue, and tea-
colored urine after repeated consumption of a decoction of
xiao-chai-hu-tang for 1.5 months. Laboratory studies showed
acute hepatitis and all markers of viral hepatitis were negative.
Liver biopsy showed a picture of acute hepatocellular hepatitis.
The symptoms improved after withdrawal of the drug, and liver
biochemical tests normalized 2 months later.

Zhixue Jiaonang
Zhixue Jiaonang (Hemorroidal Bleeding Capsule), a
preparation that contains two Chinese medicinal herbs,
Dictamni cortex (Baixianpi) and Sophorae flavescentis
radix (Kushen), is commonly used to treat hematochezia,
anal bulge, and constipation caused by hemorrhoids. The
State Food and Drug Administration of China (SFDA)
has received several reports of adverse reactions to
Zhixue Jiaonang in recent years [158,159]. Up to Septem-
ber 2008, 35 cases of adverse reactions associated with
Zhixue Jiaonang had been reported, of which 21 were
associated with abnormal liver function, cholestatic hepa-
titis, and drug-induced liver damage. After withdrawal
and symptomatic treatment, there was full recovery in
eight cases, and the rest improved markedly.
Zhuanggu Guanjie Wan
Zhuanggu Guanjie Wan (Strengthening Bones and Joints
Pill) is a compound herbal preparation consisting of Lycii
Fructus (Gouqizi), Flos Epimedium brevicornum (Yinyan-
ghuo), Angelicae pubescentis radix (Duhuo), Drynariae rhi-
zoma (Gusuibu), Dipsaci radix (Xuduan), Psoraleae fructus
(Buguzhi), Taxilli herba (Sangjisheng), Spatholobi Caulis
(Jixueteng), Rehmanniae radix praeparata (Shudihuang),
Aucklandiae radix (Muxiang), Olibanum (Ruxiang), and
Myrrha (Moyao). It is commonly used in the treatment of
osteoarthritis and lumbar muscle strains. Since 2001, there
have been increasing numbers of reports of adverse
reactions to Zhuanggu Guanjie Wan [160,161]. The most
common adverse reaction is liver damage, of which 47 cases
have been recorded among 158 patients monitored. Other
adverse reactions include rashes, pruritus, nausea and
vomiting, stomach ache, abdominal pain, diarrhea, and
high blood pressure.
Urinary tract
Jai Wey Guo Sao
Renal damage has been attributed to Jai Wey Guo Sao, a
preparation containing Angelicae sinensis radix, Rheman-
niae radix et rhizoma, Ligustici rhizoma, Paeoniae
lactiflore radix, ginseng root, Eucommiae cortex, and
honey [162].

A 36-year-old woman was admitted to hospital because of
general malaise. She had lost 5 kg within 6 months. She was
found to have interstitial renal fibrosis and irreversible renal
insufficiency. She had taken a Chinese herbal mixture Jai wey
guo sao to treat irregular menses.
The causative agent in this case could not be identified
beyond doubt.
Lianbizhi Injection
Lianbizhi Injection is a sterilized fluid that contains andro-
grapholide sodium bisulfate, which has antibacterial and
anti-inflammatory effects and is commonly used to treat
bacillary dysentery, pneumonia, and acute tonsillitis. It
has been associated with acute renal failure, and the
SFDA has issued warnings on its clinical use [163–165].
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Herbal medicines 725
Skin
The most common adverse event seen with topical tradi-
tional Chinese medicines is contact dermatitis. In a retro-
spective study in Singapore of 10 patients with adverse
cutaneous reactions to topical traditional Chinese medi-
cines the clinical manifestation ranged from eczematous
lesions to urticarial plaques and blisters. The results sug-
gested that essential oils in the medicated oils may be the
allergens [166].
Ciwujia Injection
Ciwujia Injection is a sterilized injection fluid made of
Radix et Caulis Acanthopanacis senticosi, (Siberian Gin-
seng injection).

A 40-year-old woman with vertebrobasilar insufficiency was
given an intravenous infusion of Ciwujia Injection 250 ml for
vertigo after an injection of Xuesaitong (Panax notoginseno-
sides as the main ingredients) in isotonic saline 250 ml [167].
Nearly 40 minutes into the infusion she developed a pruritic
maculopapular rash from the neck to the chest, and then
spreading all over the body. The rash resolved with oral cetir-
izine hydrochloride 10 mg, intravenous dexamethasone sodium
phosphate 5 mg, and intravenous calcium gluconate 20 ml.
Jinshuibao Capsule
Jinshuibao Capsule (Golden Water Treasure Capsule),
made from cultured Cordyceps mycelia, is widely used in
China for improving kidney function in patients with
chronic kidney disease. Although it is believed to be as
safe in clinical practice as wild Cordyceps, a precious
Chinese medicine, it has been reported to cause adverse
skin reactions [168].

A 27-year-old man with nephritis developed recurrent edema
of the face and both legs. He was given oral Jinshuibao three
capsules tds, in combination with prednisone and dipyridamole.
About 10 hours after the first dose, he developed erythema with
severe itching in the chest, back, and limbs, and sporadic rashes.
He reported having used oral dipyridamole without a similar
experience. The Jinshuibao was then stopped, and he was given
oral chlorphenamine and intravenous dexamethasone 5 mg.
The erythema and rash gradually diminished over 2 days.
Lianhuaqingwen Capsule
Lianhuaqingwen Capsule (Honeysuckle and Forsythiae-
Containing Capsule for Clearing the Epidemic Disease) is
a compound herbal product for treatment of the common
cold and influenza, including H1N1, and hand, foot, and
mouth disease. According to Chinese medicine theory,
these conditions may be caused by wind-heat and usually
cause symptoms such as sore throat, headache, fever, and
cough [169]. The herbs in this product are Forsythiae
fructus (Lianqiao), Lonicerae japonicae flos (Jinyinhua),
Ephedrae herba (Mahuang), Armeniacae semen amarum
(Kuxingren), Gypsum fibrosum (Shigao), Isatidis radix
(Banlangen), Dryopteridis crassirhizomatis rhizome
(Mianmaguanzhong), Houttuyniae herba (Yuxingcao),
Pogostemonis herba (Guanghuoxiang), Rhei radix et rhi-
zome (Dahuang), Rhodiolae crenulatae radix et rhizome
 726 Herbal medicines
(Hongjingtian), l-menthol (Bohenao), and Glycyrrhizae
radix et rhizoma (Gancao). Lianhuaqingwen capsule can
inhibit the growth of many kinds of viruses and bacteria,
reduce fever and inflammation, and boost the immune
system. An allergic rash has been associated with the use
of Lianhuaqingwen Capsule [170].

A 35-year-old woman with bronchitis was given ceftezole
sodium injection and oral Lianhuaqingwen, four capsules tds.
After 2 days, she developed a rash on the chest and both arms.
The Lianhuaqingwen was stopped immediately and her symp-
toms subsided in 20 minutes after an intramuscular injection of
promethazine 25 mg and dexamethasone 5 mg. She continued
to take ceftezole sodium and ambroxol, and made an unevent-
ful recovery.
Psoralea (Fabaceae)
Psoralea fruit is commonly used, both externally and inter-
nally, to treat vitiligo in various traditional medical sys-
tems, such as Islamic medicine [171], Indian Ayurvedic
medicine [172], and Chinese medicine [173]. Topical use
has been associated with skin irritation [174].
Reduning Injection
Reduning injection (Quench the Extreme Heat injection)
is a compound herbal preparation containing Artemisiae
annuae herba (Qinghao), Lonicerae japonicae flos (Jinyin-
hua), and Gardeniae fructus (Zhizi). It is usually used to
treat high fevers due to upper respiratory tract infections.
Local tissue damage after administration of Reduning
injection has been reported [175].

A 2-month-old girl with bronchopneumonia was given a micro-
pump intravenous injection of 4 ml Reduning in 50 ml of 10%
dextrose. After about 1 hour she developed oozing and swelling
at the puncture site and the local site was dark red with a 1 cm
bubble. The infusion was stopped and the skin healed without
scars after local wound care for 2 weeks.
Presumably this was due to local extravasation.
Shenling Baizhu San
Baishu San (Ginseng, Poria and Atractylodes Macroce-
phala Powder), an over-the-counter Chinese herbal for-
mula that is commonly used to help digestion, consists of
10 herbs: Ginseng radix et rhizome (Renshen), Poria (Ful-
ing), Atractylodis macrocephalae rhizoma (Baizhu), Dios-
coreae rhizoma (Shanyao), Lablab semen album
(Baibiandou), Nelumbinis semen (Lianzi), Coicis semen
(Yiyiren), Amomi fructus (Sharen), Platycodonis radix
(Jiegeng), and Glycyrrhizae radix et rhizoma (Gancao).
It has been reported to cause erythema multiforme [176].

A 5-month-old girl developed swollen red skin around her eyes
and mouth 1 day after taking three doses of Shenling Baizhu
San. After stopping the medication, her skin lesion worsened
and spread to the whole body, with erythema multiforme and
exfoliation. She became agitated, and cried and moved rest-
lessly. She was given hydrocortisone, penicillin, promethazine,
vitamin C, and calamine lotion, and her skin condition gradu-
ally resolved after 1 week.

A 8-month-old boy developed similar symptoms after two
doses of the same brand of Shenling Baizhu San. The skin lesion
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also included bullae, which was easily ruptured. He made a
gradual recovery treatment with hydrocortisone, ceftriaxone,
calamine lotion, a sedative, and medications for anaphylaxis.
Hair
Rio Hair Naturalizer System
Rio Hair Naturalizer System is a complex mixture of
metallic salts and botanical extracts promoted to
straighten curled hair. The product has been popular
with African Americans in the USA. A survey of 464
individuals who had complained to the FDA about this
remedy showed that 95% had experienced hair breakage
and hair loss [177]. Three-quarters of those who had hair
loss had lost 40% or more; regrowth took 8 months on
average.
Immunologic
Banlangen soft capsule
Banlangen soft capsule, an over-the-counter Chinese
herbal medicine made from Isatidis radix (Banlangen), is
commonly used to treat influenza and sore throat. An
allergic reaction has been attributed to this medication
[178]. The compound ingredients in Isatidis radix and the
residue from rupture of soft capsule, were believed to
have contributed.

A 52-year-old woman developed skin flushing, pruritus, and
sporadic erythema multiforme after taking 4 Banlangen soft
capsules bought over the counter to treat an upper respiratory
tract infection. After the second dose she felt chest distension,
palpitation, dizziness, and vertigo. She went to hospital,
received a combination of oxygen, aminophylline, dexametha-
sone, adrenaline, and antiviral drugs and gradually recovered
over 2 days.
Bupleurum dropping pill
Bupleurum dropping pill, made from Bupleuri Radix
(Chaihu), is a commonly used over-the-counter medicine
in China for the treatment of upper respiratory infection,
fever, and hepatitis. It has been reported to be associated
with allergic reactions [179].

A 21-year-old woman with an upper respiratory infection took
oral amoxicillin 500 mg tds and Bupleurum dropping pill
551 mg tds and about 1 hour later developed itching all over
the body and urticaria on the neck, chest, back, and limbs. The
rash resolved within 1 hour after she had been given vitamin C,
dexamethasone, and topical calamine lotion.

A 62-year-old woman developed palpitation, chest distress,
hand tremor, and cold sweating after taking Bupleurum drop-
ping pill bought from a drug store for treating the common cold.
She developed hives on the neck and chest and gradually recov-
ered 40 minutes after receiving oxygen, adrenaline, vitamin C,
and dexamethasone.
Caowu jiasu tablet
Bulleyaconitine A is made from Aconitum longtounense
T.L.Ming, and is the main ingredient of Caowu jiasu tab-
let. It has analgesic and anti-inflammatory effects and is

commonly used to treat rheumatoid arthritis, lumbar mus-
cle strains, humeroscapular periarthritis, and cancer pain.
An allergic reaction has been reported [180].

An 80-year-old woman with rheumatoid arthritis developed
numbness of the face, lips, and tongue, palpitation, dizziness,
and cold sweating about 2 hours after taking a Caowu jiasu
tablet for the second time 6 hours later after taking the first
tablet. The symptoms gradually disappeared after she had
rested for half an hour. She had a history of allergic reactions
to many substances, such as penicillin, sulfonamides, pollen,
and asphalt.
Ci wu jia Injection
Ci wu jia injection is a sterilized injection fluid made of
Radix et Caulis Acanthopanacis senticosi (also known as
Siberian ginseng), widely used in China to treat transient
ischemic attacks, cerebral arteriosclerosis, cerebral throm-
bosis, cerebral embolism, angina pectoris, coronary heart
disease, neurasthenia, and menopausal syndrome.
Adverse reactions to Ci wu jia Injection recorded in a
major Chinese database have been reviewed [181]. Of 800
clinical studies, 97 (12%) reported 285 cases of adverse
reactions, the most serious of which involved anaphylactic
shock, with four deaths. The most common reaction
reported in clinical studies was pain at the injection site.
Allergic reactions have been attributed to Ci wu jia
Injection [182,183].

A 45-year-old woman was given an intravenous infusion of Ci
wu jia injection fluid 250 ml in 40 ml of 5% dextrose for chest
pain and insomnia with abundant dreams, and 10 minutes into
the infusion suddenly developed chest distress, dyspnea, pro-
fuse sweating, and cold limbs. Her blood pressure was 90/
60 mmHg and her heart rate was 98/minute. The Ci wu jia
injection was immediately terminated and she was given oxy-
gen. Her symptoms gradually disappeared after she was given
adrenaline 0.5 mg subcutaneously plus intramuscular pro-
methazine 50 mg and dexamethasone 5 mg.

A 48-year-old woman with cerebral arteriosclerosis was given
an intravenous infusion of Ci wu jia injection 60 ml in 250 ml of
5% dextrose. A few minutes into the infusion she started to
complain of numbness in the lips and the tongue. The infusion
was immediately stopped and she was given intravenous pro-
methazine and calcium. She subsequently developed dyspnea,
profuse sweating, generalized itching, irritability, swelling of
the lips, and a swollen tongue. Laryngeal edema was diagnosed.
All of her symptoms gradually resolved after she had been
treated with intravenous dexamethasone 20 mg and other
symptomatic measures.
Danhong Injection
Danhong Injection (Salviae and Carthami injection) is
made from Salviae miltiorrhizae radix et rhizoma (Dan-
shen) and Carthami flos (Honghua). It is used for its anti-
atherosclerosis effects, to inhibit platelet aggregation, and
to protect the vascular endothelium. Danhong Injection is
commonly used in China to treat various diseases, includ-
ing those affecting the cardiovascular, respiratory, diges-
tive, and urinary systems. In a review based on a literature
search from 1994 to 2009, 21 articles reported cases of
adverse reactions, mainly allergic reactions, including
shock, skin allergies, bronchospasm, and laryngeal
edema [184]. Damage to the gastrointestinal and nervous
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Herbal medicines 727
systems, headache and fever, and acute kidney failure
were also reported.
Houzheng Wan
Houzheng Wan (Throat Disease Pill), a compound herbal
formula consisting of Radix Isatidis, artificial Cattle
bezoar, Borneolum, and Bufonis venenum, has the
claimed therapeutic effects of clearing heat, removing
toxicity, and reducing swelling to relieve pain. This pro-
prietary herbal medicine is widely used in China to treat
laryngopharyngitis and tonsillitis. Although it is generally
believed to be safe, Houzheng wan has been reported to
cause laryngeal edema [185].

A 21-year-old student developed chest distension and dyspnea
30 minutes after taking oral Houzheng wan for a flu-like illness
with a sore throat. Inhalation of oxygen was ineffective but
intravenous infusion of dexamethasone 10 mg relieved his
symptoms within 2–3 minutes.
Kudiezi Injection
Kudiezi Injection is made from Ixeritis Sonchifoliae
Herba, which is believed to improve blood circulation
and is generally used to treat coronary heart disease and
angina pectoris in China. However, it has been reported to
cause serious allergic reactions [186].

A 65-year-old woman with coronary heart disease and unstable
angina pectoris was treated with an intravenous infusion of
Kudiezi Injection 40 ml in 5% dextrose. On the third day of
the treatment, she suddenly developed shivering, cold limbs
and palpitation. The infusion was stopped immediately, and
she gradually recovered after a combination treatment of dexa-
methasone, promethazine, and bromisoval and procaine
injection.
Lingyang Ganmao Jiaonang
Lingyang Ganmao Jiaonang (Saigae Cornu Tataricae
Cold Capsule) is a commonly used over-the-counter Chi-
nese herbal mixture for the treatment of colds and flu. It
contains Saigae cornu tataricae (Lingyangjiao), Arctii
Fructus (Niubangzi), Sojae semen praeparatum (Dandou-
chi), Lonicerae Japonicae flos (Jinyinhua), Schizonepetae
herba (Jingjie), Forsythiae fructus (Lianqiao), Lophatheri
herba (Danzhuye), Platycodonis radix (Jiegeng), Pepper-
mint oil (Bohesuyou), and Glycyrrhizae radix et rhizoma
(Gancao). An allergic reaction has been reported to Lin-
gyang Ganmao Jiaonang [187].

A 62-year-old woman took Lingyang Ganmao Jiaonang cap-
sule three times in 2 days to treat a cold. She gradually devel-
oped increasing numbness, distension and itching of the lips,
pain in the palms, swollen fingers, and erythema and itching in
the hands. After she took cyproheptadine, triprolidine, and
dexamethasone her symptoms gradually disappeared.
Qing Kai Ling injection
Qing Kai Ling (which literally means “Clearing and Open-
ing with Miracles”) is a sterilized injectable formulation
that contains eight components: Radix Isatidis, Flos
 728 Herbal medicines
Lonicerae, Fructus Gardeniae, Cornu Bubali, Concha
Margaritiferae usta, baicalin, cholic acid, and porcine
deoxycholic acid. It is widely used in China in the treat-
ment of stroke, hepatitis, and cancers, and has been used
as an antidote for many forms of acute toxicity. However,
it has adverse effects, mostly allergic reactions. In a review
of articles about the adverse effects of Qing Kai Ling
injection published between 1995 and 2005 105 papers
were identified from the CNKI database [188]. Of 329
cases of adverse events reported in these publications,
194 cases were moderate allergic reactions, 56 were cases
of anaphylactic shock, and there were two cases of death
from anaphylactic shock. There were skin reactions in 49
patients, respiratory disorders in four, drug-induced fever
in 13, and lingering fever in 11. The authors believed that
Qing Kai Ling injection-induced allergic actions were
attributable to: (1) the complex chemical components pre-
sented in the formula; (2) impurities in the final product;
(3) interactions with other drugs; and (4) individual
patient susceptibility and psychological factors.
Reduning Injection
An allergic reaction to Reduning injection has been
reported [189].

A 26-year-old woman with a fever (38.9  C) was given an
intravenous infusion of Reduning injection 20 ml in 250 ml of
0.9% saline and after about 20 minutes developed gum itchi-
ness, lip numbness, chest distress, and red papules on the neck
and face; her blood pressure was 90/60 mmHg. The infusion was
stopped immediately and she was given intravenous dexameth-
asone 10 mg and calcium gluconate 20 ml in 50% dextrose. The
symptoms disappeared within 1 hour.
Ropylgallate Injection
Ropylgallate Injection is made from Paeoniae radix rubra
(Chishao), a widely used Chinese medicinal herb. It is
mainly used to treat ischemic cerebrovascular disease,
including acute cerebral infarction, cerebral thrombosis,
concussion, and post-traumatic brain syndrome. Two
allergic reactions have been reported [190].

A 64-year-old woman with cerebral infarction, dizziness, and
vertigo developed pruritus and redness over the whole body,
with sweating, palpitation, respiratory distress, and shortness of
breath after receiving an intravenous infusion of Ropylgallate
Injection 30 ml in 250 ml 0.9% NaCl. The infusion was stopped
immediately, and she was given oxygen, promethazine, dexa-
methasone, dopamine, and other symptomatic treatments. She
made an uneventful recovery.

A 74-year-old woman with cerebral atrophy, with dizziness,
headache, tinnitus, and blurred vision, developed palpitation,
severe sweating on the face, back pain, and a tachycardia after
receiving an intravenous infusion of Ropylgallate Injection
50 ml in 250 ml 0.9% NaCl. The infusion was stopped immedi-
ately and she gradually recovered 1 hour later, after being given
oxygen, promethazine, and dexamethasone.
Shen Mai Injection
Shen Mai injection is a sterilized injection fluid containing
Radix Ginseng and Radix Ophiopogonis extracts. It is
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commonly used in China to treat a wide variety of condi-
tions, such as shock, coronary heart disease, viral myocardi-
tis, and chronic pulmonary heart disease. In a systematic
review of adverse reactions associated with Shen Mai Injec-
tion (Ginseng and Ophiopogonis Injection) performed by
searching several Chinese databases, 1828 studies were
found, of which 146 (8%) mentioned 576 adverse events,
and 181 reports described 246 suspected adverse reactions
[191]. The most commonly affected age group was 40–69
(57%). In 36 cases (15%) the patients were described as
having an allergic history and 38 (15%) of the 246 reports
described anaphylactic shock. The most common adverse
reaction reported in clinical studies was headache/dizziness.
Incompatible drugs were given in 68 cases.
Although Radix Ginseng and Radix Ophiopogonis are
very safe in decoctions, Shen Mai injection can cause
allergic reactions Two cases of allergic reactions to Shen
Mai Injection have been reported [192].

A 48-year-old patient with cough, fatigue, and a lung tumor
developed flushing of the face, chest distress, dyspnea, exces-
sive sweating, dysphoria, a weak pulse, and a headache 5
minutes after receiving an intravenous infusion of Shen Mai
Injection 60 ml in 250 ml 5% dextrose.

A 27-year-old patient developed chest discomfort, dyspnea,
cold sweating, a weak pulse, and restlessness 3 minutes after
receiving an intravenous infusion of Shen Mai Injection in
250 ml 5% dextrose.
{Case reports end}
Both patients recovered gradually, 20–30 minutes after
withdrawal of Shen Mai Injection and administration of
oxygen, dexamethasone, and promethazine hydrochloride.

A 48-year-old woman with hypertension, coronary heart dis-
ease, and angina was treated with Shen Mai Injection 60 ml in
5% dextrose by intravenous infusion [193]. About 2 minutes
into the infusion, she suddenly developed palpitation, chest
distress, shortness of breath, nausea, and dizziness. Her heart
rate was 116/minute, her blood pressure 90/50 mmHg, and her
respiratory rate 32/minute. The infusion was stopped immedi-
ately and oxygen, dexamethasone, and promethazine eventu-
ally led to total amelioration of the symptoms.

A 59-year-old man with hepatic cirrhosis developed chest dis-
tension, fever, dizziness, a dark complexion, tremors in the
limbs, and mental confusion after intravenous infusion of
Shen Mai Injection for 10 seconds [194]. The injection infusion
was immediately stopped and he was given oxygen and pro-
methazine. He regained consciousness after 2 minutes and his
other symptoms gradually disappeared.
Shuang Huang Lian Injection
Shuang Huang Lian injection is a sterilized aqueous
extract of Flos Lonicerae, Radix Scutellariae, and Fructus
Forsythiae. It is commonly used in China to treat viral or
bacterial upper respiratory infections, pneumonia, tonsil-
litis, and laryngitis. However, it has been associated with a
plethora of adverse effects, mostly anaphylactic reactions
[195,196].

A 31-year-old man with bronchial asthma developed acute
asthma after intravenous administration of Shuang Huang
Lian Injection for an acute upper respiratory infection. The
injection was immediately discontinued, and his symptoms
gradually resolved after she had been given dexamethasone
and aminophylline.


A 56-year-old woman with a history of penicillin allergy and
bronchial asthma developed acute anaphylactic shock, apnea,
and cardiac arrest within 1 minute of administration of Shuang
Huang Lian Injection by intravenous infusion. She was success-
fully treated by cardiopulmonary resuscitation and large doses
of glucocorticoids.

A 13-year-old boy with no history of allergy suddenly devel-
oped acute laryngeal edema, generalized urticaria, swelling of
the eyelids, and conjunctival congestion after an intravenous
infusion of Shuang Huang Lian Injection for an acute upper
respiratory tract infection. The medication was stopped imme-
diately, he was given methylprednisolone 500 mg, and he made
an uneventful recovery.

A 28-year-old woman with a history of penicillin allergy devel-
oped generalized urticaria, nausea, and vomiting after an intra-
venous infusion of Shuang Huang Lian Injection. The
medication was stopped immediately and her symptoms grad-
ually resolved after she had been given dexamethasone and
aminophylline.

A 40-year-old man developed anaphylactic shock 10 minutes
after an intravenous infusion of Shuang Huang Lian Injection
(0.6 g of freeze-dried Shuang Huang Lian powder dissolved in
250 ml 5% glucose–saline). The medication was immediately
withheld and he was treated for shock. He made a full recovery.
Shuxuening Injection
Shuxuening Injection (Comforting and Calming Blood
Injection) is a sterilized fluid made from Ginkgo folium
(Yinxingye), with total flavonol glycosides and ginkgo-
lides as the main active principles. It is generally used in
China for the treatment of ischemic cardiovascular and
cerebrovascular diseases. Eight cases of adverse reactions
have been reported. Allergic reactions, such as urticaria,
bronchospasm, macular rashes, palpitation, nausea, and
chest distension, were observed in six cases after intrave-
nous infusion of Shuxuening Injection [197,198]. Two
cases of anaphylactic shock were observed 2–3 minutes
into the infusion, and the patients gradually recovered
after treatment [199,200].
Suxiao Jiuxin Wan
Suxiao Jiuxin Wan (“Swift Acting Cardiac Saving Pill”), a
formulation that contains two Chinese medicines, Rhi-
zoma Chuanxiong and Borneolum, is commonly used to
prevent and treat attacks of angina. It has been associated
with anaphylactic laryngeal edema [201].

A 38-year-old woman took Suxiao Jiuxin Wan sublingually for
suspected angina pectoris and about 10 hours later developed
generalized pruritus and rash and a feeling of obstruction from
foreign matter in the throat. Self-medication with chlorphena-
mine maleate 10 mg failed to ameliorate the symptoms and she
gradually developed a hoarse voice, numbness in the lips, and
swelling of the eyelids. There were wheezes on lung ausculta-
tion. Dexamethasone 10 mg intravenously produced gradual
relief of the feeling of obstruction in the throat and the rash
disappeared. She made a complete recovery within 2 days.
Tanreqing Injection
Tanreqing Injection (Clear Phlegm and Heat injection),
made from Scutellariae radix (Huangqin), Lonicerae japo-
nicae flos (Jinyinhua), Forsythiae fructus (Lianqiao), Pul-
vis fellis ursi (Xiongdanfen), and goat horn, is commonly
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Herbal medicines 729
used to treat respiratory tract infections. It has been
reported to cause anaphylactic shock [202].

A 2-month-old boy developed dysphoria, facial pallor, lip cya-
nosis, and a blood pressure of 60/40 mmHg after an intravenous
infusion of Tanreqing Injection. The infusion was stopped
immediately and he recovered in 10 minutes after administra-
tion of oxygen and dexamethasone.
Xiangdan Injection
Xiangdan Injection (Dalbergiae and Salviae Injection),
made from Dalbergiae odoriferae lignum (Jiangxiang)
and Salviae miltiorrhizae radix et rhizoma (Danshen), is
said to relax blood vessels and improve blood flow in the
coronary arteries, and is usually used for the treatment of
angina and myocardial infarction. During 2011, the State
Food and Drug Administration of China (SFDA) received
2413 reports of suspected adverse reactions associated
with Xiangdan injection, mainly involving the respiratory,
cardiovascular, central and peripheral nervous systems
and the skin. Among them, 180 cases (7.5%) were consid-
ered to be serious, including allergic reactions and dys-
pnea [203]. Xiangdan injection has also been reported to
cause shivering [204].
Xingnaojing Injection
Xingnaojing Injection (Awakening Brain and Sedating
injection), a sterilized aqueous extract of Bovis calculus
(Niuhuang), Moschus (Shexiang), Borneolum syntheti-
cum (Bingpian), and Gardeniae fructus (Zhizi), is com-
monly used in China to treat coma in stroke or traumatic
injuries. It has been reported to cause serious allergic
reactions [205].

A 73-year-old man developed shivering and spasm 25 minutes
into an intravenous infusion of Xingnaojing Injection 20 ml in
isotonic saline 250 ml for cerebral infarction. The infusion was
stopped immediately. He gradually recovered 40 minutes later
after receiving oxygen, adrenaline, and promethazine.

A 62-year-old man was given Xingnaojing Injection 30 ml in
5% dextrose 250 ml. About 10 minutes into the infusion, he
developed chest distension, shortness of breath, a flushed com-
plexion, a tachycardia, and a raised blood pressure. The infu-
sion was stopped immediately. After receiving oxygen,
dexamethasone, and promethazine he made an uneventful
recovery.
Xixinnao Injection
Xixinnao Injection (Asarone injection), which is made
from Acori tatarinowii rhizoma (Shichangpu) and whose
main ingredient is a-asarone, is commonly used in China
to treat pneumonia, bronchial asthma, and chronic
obstructive pulmonary disease accompanied by cough
and asthma. The National Center for ADR Monitoring
in China received 5631 case reports about Xixinnao injec-
tion between 1 January 2004 and 28 February 2011. The
main adverse reactions were anaphylactic shock, other
allergic reactions and cyanosis, damage to skin and
appendages, and gastrointestinal damage. The number of
serious cases was 710 (13%), and more than half of these
occurred in children under than 6 years old [206,207].

A 9-year-old boy with acute bronchopneumonia developed
throat itchiness, chest stuffiness, cyanosis of the face and
 730 Herbal medicines
around the mouth, and a weak pulse 30 seconds into an intra-
venous infusion of Xixinnao Injection 8 mg in 100 ml 5% dex-
trose. The infusion was stopped immediately. He gradually
recovered over 3 hours after receiving oxygen and methylpred-
nisolone sodium succinate.
Xiyanping Injection
Xiyanping Injection (Pleasure to Control Inflammation
injection), whose main ingredient is water-soluble andro-
grapholide, is used for its antiviral, antibacterial, antipy-
retic and anti-inflammatory effects. It has been reported
to cause anaphylactic shock [208,209].

A seven-month-old girl with a fever (38.4  C) and an upper
respiratory tract infection was given an intravenous infusion
of Xiyanping Injection 3 ml in 100 ml 5% dextrose and after
about 5 minutes developed chest distension, shortness of
breath, dysphoria, pallor, lip cyanosis, and very cold limbs.
The infusion was stopped immediately and she gradually recov-
ered in 10 minutes after a combination of oxygen and intrave-
nous dexamethasone and adrenaline.

A 51-year-old woman with cough and a fever (38  C) was given
an intravenous infusion of Xiyanping Injection 200 mg in
250 ml 5% dextrose and after 20 minutes suddenly developed
chest distension, palpitation, shivering, dysphoria, facial pallor,
intolerance of cold, and a low blood pressure (80/50 mmHg).
The infusion was stopped immediately and she made an
uneventful recovery after receiving oxygen, adrenaline, dexa-
methasone, and diphenhydramine.
Xuesaitong Tablet/Injection
Xuesaitong (Unblock the Blood Blockage), with notoginse-
noside extracted from Notoginseng radix et rhizome (Sanqi)
as the main ingredient, is usually used to treat ischemic
cerebrovascular disease. It is available as tablets, injections,
or lyophilized powder. In a review of reports published
between 1992 and 2009 there were 64 adverse events, of
which one was associated with the tablet, seven with the
powder, and 56 with the injection [210]. The adverse reac-
tions involved urinary, respiratory, skin, digestive, blood,
and other systems. Except in one fatal case, the symptoms
resolved after withdrawal of Xuesaitong and administration
of anti-allergic and symptomatic treatments.

A 53-year-old man with cerebral ischemia was given an infusion
of Xuesaitong 400 mg/day [211]. There were no adverse events
during the first 2 days, but on the third day he suddenly lost
consciousness, foamed at the mouth, and had cold limbs, a weak
pulse, and tachypnea. The Xuesaitong was withdrawn immedi-
ately and he was given oxygen, adrenaline, dexamethasone, and
vitamin C. He gradually recovered within half an hour. He later
said that he had drunk 150 ml of white wine 1 hour before the
infusion.
Yan Hu Ning injection
Yan Hu Ning injection contains andrographolide, the
active ingredient of a medicinal herb Herba Andrographi-
tis. It is commonly used in China to treat viral pneumonia
and upper respiratory infections. Although associated
adverse reactions are rare in adults, it has been associated
with allergic reactions in children [212,213].

A 2.5-year-old boy developed a red complexion, profuse sweat-
ing, and shortness of breath about 35 minutes into an
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intravenous infusion of Yan Hu Ning injection 80 mg in
150 ml 5% GNS for suppurative tonsillitis. The infusion was
stopped immediately and intravenous dexamethasone resulted
in amelioration of the allergic reaction.

A 10-year-old girl developed itching in the limbs, followed by a
red complexion, red eyes, abdominal pain, a generalized rash
with pruritus, chest distension, and shortness of breath about 24
minutes into an intravenous infusion of Yan Hu Ning injection
120 ml in 150 ml of 5% dextrose for an upper respiratory infec-
tion. The infusion was stopped immediately and she was given
dexamethasone and promethazine, which led to complete
resolution.

A 7-year-old boy developed anaphylactic shock with a pale
complexion, shivering, and an erythematous rash on the fore-
head about 20 minutes into an intravenous infusion of Yan Hu
Ning injection for suppurative tonsillitis. The infusion was
immediately stopped and he was given dexamethasone and
promethazine, which completely relieved the allergic reaction.
The underlying mechanism of Yan Hu Ning-induced aller-
gic reaction is unknown, but it is probably attributable to
impurities in the product, allergic susceptibility of the
patients, and perhaps too rapid intravenous infusion.
If the last mechanism is involved this reaction could be a
non-IgE-mediated anaphylactic reaction, due to histamine
release, similar to the red man syndrome after vancomycin.
Yinzhihuang Injection
Yinzhihuang Injection (Artemisiae, Gardeniae, and Scu-
tellariae Injection), made from Artemisiae scopariae herba
(Yinchen), Gardeniae fructus (Zhizi), Scutellariae radix
(Huangqin), and Lonicerae japonicae flos (Jinyinhua), is
commonly used in China to treat acute hepatitis and
chronic persistent hepatitis. An allergic reaction has
been associated with Yinzhihuang Injection [214].

A 32-year-old man with hepatitis A was given an intravenous
infusion of Yinzhihuang Injection 20 ml in 250 ml dextrose and
after 20 minutes developed pruritus and dizziness, and his blood
pressure fell to 50/30 mmHg. The infusion was stopped imme-
diately and he was given promethazine and dexamethasone.
His symptoms gradually resolved after 5 minutes and his
blood pressure returned to 90/60 mmHg.
Yu xing cao injection
Yu xing cao injection is a sterilized fluid made from a
Chinese herb, Herba Houttuniae. It is widely used to treat
upper respiratory infections, pneumonia, and gynecologi-
cal inflammatory conditions. In a systematic review of
adverse drug reactions associated with Yu xing cao injec-
tion, 1232 cases were identified [215]. Respiratory diseases
accounted for 52%, followed by reproductive system dis-
eases (4.3%) and urinary tract diseases (3.7%). Serious
systemic adverse reactions accounted for 23% of the
total. All cases of death were caused by anaphylactic
shock, except in one patient, who died of multiple organ
failure caused by purpura. The risk from intravenous injec-
tion of Houttuynia was higher than that of intramuscular
injection (OR ¼ 6.9, 95% CI ¼ 1.9, 57). The fastest-onset of
was at 1 minute after injection. Combinations with cepha-
losporins, penicillin, and macrolides increased the risks.

A 45-year-old man with an upper respiratory infection was
given an intravenous infusion of Yu xing cao Injection 50 ml
 Herbal medicines 731

and suddenly developed violent coughing, chest distress, dys- Table 5 Potential impurities that should be taken into account
pnea, a sore throat, dry lips, generalized pruritus, numbness of in the quality control of herbal medicines
the limbs, and a profuse cold sweat [216]. The symptoms
resolved with immediate anti-shock treatment and he made Type of
an uneventful recovery. impurity Examples

Allopathic Analgesic and anti-inflammatory agents (for

Body temperature drugs example aminophenazone, indometacin,
phenylbutazone), benzodiazepines,
Essiac glucocorticoids, sulfonylureas, thiazide
Essiac is a Canadian herbal mixture promoted as a cancer diuretics, thyroid hormones
cure. It has been reported to have caused fever [217]. Botanicals Atropa belladonna, Digitalis species,
A 46-year-old woman with a squamous cell carcinoma Colchicum, Rauwolfia serpentina,
pyrrolizidine-containing plants (see separate
of the cervix developed neutropenic fever during radiation
monograph on pyrrolizidines)
therapy, 10 days after taking Essiac. The fever resolved
Fumigation Ethylene oxide, methyl bromide, phosphine
after antibiotic therapy, but it delayed her radiation ther- agents
apy for 9 days and required 4 days of hospitalization. Heavy metals Arsenic, cadmium, lead, mercury
The authors felt that Essiac had caused this problem, Inorganic Didichromates
but causality was uncertain, not least because she also chemicals
took four other herbal medicaments. Micro- Escherichia coli (certain strains),
organisms Pseudomonas aeruginosa, Salmonella,
Shigella, Staphylococcus aureus
Microbicidal Aflatoxins, bacterial endotoxins
DRUG ADMINISTRATION toxins
Pesticides Carbamate insecticides and herbicides,
Injectable herbal formulations chlorinated pesticides (for example aldrin,
In recent decades many Chinese herbal medicines have dieldrin, heptachlor, DDT, DDE, HCB, HCH
isomers), dithiocarbamate fungicides,
been manufactured as injectable formulations and are
organic phosphates, triazine herbicides
being used in a wide variety of medical conditions. How- 134
Radionuclides Cs,137Cs,103Ru, 131I, 90Sr
ever, these injectable formulations are not without
adverse effects and reactions; in fact, many of them often
cause serious adverse reactions, some of them life- contaminants is not possible.” However, there have been
threatening or fatal. Consequently, the State Food and many reports of adulteration and contamination relate to
Drug Administration of China issued a number of man- Chinese herbal remedies [232]. Instances include adulter-
dates and guidelines to regulate the production, quality ation/contamination with conventional drugs [233,234],
control, evaluation of efficacy, information sheets, and heavy metals [235–241], and other substances [242,243].
safe use of this category of Chinese medicines [218–223]. When 27 samples of commercially available chamomile
formulations were tested in Brazil, it was found that all of
them contained adulterants and only 50% had the
Impurities in herbal formulations essential oils needed to produce anti-inflammatory activ-
Quality control for herbal medicaments that are sold as ity [244].
dietary supplements in most countries is poor [224,225]. Legislation to control the quality of traditional Chinese
Thus, considerable variations in the contents of active medicines was implemented in Hong Kong in 1989, since
ingredients have been reported, with lot-to-lot variations when proprietary Chinese medicines have been recalled
of up to 1000% [226]. In most countries, the sale and by government bodies after inspection of products avail-
supply of herbal remedies is to a large extent uncontrolled able on the market [245]. This information can be used as
and unregulated; most herbal remedies are sold as unli- an alert when these products are re-distributed to other
censed food supplements and their safety, efficacy, and regions.
quality have therefore not been assessed by licensing
authorities. Adulteration and contamination of herbal
remedies with other plant material and conventional Allopathic drugs
drugs have been documented [33,227] (Table 5). Chinese herbal preparations may contain allopathic drugs
Concerns about the quality and safety of herbal reme- [246]. A systematic review included 18 case reports, two
dies are justified, and there have been repeated calls for case series, and four analytical studies showing adultera-
greater control and regulation [36,228,229]. tion with various allopathic drugs [247]. The adulterants
Drug contaminants and adulterants are both varieties of included phenazone (aminopyrine), clobetasol propionate
impurity, a substance present in addition to the substance and other glucocorticoids, diazepam, diclofenac, gliben-
that the synthesis was intended to produce, either arising clamide, hydrochlorothiazide, indometacin, mefenamic
by accident or unavoidably (a contaminant) or having acid, methylsalicylate, phenacetin, phenylbutazone, and
been deliberately added (an adulterant) [230]. phenytoin.
The authors of a survey of German importers of In 2002 the Medicines Safety Authority of the Ministry
Chinese herbs concluded that “only rarely” had herbal of Health in New Zealand (Medsafe) ordered the with-
drugs to be returned because of contamination [231]. drawal of several traditional Chinese medicines sold as
The authors also stated that “a 100% check for all possible herbal remedies, since they contained scheduled

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 732 Herbal medicines
medicines and toxic substances [248]. The products
included the following allopathic drugs:


Wei Ge Wang tablets, which contained sildenafil


Sang Ju Gan Mao Pian tablets, which contained diclo-
fenac and chlorphenamine


Yen Qiao Jie Du Pian capsules, which contained chlor-
phenamine, diclofenac, and paracetamol


Xiaoke Wan pills, which contained glibenclamide


Shuen Feng cream, which contained ketoconazole


Dezhong Rhinitis drops, which contained ephedrine
hydrochloride.
The New Zealand Director General of Health issued a
Public Statement asking people to stop taking these prod-
ucts and to seek medical advice. Medsafe asked all
importers and distributors of traditional Chinese medi-
cines to cease all distribution and sale of these products,
to withdraw them from retail outlets, and to ensure that
other products they sell do not contain scheduled
medicines.
Barbiturates. Phenobarbital has been reported as a con-
taminant in a Chinese patent medicine [249].
A 10-year-old boy developed respiratory depression
and became comatose after taking the Chinese patent
medicine “Diankexing” for 6 months. His urine phenobar-
bital concentration was 95 mg/ml (target range 20–
40 mg/ml). The remedy was withdrawn and he was success-
fully treated with activated charcoal.
Benzodiazepines. Two herbal medicines PC-SPES and
SPES, marketed as “herbal dietary supplements” for
“prostate health” and for “strengthening the immune sys-
tem” respectively and sold through the internet, by mail
order, by phone order, and through various distributors
and health-care professionals, were shown in 2002 by the
California Department of Health to have been contami-
nated with alprazolam and warfarin [250]. The Canadian
Medicines Regulatory Authority also reported similar
contaminations. In view of these reports Health Canada,
the Irish Medicines Board, and the State Health Director
of California all warned consumers to stop using these two
products immediately and to consult their health-care
practitioners. Botanic Lab also informed consumers of
these laboratory findings and issued a product recall of
all lots of PC-SPES, pending further reports from addi-
tional testing of PC-SPES in both commercial and aca-
demic laboratories.
In 2001 the California State Health Director warned
consumers to stop using the herbal product Anso Comfort
capsules immediately, because the product contains the
undeclared prescription benzodiazepine chlordiazepoxide
[251]. Anso Comfort capsules, available by mail or tele-
phone order from the distributor in 60-capsule bottles,
were clear with dark green powder inside. The label was
yellow with green English printing and a picture of a plant.
An investigation by the California Department of Health
Services Food and Drug Branch and Food and Drug Lab-
oratory showed that the product contained chlordiazepox-
ide. The ingredients for the product were imported from
China and the capsules were manufactured in California.
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Advertising for the product claimed that the capsules were
useful for the treatment of a wide variety of illnesses,
including high blood pressure and high cholesterol, in
addition to claims that it was a natural herbal dietary
supplement. The advertising also claimed that the product
contained only Chinese herbal ingredients and that con-
sumers could reduce or stop their need for prescribed
medicines. No clear medical evidence supported any of
these claims. The distributor, NuMeridian (formerly
known as Top Line Project), voluntarily recalled the prod-
uct nationwide.
A San Francisco woman with a history of diabetes and
high blood pressure was hospitalized in January 2001 with
life-threatening hypoglycemia after she consumed Anso
Comfort capsules. This may have been due to an interac-
tion of chlordiazepoxide with other unspecified medica-
tions that she was taking.
Glucocorticoids. Wau Wa cream, marketed in several
countries as a herbal cream for eczema, was found to
contain 0.013% clobetasol propionate, a glucocorticoid
that does not occur naturally, explaining its surprising
therapeutic efficacy in three patients [252].
Betamethasone, 0.1–0.3 mg per capsule, was detected
in Cheng Kum and Shen Loon, two herbal medicines
used for joint pains, skin problems, colds, menopausal
symptoms, and dysmenorrhea [253]. The recommended
daily adult dose of Cheng Kum was 1–3 capsules per day,
and there were reports of glucocorticoid-induced adverse
reactions in patients taking Cheng Kum and Shen Loon,
even in the absence of other exogenous glucocorticoster-
oid consumption.

Two patients, a 29-year-old woman and a 10-year-old girl,
developed Cushingoid features after taking Shen Loon for
4 and 5 months respectively [254]. Their morning plasma corti-
sol concentrations were increased and adrenal suppression was
confirmed by a short Synacthen test. Both recovered after
withdrawal of the remedy and treatment with prednisone.
The New Zealand Medicines and Medical Devices Safety
Authority (Medsafe) notified that the further importation
of these herbal products into New Zealand would be
stopped at Customs. However, because of the risk of
adrenal suppression from glucocorticoids, consumers
were sent a letter advising them against abruptly disconti-
nuing these products. Medsafe issued a letter to doctors
advising them to determine whether patients taking
Cheng Kum or Shen Loon were at risk of adrenal suppres-
sion by estimating the potential total dose of glucocorti-
coid (from Cheng Kum or Shen Loon plus any exogenous
steroids) and the duration of use, by examining the patient
for signs of glucocorticoid excess, and by ascertaining if
other risk factors for adrenal suppression were present
(such as Addison’s disease and AIDS).
Hypoglycemic drugs. In 2000 the California Depart-
ment of Health Services Food and Drug Branch issued a
warning to consumers that they should immediately stop
using five herbal products, because they contained two
prescription drugs that were not listed as ingredients and
that are unsafe without monitoring by a physician [255].
The products were Diabetes Hypoglucose Capsules, Pearl
Hypoglycemic Capsules, Tongyi Tang Diabetes Angel
Pearl Hypoglycemic Capsules, Tongyi Tang Diabetes

Angel Hypoglycemic Capsules, and Zhen Qi Capsules.
The products were available by mail order and could be
purchased by telephone or via the Internet. Their manu-
facturers claimed that they contained only natural Chinese
herbal ingredients. However, after a diabetic patient in
Northern California had had several episodes of hypogly-
cemia after taking Diabetes Hypoglucose Capsules, an
investigation by the Department showed that they contain
the antidiabetic drugs glibenclamide (glyburide) and
phenformin.
Non-steroidal anti-inflammatory drugs (NSAIDs). In
2006 the Department of Health of Hong Kong urged
members of the public not to buy or take two brands of
proprietary Chinese medicines containing NSAIDs [256]:

Chuifong Toukuwan and Nan Lien Chuifong Toukuwan, which
were marketed for treatment of rheumatoid arthritis and con-
tained diclofenac

Jin Feng Brand Gallinaci Bak Foong Pills; Baozhitang
Gallinaci Pai Feng Pills; Pujitang Gallinaci Pai Feng Pill; Jinbei
Brand Gallinaci Pai Feng Pills; and Tongjitang Gallinaci Pai
Feng Pills; all contained diclofenac and paracetamol.
Penicillamine. Penicillamine unexpectedly caused myas-
thenia gravis when present as an unrecognized additive in
Chinese herbs [257].
Sibutramine. Adulteration of a herbal medicine with
sibutramine has been reported [258].

A young healthy woman took a Chinese herbal medicine called
LiDa Dai Dai Hua Jiao Nang and on the second day developed a
severe headache, vertigo, and numbness. She stopped taking it
and the symptoms disappeared within 2 days. Sibutramine was
identified in her urine sample and the capsules each contained
27.4 mg of sibutramine base, about twice the amount of the
highest single dosage form available on the market in Germany.
Botanicals
Two cases have been reported of contamination of plan-
tain (a plant of the genus Plantago) by Digitalis lanata
[259]. Both patients suffered from serious overdose of
cardiac glycosides with toxic serum digoxin concentrations
as a result.
Heavy metals
Of 260 Asian patent medicines available in California, 7%
contained undeclared pharmaceuticals. When 251 samples
were tested for heavy metals, 24 products contained at
least 10 parts per million of lead, 36 contained arsenic,
and 35 contained mercury [260].
A total of 54 samples of Asian remedies, purchased in
Vietnam, Hong Kong, Florida, New York, and New
Jersey, were analysed for heavy metal adulteration [261].
They contained concentrations of arsenic, lead, and mer-
cury that ranged from merely exceeding published guide-
lines (74%) to toxic (49%).
Ayurvedic medicines have repeatedly been associated
with arsenic poisoning, including hyperpigmentation and
hyperkeratosis [262] and heavy metal poisoning can follow
ingestion of Ayurvedic preparations containing arsenic
and mercury [124,263]. Of 70 unique Ayurvedic products
manufactured in India or Pakistan and sold in Boston,
mostly for gastrointestinal disorders, 14 contained lead,
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Herbal medicines 733
mercury, and/or arsenic, in concentrations up to about
100 mg/g [264,265].
Arsenic. Three Singapore patients with chronic arsenic
poisoning and characteristic skin changes had taken Chi-
nese herbal remedies for many years to treat their asthma;
two had cancers likely to have been due to arsenic [266].
In 2002 the Medicines Safety Authority of the Ministry
of Health in New Zealand (Medsafe) ordered the with-
drawal of several traditional Chinese medicines sold as
herbal remedies, since they contained scheduled medi-
cines and toxic substances [248]. The products included
Niu Huang Jie Du Pian tablets, which contain 4% arsenic.
Lead. In Taipei, 319 children aged 1–7 years were
screened for increased blood lead concentrations [267].
The consumption of Chinese herbal medicines was signif-
icantly correlated with blood lead concentrations. In 2803
subjects from Taipei a history of herbal drug taking
proved to be a major susceptibility factor for increased
blood lead concentrations [268].

A 56-year-old woman developed the signs and symptoms of
lead poisoning after taking an Indian herbal medicine for
many years [269]. Her blood and urine lead concentrations
were 1530 ng/ml and 4785 mg/day. She also had raised liver
enzymes. After withdrawal of the remedy and treatment with
penicillamine, she made a full recovery.

A 5-year-old boy of Indian origin with encephalopathy, sei-
zures, and developmental delay developed persistent anemia
[270]. The more obvious causes were ruled out and his blood
lead concentration was high (860 ng/ml). He was treated with
chelation therapy and his blood lead concentration fell. For the
previous 4 years his parents had given him “Tibetan Herbal
Vitamins,” produced in India, which contained large amounts
of lead. The investigators calculated that over that time he had
ingested around 63 g of lead.

A 26-year-old woman took an Ayurvedic remedy (Astrum FE
Femikalp) for sterility [271]. It contained lead 113 mg/kg. Her
blood lead concentration was raised and normalized 1 month
after withdrawal of the remedy. Lead poisoning was also con-
firmed by hair analysis.

A 39-year-old Indian man with jaundice consulted a traditional
practitioner in his village, who gave him a syrup called kadda
(in the Indian local language). He took 10–15 ml of the syrup
every morning on an empty stomach for 10 days and developed
vomiting and severe abdominal pain [272]. Lead poisoning was
confirmed when the blood lead concentration was measured. A
combination of chelation therapy and nutritional supplements
reduced the body lead burden. The original syrup had been
consumed and could not be tested for lead content.
In 2006 Health Canada issued an advisory notice to con-
sumers, warning against the use of Jambrulin, an Ayurve-
dic medicinal product with a high content of lead [273].
Intrauterine lead intoxication has been reported [274].

A 24-year-old pregnant woman, who had recently emigrated
from India, had periodically over the course of 9 years taken
tablets prescribed by an Ayurvedic doctor for a gastrointestinal
complaint. The tablets had a high lead content. She presented at
30 weeks’ gestation with abdominal pain and progressive con-
fusion, culminating in seizures. Her erythrocytes showed typical
basophilic stippling and her blood lead concentration was
5.2 mmol/l (reference range 0.06–0.6 mmol/l). She was given
intramuscular dimercaprol and intravenous calcium disodium
edetate and 36 hours later had an antepartum hemorrhage;
labor was induced and she gave birth by vaginal delivery to a
1.6 kg girl, who was flaccid and areflexic and did not move in
response to noxious stimuli, but had spontaneous ocular
 734 Herbal medicines
movements. She had bilateral diaphragmatic palsy. The cord
blood lead concentration was 7.6 mmol/l, the erythrocyte porphy-
rin concentration was 20 mmol/l (reference range 0.4–1.7 mmol/l),
and radiography of the long bones showed increased bone den-
sity adjacent to the metaphyses. The infant was given chelation
dimercaprol (4 mg/kg every 4 hours) and intravenous calcium
disodium edetate 50 mg/kg. The blood lead concentration ini-
tially rose to 12 mmol/l and then fell rapidly over the next few
days. A high urinary lead concentration on day 4 (52 mmol/l)
showed that lead was being excreted. Facial, bulbar, proximal
limb, and diaphragmatic muscle activity improved.
Mercury. Adulteration of a herbal medicine with mercury
has been reported [275].

A 5-year-old Chinese boy developed motor and vocal tics. His
parents had given him a Chinese herbal spray to treat mouth
ulcers. The spray contained mercury 878 ppm. Mercury poison-
ing was confirmed by the blood mercury concentration
(183 nmol/l, normal value for adults under 50 nmol/l).
Inorganic chemicals
There is a practice among urbanized South African blacks
to replace traditional herbal ingredients of purgative
enemas with sodium or potassium dichromate. This switch
can result in serious toxicity, characterized by acute renal
insufficiency, gastrointestinal hemorrhage, and hepato-
cellular dysfunction [276,277].
Micro-organisms
The Department of Health in Hong Kong ordered the
immediate recall of 17 proprietary Chinese medicines
after laboratory tests showed that the total bacterial
count exceeded the maximum permitted limit for registra-
tion of such medicines in both Hong Kong and Macau
(Table 6). Some of these products are intended for pedi-
atric use.
When 62 samples of medicinal plant material and 11
samples of herbal tea were examined in Croatia, fungal
contamination was found to be abundant [278]. Aspergil-
lus flavus, a known producer of aflatoxins was present in
11 and one sample respectively. Mycotoxins were found in
seven of the samples analysed.
Table 6 Proprietary Chinese medicines recalled after
laboratory tests showed that the total bacterial count exceeded
the maximum permitted limit
Bao Zhu Brand Bo Ying Pills Chu Pai Chut Lee San
Bao Zhu Brand Chut Lee San Chu Pai Hou Tsao San
Bao Zhu Brand Hou Tsao San Hou Tsao San
Bo Ying Pills Hung Win Bo Ying Pills
Chi Chun Tang Chu Pai Bo Ying Kui Hua Chut Lee San
Dan Bird’s Nest & Pearl
Chi Chun Tang Chu Pai Chut Lee Po Wo Tong Ging Fung San
San Po Wo Tong Hou Tsao San
Chi Chun Tang Chu Pai Hou Po Wo Tong Wui Chun Tan
Tsao San for Children
Chi Chun Tang Pearl Bat Po Xian Cao Tang Chu Pai Hou
Keng Foong Powder Tsao San
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Pesticides
Some herbal medicaments are contaminated with pesti-
cides [279].
Drug overdose
In a retrospective study of 2764 poisoning cases admitted
to eight urban hospitals in Zimbabwe between 1998 and
1999, 7% of all cases and 13% of all deaths were related to
traditional medicines [280]. The authors noted that these
figures were markedly lower than those from a similar
survey 10 years before.
SUSCEPTIBILITY FACTORS
Owing to extensive modifications of drug formulations
and chemical extracts from an expanding range of natural
products, herbal formulations may contain ingredients
that are particularly harmful to individuals with glucose-
6-phosphate dehydrogenase (G6PD) deficiency. Extra
vigilance is therefore required when herbal medicinal for-
mulations, including topical applications, are used by
patients with G6PD deficiency and even their carers [281].
DRUG-DRUG INTERACTIONS
Antiplatelet drugs and anticoagulants
Multiple interactions can occur if a patient is taking sev-
eral different herbal preparations [40].

A 77-year-old lady developed epigastric pain and hematemesis.
Her clotting was normal. After identical symptoms 4 months
before, a gastroscopy had shown a large sliding intrathoracic hiatus
hernia with severe esophagitis. She had been given lansoprazole
30 mg/day. She had also taken garlic, St John’s wort, feverfew,
Echinacea, and ginseng. The herbal remedies were withdrawn.
Garlic, feverfew, and ginseng all inhibit platelet aggrega-
tion and could have increased the risk of bleeding in this
case, particularly since they were taken in combination.
An interaction between lansoprazole and St John’s wort
may also have contributed, since lansoprazole is metabo-
lized by CYP2C19, which is induced by St John’s wort.
In a cross-sectional survey of the use of herbal medi-
cines that might interfere with the effects of antiplatelet
drugs or anticoagulants among 250 patients, 106 (42%)
were taking herbs, of whom 76 (72%) had using them for
the past 12 months [282]. Overall, almost 31% were taking
one or more herbal medicines that are thought to interact
with antiplatelet drugs or anticoagulants: ginseng (Panax
ginseng), garlic (Allium sativum), and ginkgo (Ginkgo
biloba). A large proportion of respondents involved in
potential drug–herb interaction were elderly (63%). How-
ever, more than 90% of herbal users did not disclose the
use of herbal medicines to their health professionals.
The risk of bleeding associated with the use of alterna-
tive medicines has been evaluated in 171 patients taking
warfarin in a prospective study in an acute-care academic
research hospital in Canada [283]. The patients completed
a 16-week diary by recording bleeding events; 87 (51%)

reported at least one bleeding event and 73 (43%) indi-
cated that they had used at least one alternative medicine
previously reported to interact with warfarin. The thera-
pies associated with an increased risk of self-reported
bleeding included cayenne, ginger, willow bark, St John’s
wort, and coenzyme Q10. Use of more than one alterna-
tive medicine while taking warfarin was also a significant
susceptibility factor. Ubidecarenone (coenzyme Q10)
(OR ¼ 3.69, 95% CI ¼ 1.88, 7.24) and ginger (OR ¼ 3.20,
95% CI ¼ 2.42, 4.24) were independently associated with
an increased risk of self-reported bleeding.
Shengmaiyin (Promoting the Pulse Drink) is a popular
Chinese herbal product, which contains Ginseng radix et
rhizoma rubra (Hongshen), Ophiopogonis radix (Mai-
dong), and Schisandrae chinensis fructus (Wuweizi).
Shengmaiyin is commonly used for cardiovascular and
cerebrovascular diseases and oxidative damage in other
organs [284–286]. It has been reported to interact with
warfarin, causing bleeding [287].

A 71-year-old man taking stable warfarin therapy (2.25 mg/
day) with an INR of 1.8–2.2 after heart valve replacement lost
consciousness and had an INR of 5.1 after consuming Sheng-
maiyin (10 ml/day) for 7 days. A CT scan showed a hematoma
in the left temporoparietal region. Both warfarin and the herbal
product were withheld and he was given intravenous vitamin K1
40 mg. On the second day a craniectomy was performed to
remove the intracerebral hematoma. He remained confused
and restless for 2 days, but progressively recovered.
Phenytoin
In two patients the use of Shankhapushpi, an Ayurvedic
preparation, was associated with reduced antiepileptic
activity of phenytoin and reduced plasma phenytoin con-
centrations [288].
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