Herbal poisoning management

Investigations

• Basic blood count, renal function, liver function, and electrocardiogram

• Heavy metal screening if suspected or if symptoms are non-specific

• Analysis methods exist for some herbal toxins only:

  • Colchicines (HPLC, GC-MS)

  • Tropane alkaloids (GC-MS)

  • Oxalate (GC-MS)

  • Vinca alkaloids (HPLC)

  • Cardioactive steroids (immunoassay)

• Check with local laboratory availability

Organ toxicities, toxidromes, and associated herbal or dietary xenobiotics

Cardiac toxicity

• Sodium channel effects: Aconitum species (widened QRS, shock)

• Digoxin-like effects: Digitalis species, bufo toads

Central nervous system toxicity

• Seizures: strychnine, thujone, essential oils (camphor, eucalyptus)

• Sedation: Valeriana species, kava kava

Dermatological toxicity

• Blistering: cantharidin (Chinese blister beetle)

Hematological toxicity

• Coagulopathies: ginger, garlic, ginkgo

• Agranulocytosis: colchicine, podophyllotoxin

Hepatotoxicity

• Hepatitis: multiple agents, germander commonly reported

• Veno-occlusive disease: pyrrolizidine alkaloids (comfrey, Senecio species, Heliotropium species)

Nephrotoxicity

• Renal failure: Aristolochia species

• Hypertension, hyperkalemia: licorice

Anticholinergic toxicity

• Datura metel (commonly used in traditional Chinese medicine)

• Hexing herbs: Atropa species, Hyoscyamus species, Mandragora officinarum (common in Western herbal practice)

Sympathomimetic toxicity

• Ephedra species

• Citrus aurantium (bitter orange)

Salicylate poisoning

• Willow bark

• Checkerberry

Non-pharmacological treatment

• Ask specifically regarding use of herbal products and correlate with toxidromes

• Secure sample for identification:

  • Actual herbs or product used

  • Prescription or packaging

• Provide good resuscitative, symptomatic, and supportive care

• Instruct patient and family to stop using the product

• Consider outpatient monitoring of renal function, liver function, and blood counts

• Report case to regulatory authority

• Report unusual cases to National Poison Control Center

Pharmacological treatment

• Use specific antidote if appropriate

• Activated charcoal may be given in acute overdose of toxic dietary supplements and herbal medicines if there is adequate airway protection

• Compound sodium lactate or 0.9% sodium chloride (IV) 30 mL/kg (up to 2 liters over 24 hours) if shock is present