Abstract
In the present review, the main objective was to report the incidence and causes of herbal medicines induced anticholinergic poisoning in Hong Kong during 1989–2012 and to emphasize the importance of pharmacovigilance, investigations and preventive measures. Relevant papers, official figures and unpublished data were obtained from Medline search, the Department of Health and the Drug and Poisons Information Bureau. In the New Territories East (where ~20% of the Hong Kong population lived), the incidence of herbal medicines induced anticholinergic poisoning during 1989–1993 was 0.09 per 100,000 population. There were no confirmed cases during 1994–1996. In the whole of Hong Kong, the incidence during 2000–June 2005 was 0.03 per 100,000 population. Contamination of Rhizoma Atractylodis (50%) and erroneous substitution (42%) were the main causes. The incidence during 2008–2012 was 0.06 per 100,000 population. Contamination of non-toxic herbs (50%) and erroneous substitution (41%) were the main causes. In Hong Kong, contamination of non-toxic herbs by tropane alkaloids and substitution of Flos Campsis by toxic Flos Daturae Metelis were the predominant causes of herbal medicines induced anticholinergic poisoning. Systematic studies along the supply chain are necessary to identify the likely sources of contamination. If erroneous substitution of Flos Campsis by Flos Daturae Metelis could be prevented, 40% of herbal medicines induced anticholinergic poisoning would not have occurred. Regular inspection of the retailer, continuing education for the staff in the herbal trade and repeated publicity measures will also be required. Pharmacovigilance of herbal medicines should help determine the incidence and causes of adverse reactions and monitor the effectiveness of preventive measures.
Highlights
In Hong Kong, both traditional medicine and western medicine are widely accepted by the public
In Hong Kong, contamination of non-toxic herbs by tropane alkaloids and substitution of Flos Campsis by toxic Flos Daturae Metelis were the predominant causes of herbal medicines induced anticholinergic poisoning
Adverse reactions to herbal medicines and drugs accounted for 0.2% and 4.4% of acute admissions to general medical wards [2,3]
Summary
In Hong Kong, both traditional medicine and western medicine are widely accepted by the public. Surveillance of acute hospital admissions since 1989 [4] and spontaneous reports received since 2007 by the four territory-wide poison control units [5,6,7] of the Hong Kong Poison Control Network (http://www.hkpcn.org.hk) indicate that herbs containing or contaminated with Aconitum alkaloids (e.g., aconitine, mesaconitine, hypaconitine, yunaconitine and crassicauline A) and tropane alkaloids (e.g., atropine, hyoscyamine and scopolamine) remain the two most important causes of herbal. The tropane alkaloid content is the highest in the flowers of the Datura species [12] Overdose of their flowers as herbal medicines or consumption of non-toxic herbs contaminated by such plant parts is associated with a higher risk of anticholinergic poisoning [10]. In severe cases (e.g., profound delirium), physostigmine, a cholinesterase inhibitor, should be used to reverse anticholinergic toxicity [12]
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