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Although, there is increased awareness of the widespread use of herbal preparations in the United States, frequently physicians seek information about the use of these products only after the patient demonstrates toxicity perhaps not completely attributable to a pharmaceutical product or a disease process. Some historical examples of toxicity from herbal usage include the death a professional baseball pitcher from ephedra in 2003, and its subsequent banning by the FDA in 2004;183 six cases of anticholinergic poisoning from contaminated Paraguay tea in New York City in 1994;33,95 three cases of life-threatening bradycardia following consumption of Jin Bu Huan tablets in Colorado in 1993;38 and four cases of agranulocytosis with one death following consumption of Chui Fong Tou Ku Wan in San Francisco in 1975.168 Although few studies have examined this issue, most herbal preparations used in developed countries appear to be safe. From 1983 to 1989, the National Poisons Unit, London, received 1070 inquiries regarding exposures to herbal extracts, of which 270 (25.2%) patients were symptomatic. The investigators were able to demonstrate a probable association between exposure and effect in only 32 of the 270 cases (12%).159 In Hong Kong, Chinese herbal medicines and proprietary medicines accounted for only 0.2% of all acute medical admissions despite their use by 40%–60% of the population whereas Western medications were responsible for 4.4% of acute medical admissions.48,49 In the United States, a multicenter poison center study reported in 2003 collected 2253 calls involving dietary supplements including herbals; 493 patient exposures were determined to be caused by dietary supplement and were associated with 5 deaths, 13 seizures, 8 cases of coma, and 9 cases of hepatotoxicity.154 The overall severity outcome among dietary supplement cases was greater compared to outcomes of other poison center—reported exposures.154 In developing countries where herbal usage is much greater, reported poisoning from herbal preparation usage appears to be higher. In Southern Africa and in Oman, traditional medicines account for 6%–15% of hospital admissions for acute poisonings.92,107,127,187

The botanical definition of the term herb is specific for certain leafy plants without woody stems. However, the term herbal preparations often includes nonherb plant materials, even animal and mineral products. Thus, in a broad sense, the term herbals includes any "natural" or "traditional" remedy, but these terms also are poorly defined. Although these products often are also called medications, this terminology may be inaccurate and misleading. Many herbal preparations purportedly are used for their nonspecific "adaptogenic" properties by permitting the body return to a normal state by resisting stress, but they lack any specific medicinal effects. Because many herbal users and herbalists do not consider herbal preparations medications, use of the term herbal medicine by the clinician may convey a different, and perhaps unintended, meaning. For these reasons, it may be inappropriate and without benefit to refer to these products as medication, but they are xenobiotics.

Herbal preparations are ...

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