Pancreatitis after herbal supplement consumption.

The paper by Hillesheim and Whitcomb describes an interesting report of a young female who develops pancreatitis after consuming a popular herbal supplement used for improving sexual libido. This case reminds us of two key issues: first of all, herbal products and supplements are becoming more important to our daily practice of medicine; and, secondly, one must remember to consider them as a possible etiology of disease processes.

Herbal medicines are becoming increasingly popular in everyday life. This is evidenced by the increasing number of late night TV infomercials, spam e-mails, radio advertisements, and the ever growing "natural products" aisles in grocery stores. These products are labeled as safe and cost-effective alternatives to traditional medicines. While there is some use for herbals in today's practice of allopathic medicine, not all herbals are safe. Debates are ongoing about the safety and efficacy of these products, and currently there is an attempt to legislate them more strictly. Despite the controversial nature of this topic, it is estimated that 12 to 71% of the United States population uses one form of herbal medication or another. (1) A vast majority of these people have never visited a practitioner licensed or trained in the use of these medications. A bill in the House of Representatives estimates the number of consumers to be over 150 million, and in 2004, over 20 billion dollars were spent by consumers on herbal products. (2)

Supporters of herbals tout the cost factor and the ease of acquiring these supplements. The high cost of some prescription medications leads people to look for cheaper alternatives. They argue that these treatments are natural and have been used for thousands of years by practitioners of ayurvedic and herbal medicine in India and China. In addition, proponents argue that limiting or restricting the use of these products violates constitutional rights of consumers. The fact that one can go to the local pharmacy or supermarket and buy these without going to a doctor and obtaining a prescription adds an angle to healthcare with which many of us are uncomfortable.

Opponents of the use of herbals and supplements cite the large number of side effects that have been attributed to them. The lack of randomized controlled trials (RCT) and adverse effect reporting have been major points of contention. The ephedra controversy of the early part of this decade is well-documented, and it highlights some of the problems that can be attributed to uncontrolled and irresponsible use. Numerous side effects have been attributed to herbals, including hepatotoxicity, nephrotoxicity, and now pancreatitis among others. (1,3,4) Another point that is mentioned in the literature is the large number of interactions that occur when supplements are taken concomitantly with prescription medications, thus altering the therapeutic effects. (3) The lack of standardization also presents a dilemma; many times what one patient gets in a formulation is not the same as in another. Adulteration is not uncommon, with many products having undisclosed components. (4) Currently, there is no reliable method to police the sale of supplements, as many are available over the web. The FDA does not have any control over these products, and neither do any regulatory boards exist for them. More consumers, including minors, are buying products without realizing the potential dangers. (5)

The debate rages as to how and if to regulate herbals. Regardless of what an individual believes in regards to herbal products and dietary supplements, the fact is that they are here to stay. This makes some of us, as allopathic trained providers, uncomfortable. This is a result of a combination of factors, including perceived lack of reliability, lack of regulation, and lack of knowledge. As healthcare providers, we have to realize that the side effects of many of these products are unknown to us, and as more formulations become available to the general public, we will be asked to decipher and cure symptoms as they arise. As the authors of the article have done, we must consider herbals as a cause of any disease process that occurs in patients in which the etiology is not obvious.

References

1. Bent S, Ko R. Commonly used herbal medicines in the United States: a review [see comment]. Am J Med 2004;116:478-485.

2. Dietary Supplement Regulatory Implementation Act of 2005 (2005).

3. De Smet PA. Herbal remedies. N Engl J Med 2002;347:2046-2056.

4. Marcus DM, Grollman AP. Botanical medicines: the need for new regulations. N Engl J Med 2002;347:2073-2076.

5. Bonakdar RA. Herbal cancer cures on the Web: noncompliance with The Dietary Supplement Health and Education Act. Fam Med 2002;34:522-527.

Mankanwal S. Sachdev, MD

From the Department of Gastroenterology, University of Tennessee, Memphis, TN.

Reprint requests to Mankanwal S. Sachdev, MD, University of Tennessee--Gastroenterology, 920 Madison Suite 240, Memphis, TN 38163. Email: [e-mail]

Accepted June 27, 2006.