Potential risks associated with the use of herbal anti-obesity products

Increased risk of major adverse cardiovascular events in young and middle-aged adults with obesity receiving Chinese herbal medicine: A nationwide cohort study

BACKGROUND

Many patients with obesity in Taiwan seek Chinese herbal medicines (CHM) from traditional Chinese medicine (TCM) clinics. This study aimed to estimate the risk of major adverse cardiovascular events (MACEs) in adults diagnosed with obesity, with or without CHM.

METHODS

Patients with obesity aged 18 to 50 years were identified using diagnostic codes from Taiwan's National Health Insurance Research Database between 2008 and 2018. We randomized 67 655 patients with or without CHM using propensity score matching. All patients were followed up from the start of the study until MACEs, death, or the end of 2018. A Cox proportional regression model was used to evaluate the hazard ratios of MACEs in the CHM and non-CHM cohorts.

RESULTS

During a median follow-up of 4.2 years, the CHM group had a higher incidence of MACEs than the non-CHM control cohort (9.35 vs 8.27 per 1000 person-years). The CHM group had a 1.13-fold higher risk of MACEs compared with the non-CHM control (adjusted hazard ratio [aHR] = 1.13; 95% CI], 1.07-1.19; p < 0.001), especially in ischemic stroke (aHR = 1.18; 95% CI, 1.07-1.31; p < 0.01), arrhythmia (aHR = 1.26; 95% CI, 1.14-1.38; p < 0.001), and young adults aged 18 to 29 years (aHR = 1.22; 95% CI, 1.05-1.43; p < 0.001).

CONCLUSION

Although certain CHMs offer cardiovascular benefits, young and middle-aged obese adults receiving CHM exhibit a higher risk of MACEs than those not receiving CHM. Therefore, TCM practitioners should be cautious when prescribing medications to young patients with obesity, considering their potential cardiovascular risks.

Toxicity from illegitimate slimming agents - a 10-year case series at a tertiary toxicology laboratory in Hong Kong

CONTEXT

This retrospective case-series study aims to provide an overview of the clinical, biochemical and analytical findings in patients who presented with toxicity related to the use of illegitimate slimming agents in Hong Kong from the perspective of a tertiary referral toxicology laboratory.

METHODS

All clinical cases referred to the Hospital Authority Toxicology Reference Laboratory, Hong Kong with clinical suspicion of illegitimate slimming agent-related toxicity between January 2008 and December 2017 were reviewed retrospectively. The use of illegitimate slimming agents included the use of (1) deregistered slimming agents, (2) drug analogues that were not registered drugs, (3) registered drugs not approved for the indication of weight reduction (whether prescribed by a doctor or not), and (4) prescription-only slimming agents without a doctor's prescription. Patients taking registered weight-reducing drugs prescribed by a doctor were excluded. Patient demographics, clinical features, relevant laboratory investigations, and toxicological findings were analyzed.

RESULTS

From 2008 to 2017, a total of 346 patients were analytically confirmed by our laboratory to have clinical toxicity related to the use of illegitimate slimming agents. The median age of the patients was 27 years and 92.5% of the patients were female. The most common clinical presentations included psychiatric features, sympathomimetic toxicity, hypokalemia, and abnormal thyroid function tests. Fatal or severe clinical toxicity was observed in 10% of the cases. The major classes of drugs detected on our analytical platforms were stimulants (e.g., sibutramine), laxatives (e.g., anthraquinones), diuretics (e.g., hydrochlorothiazide), and thyroid hormones (e.g., animal thyroid tissue). These illegitimate slimming agents were obtained from various sources including the Internet, over-the-counter in community pharmacy, or unspecified local sources.

DISCUSSION AND CONCLUSIONS

The use of slimming agents is common worldwide; apart from taking registered slimming agents prescribed by registered practitioners, many users obtain slimming agents from various illegitimate sources. The unregulated use of these drugs can be associated with significant clinical toxicity. This study provides a current landscape of illegitimate slimming agent toxicity in Hong Kong to frontline clinicians and other toxicology professionals. Collaboration between clinicians, laboratories, and government authorities would be imperative to prevent further health adversities related to the misuse of these agents.

Obesity Therapy: How and Why?

Background:

Obesity represents the second preventable mortality cause worldwide, and is very often associated with type 2 Diabetes Mellitus (T2DM). The first line treatment is lifestyle modification to weight-loss, but for those who fail to achieve the goal or have difficulty in maintaining achieved results, pharmacological treatment is needed. Few drugs are available today, because of their side effects.

Objective:

We aim to review actual pharmacological management of obese patients, highlighting differences between Food and Drug Administration - and European Medicine Agency-approved molecules, and pointing out self-medications readily obtainable and widely distributed.

Methods:

Papers on obesity, weight loss, pharmacotherapy, self- medication and diet-aid products were selected using Medline. Research articles, systematic reviews, clinical trials and meta-analyses were screened.

Results:

Anti-obesity drugs with central mechanisms, such as phentermine and lorcaserin, are available in USA, but not in Europe. Phentermine/topiramate and naltrexone/bupropion combinations are now available, even though the former is still under investigation from EMA. Orlistat, with peripheral mechanisms, represents the only drug approved for weight reduction in adolescents. Liraglutide has been approved at higher dose for obesity. Anti-obesity drugs, readily obtainable from the internet, include crude-drug products and supplements for which there is often a lack of compliance to national regulatory standards.

Conclusion:

Mechanisms of weight loss drugs include the reduction of energy intake or the increase in energy expenditure and sense of satiety as well as the decrease of hunger or the reduction in calories absorption. Few drugs are approved, and differences exist between USA and Europe. Moreover, herbal medicines and supplements often sold on the internet and widely used by obese patients, present a risk of adverse effects.

A new approach to ion exchange chromatography with conductivity detection for adulterants investigation in dietary supplements

The extent of adulteration of dietary supplements has significantly increased in recent years. This situation worries health authorities and requires auxiliary analytical tools for the investigation of illegal substances purposely added. Ion exchange chromatography with conductivity detection is a consolidated analytical technique for the determination of inorganic compounds in various matrices. This technique has been applied to the pharmaceutical characterization of mainly impurities and degradation products. This work presents a new approach to ion exchange chromatography as a screening method to investigate the presence of amfepramone, femproporex, sibutramine, bisacodyl and amiloride in dietary supplements advertised for weight loss. The method was optimized and validated using a Metrosep C4 100/4.0 cation exchange column. The mobile phase consisted of 1.8 mm HNO₃ containing 2% acetonitrile (v/v), with a flow rate of 0.9 ml min^-1 , and nonsuppressed conductivity detection was applied. The limits of detection and quantification varied from 1.01 to 3.62 mg L^-1 and from 1.48 to 8.72 mg L^-1 , respectively. The proposed method was successful applied to 78 solid dietary supplement samples, in two of which adulterations were found. Moreover, ion exchange chromatography with conductivity detection could be easily used for quality control without prior complex sample pre-treatment.

Worldwide Occurrence and Investigations of Contamination of Herbal Medicines by Tropane Alkaloids

Tropane alkaloids occur mainly in Solanaceae plants. In the present review, the main objective is to describe the worldwide occurrence and investigations of anticholinergic poisoning due to the contamination of herbal teas and herbs by tropane alkaloids. Tropane alkaloid poisoning can occur after consumption of any medicinal plant if Solanaceae plants or plant parts are present as contaminants. Globally, almost all reports in 1978–2014 involve herbal teas and one of the prescribed herbs in composite formulae. Contamination most likely occurs during harvest or processing. As for prescribed herbs, on-site inspection is necessary to exclude cross-contamination and accidental mix-up at the retail level. The diagnosis is confirmed by screening for the presence of Solanaceae species and tropane alkaloids. Herbal teas and herbs contaminated by tropane alkaloids can pose a serious health hazard because these relatively heat-stable alkaloids may exist in large quantities. The WHO repeatedly emphasises the importance of good agricultural and collection practices for medicinal plants. DNA barcoding is increasingly used to exclude the presence of contaminants (particularly toxic species) and product substitution. All suspected cases should be reported to health authorities so that investigations along the supply chain and early intervention measures to protect the public can be initiated.

Chromatographic fingerprinting as a strategy to identify regulated plants in illegal herbal supplements

Erectile dysfunction (ED) is a sexual disorder characterized by the inability to achieve or maintain a sufficiently rigid erection. Despite the availability of non-invasive oral treatment options, many patients turn to herbal alternatives. Furthermore, herbal supplements are increasingly gaining popularity in industrialized countries and, as a consequence, quality control is a highly important issue. Unfortunately, this is not a simple task since plants are often crushed and mixed with other plants, which complicates their identification by usage of classical approaches such as microscopy. The aim of this study was to explore the potential use of chromatographic fingerprinting to identify plants present in herbal preparations intended for the treatment of ED. To achieve this goal, a HPLC-PDA and a HPLC-MS method were developed, using a full factorial experimental design in order to acquire characteristic fingerprints of three plants which are potentially beneficial for treating ED: Epimedium spp., Pausinystalia yohimbe and Tribulus terrestris. The full factorial design demonstrated that for all three plant references a C8 column (250mm×4.6mm; 5µm particle size) is best suited; methanol and an ammonium formate buffer (pH 3) were found to be the best constituents for the mobile phase. The suitability of this strategy was demonstrated by analysing several self-made triturations in three different botanical matrices, which mimic the influential effects that could be expected when analysing herbal supplements. To conclude, this study demonstrates that chromatographic fingerprinting could provide a useful means to identify plants in a complex herbal mixture.

Adverse Psychiatric Effects Associated with Herbal Weight-Loss Products

Obesity and overeating are among the most prevalent health concerns worldwide and individuals are increasingly using performance and image-enhancing drugs (PIEDs) as an easy and fast way to control their weight. Among these, herbal weight-loss products (HWLPs) often attract users due to their health claims, assumed safety, easy availability, affordable price, extensive marketing, and the perceived lack of need for professional oversight. Reports suggest that certain HWLPs may lead to onset or exacerbation of psychiatric disturbances. Here we review the available evidence on psychiatric adverse effects of HWLPs due to their intrinsic toxicity and potential for interaction with psychiatric medications.

Herbal hepatotoxicity: a critical review

This review deals with herbal hepatotoxicity, identical to herb induced liver injury (HILI), and critically summarizes the pitfalls associated with the evaluation of assumed HILI cases. Analysis of the relevant publications reveals that several dozens of different herbs and herbal products have been implicated to cause toxic liver disease, but major quality issues limit the validity of causality attribution. In most of these reports, discussions around quality specifications regarding herbal products, case data presentations and causality assessment methods prevail. Though the production of herbal drugs is under regulatory surveillance and quality aspects are normally not a matter of concern, low quality of the less regulated herbal supplements may be a critical issue considering product batch variability, impurities, adulterants and herb misidentifications. Regarding case data presentation, essential diagnostic information is often lacking, as is the use of valid and liver specific causality assessment methods that also consider alternative diseases. At present, causality is best assessed by using the Council for International Organizations of Medical Sciences scale ( CIOMS) in its original or updated form, which should primarily be applied prospectively by the treating physician when evaluating a patient rather than retrospectively by regulatory agencies. To cope with these problems, a common quality approach by manufacturers, physicians and regulatory agencies should strive for the best quality. We propose steps for improvements with impact on future cases of liver injury by herbs, herbal drugs and herbal supplements.

Vietnamese traditional medicine from a pharmacist's perspective

Traditional medicine plays an important role in the healthcare system of Vietnam. Vietnamese traditional medicine (VTM) is underpinned by the oriental philosophy and theory of healing. VTM is largely influenced by traditional Chinese medicine, but differs to a certain extent. VTM is largely not evidence-based from a clinical perspective but subclinical research data from the past decades support the traditional use of many herbal VTM drugs. For safe use, knowledge of the occurrence of adverse reactions and herb-drug interactions is necessary. The Vietnamese government supports further development of VTM in a scientific way and integration of VTM with Western medicine. This article first gives an overview of the general aspects of VTM (historical perspective, regulatory aspects, comparison with traditional Chinese medicine, philosophical background, the Vietnamese market situation, quality assurance and formulations), and subsequently focuses on its safe and effective use in Vietnamese clinical pharmacy and medical practice.

Community Pharmacists role in obesity treatment in Kuwait: a cross-sectional study

BACKGROUND

Obesity is a growing health concern in Kuwait. Obesity has been identified as a key risk factor for many chronic diseases including hypertension, dyslipidemia and type 2 diabetes mellitus. It has been shown that community pharmacists' involvement is associated with successful weight management in developed countries. This study was conducted to investigate the role of community pharmacists in obesity counseling, and to identify the barriers to counseling in Kuwait.

METHODS

A descriptive cross-sectional study involved 220 community pharmacies that were selected via stratified and systematic random sampling. A pretested self-administered questionnaire collected information on frequency and comfort level with obesity counseling, and the perceived effectiveness of four aspects of obesity management (diet and exercise, prescribed antiobesity medications, diet foods, and nonprescription products and dietary supplements). Information on perceived confidence in achieving positive outcomes as a result of counseling and barriers to counseling was also collected. Descriptive and Spearman' r analysis were conducted using SPSS version 17. Responses with Likert scale rating 1(low score) to 5 (high score) and binary choices (yes/no) were presented as mean (SD) and (95% CI), respectively.

RESULTS

The response rate was 93.6%. The overall mean (SD) responses indicated that pharmacists counseled obese patients sometimes to most of the time, 3.67 (1.19) and were neutral to comfortable with counseling about aspects of obesity management, 3.77 (1.19). Respondents perceived obesity management aspects to be somewhat effective, 3.80 (1.05). Of the four aspects of obesity management, diet and exercise, and diet foods were the highest ranked in terms of frequency of counseling, comfort level and perceived effectiveness. Pharmacists were neutral to confident in achieving positive outcomes as a result of obesity counseling, 3.44 (1.09). Overall mean responses of counseling obese patients by pharmacists were positively correlated with their perceived comfort with counseling and perceived effectiveness of obesity management aspects. The most anticipated barriers to obesity counseling were lack of patient awareness about pharmacists' expertise in counseling 76.2% (95% CI: 69.7-81.7) and pharmacists' opinions that obese patients lack willpower and are non-adherent to weight reduction interventions 71.8% (95% CI: 65.1-77.8).

CONCLUSIONS

Strengths, weaknesses and barriers related to obesity counseling by pharmacists in Kuwait were identified, and suggestions were provided to strengthen that role.

Continuous reporting of new cases in Spain supports the relationship between Herbalife® products and liver injury

PURPOSE

Previous publications have linked Herbalife® products to hepatotoxicity. The identification of earlier cases in which the culprit agent could not be established raised the hypothesis of a possible contamination of some specific batches of Herbalife products.

METHODS

We searched the Spanish Pharmacovigilance Centres' database of adverse reactions for reports of liver injury associated with the use of Herbalife products from 2003, when the first case was submitted, through September 2010.

RESULTS

The search resulted in 20 reports of liver damage (mean age, 49 years; 16 women), with 12 patients (60%) requiring hospitalization. Hepatocellular damage predominated, and nine (53%) of the hepatocellular cases with bilirubin values were jaundiced, fulfilling the Hy's law criteria, which increases the risk for serious outcomes. Two patients experienced a positive rechallenge. One patient developed cirrhosis, whereas all the others recovered. Causality assessment by the Karch and Lasagna modified algorithm showed a category of definite in 1 case, probable in 14, and possible in 5. Analysis of the different Herbalife products that each patient had taken did not enable us to identify any commonly known hepatotoxic ingredient.

CONCLUSIONS

Our results support the relationship between the consumption of Herbalife products and hepatotoxicity, underscore the concern regarding the liver-related safety of this dietary supplement, and emphasize the need to establish further regulatory measures.

Biological reactive intermediates (BRIs) formed from botanical dietary supplements

The use of botanical dietary supplements is increasingly popular, due to their natural origin and the perceived assumption that they are safer than prescription drugs. While most botanical dietary supplements can be considered safe, a few contain compounds, which can be converted to biological reactive intermediates (BRIs) causing toxicity. For example, sassafras oil contains safrole, which can be converted to a reactive carbocation forming genotoxic DNA adducts. Alternatively, some botanical dietary supplements contain stable BRIs such as simple Michael acceptors that react with chemosensor proteins such as Keap1 resulting in induction of protective detoxification enzymes. Examples include curcumin from turmeric, xanthohumol from hops, and Z-ligustilide from dang gui. Quinones (sassafras, kava, black cohosh), quinone methides (sassafras), and epoxides (pennyroyal oil) represent BRIs of intermediate reactivity, which could generate both genotoxic and/or chemopreventive effects. The biological targets of BRIs formed from botanical dietary supplements and their resulting toxic and/or chemopreventive effects are closely linked to the reactivity of BRIs as well as dose and time of exposure.

Effect of oral intake of capsaicinoid beadlets on catecholamine secretion and blood markers of lipolysis in healthy adults: a randomized, placebo controlled, double-blind, cross-over study

BACKGROUND

In the present investigation we compared blood epinephrine (EPI), norepinephrine (NE), free fatty acids (FFA) and glycerol concentrations in response to a capsaicinoid supplement or placebo in healthy adults before and after acute exercise.

METHODS

Twenty subjects ingested a placebo or supplement (Capsimax, OmniActive Health Technologies; 2 mg capsaicinoids in a microencapsulated matrix) with one week separating conditions. Fasting blood samples were collected during each visit; 30 minutes following a rest period and before placebo or supplement intake (Pre); 2 hours post intake (2 hr); one minute following the cessation of 30 minutes of exercise performed at 65% of maximal heart rate reserve (2.5 hr); 90 minutes following the cessation of exercise (4 hr). Heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressure were recorded at all times.

RESULTS

A time effect was noted for HR, SBP, and DBP (p < 0.05), with HR and SBP higher at 2.5 hr compared to Pre (due to exercise) and DBP lower at 2.5 hr compared to Pre. No interaction or condition effects were noted for EPI, NE, FFA, or glycerol (p > 0.05). However, a time effect was noted for all variables (p < 0.0001), with values higher than Pre at 2.5 hr for EPI and glycerol, at 2 hr and 2.5 hours for FFA, and at 2 hr, 2.5 hr, and 4 hr for NE (p < 0.05). In terms of percent change from Pre, glycerol was higher with Capsimax than for placebo at 4 hr (p = 0.011) and FFA was higher with Capsimax than for placebo at 2 hr (p = 0.025) and at 2.5 hr (p = 0.015).

CONCLUSION

Ingestion of low dose (2 mg) Capsimax was associated with an increase in blood FFA and glycerol at selected times post ingestion, as compared to placebo. However, Capsimax had no differing effect on EPI or NE compared to placebo. Lastly, no difference was noted in HR, SBP, or DBP between placebo and Capsimax.

Effect of the dietary supplement Meltdown on catecholamine secretion, markers of lipolysis, and metabolic rate in men and women: a randomized, placebo controlled, cross-over study

BACKGROUND

We have recently reported that the dietary supplement Meltdown increases plasma norepinephrine (NE), epinephrine (EPI), glycerol, free fatty acids (FFA), and metabolic rate in men. However, in that investigation measurements ceased at 90 minutes post ingestion, with values for blood borne variables peaking at this time. It was the purpose of the present investigation to extend the time course of measurement to 6 hours, and to include women within the design to determine if sex differences to treatment exist.

METHODS

Ten men (24 +/- 4 yrs) and 10 women (22 +/- 2 yrs) ingested Meltdown or a placebo, using a randomized, cross-over design with one week separating conditions. Blood samples were collected immediately before supplementation and at one hour intervals through 6 hours post ingestion. A standard meal was provided after the hour 3 collection. Samples were assayed for EPI, NE, glycerol, and FFA. Five minute breath samples were collected at each time for measurement of metabolic rate and substrate utilization. Area under the curve (AUC) was calculated. Heart rate and blood pressure were recorded at all times. Data were also analyzed using a 2 (sex) x 2 (condition) x 7 (time) repeated measures analysis of variance, with Tukey post hoc testing.

RESULTS

No sex x condition interactions were noted for AUC for any variable (p > 0.05). Hence, AUC data are collapsed across men and women. AUC was greater for Meltdown compared to placebo for EPI (367 +/- 58 pg x mL(-1) x 6 hr(-1) vs. 183 +/- 27 pg x mL(-1) x 6 hr(-1); p = 0.01), NE (2345 +/- 205 pg x mL(-1) x 6 hr(-1) vs. 1659 +/- 184 pg x mL(-1) x 6 hr(-1); p = 0.02), glycerol (79 +/- 8 microg x mL)-1) x 6 hr(-1) vs. 59 +/- 6 microg x mL(-1) x 6 hr(-1); p = 0.03), FFA (2.46 +/- 0.64 mmol x L(-1) x 6 hr(-1) vs. 1.57 +/- 0.42 mmol x L(-1) x 6 hr(-1); p = 0.05), and kilocalorie expenditure (439 +/- 26 kcal x 6 hrs(-1) vs. 380 +/- 14 kcal x 6 hrs(-1); p = 0.02). No effect was noted for substrate utilization (p = 0.39). Both systolic and diastolic blood pressure (p < 0.0001; 1-16 mmHg), as well as heart rate (p = 0.01; 1-9 bpm) were higher for Meltdown. No sex x condition x time interactions were noted for any variable (p > 0.05).

CONCLUSION

Ingestion of Meltdown results in an increase in catecholamine secretion, lipolysis, and metabolic rate in young men and women, with a similar response for both sexes. Meltdown may prove to be an effective intervention strategy for fat loss, assuming individuals are normotensive and their treatment is monitored by a qualified health care professional.