What risks do herbal products pose to the Australian community?

Roger W Byard, Ian Musgrave, Garth Maker and Michael Bunce
Med J Aust 2017; 206 (2): . || doi: 10.5694/mja16.00614
Published online: 6 February 2017


Traditional herbal products are widely used in Australia to treat a broad range of conditions and diseases. It is popularly believed that these products are safer than prescribed drugs. While many may be safe, it is worrying that the specific effects and harmful interactions of a number of their components with prescription medications is not well understood. Some traditional herbal preparations contain heavy metals and toxic chemicals, as well as naturally occurring organic toxins. The effects of these substances can be dire, including acute hepatic and renal failure, exacerbation of pre-existing conditions and diseases, and even death. The content and quality of herbal preparations are not tightly controlled, with some ingredients either not listed or their concentrations recorded inaccurately on websites or labels. Herbal products may also include illegal ingredients, such as ephedra, Asarum europaeum (European wild ginger) and endangered animal species (eg, snow leopard). An additional problem is augmentation with prescription medications to enhance the apparent effectiveness of a preparation. Toxic substances may also be deliberately or inadvertently added: less expensive, more harmful plants may be substituted for more expensive ingredients, and processing may not be adequate. The lack of regulation and monitoring of traditional herbal preparations in Australia and other Western countries means that their contribution to illness and death is unknown. We need to raise awareness of these problems with health care practitioners and with the general public.

  • 1 University of Adelaide, Adelaide, SA
  • 2 Murdoch University, Perth, WA
  • 3 Trace and Environmental DNA Laboratory (TrEnD), Curtin University, Perth, WA


Competing interests:

No relevant disclosures.

  • 1. Coghlan ML, Maker G, Crighton E, et al. Combined DNA, toxicological and heavy metal analyses provides an auditing toolkit to improve pharmacovigilance of traditional Chinese medicine (TCM). Sci Rep 2015; 5: 17475.
  • 2. Ernst E. Toxic heavy metals and undeclared drugs in Asian herbal medicines. Trends Pharmacol Sci 2002; 23: 136-139.
  • 3. Braun LA, Spitzer O, Tiralongo E, et al. Naturopaths and Western herbalists’ attitudes to evidence, regulation, information sources and knowledge about popular complementary medicines. Complement Ther Med 2013; 21: 58-64.
  • 4. Smith RJ, Bertilone C, Robertson AG. Fulminant liver failure and transplantation after use of dietary supplements. Med J Aust 2016; 204: 30-32. <MJA full text>
  • 5. Ernst E. Serious adverse effects of unconventional therapies for children and adolescents: a systematic review of recent evidence. Eur J Pediatr 2003; 162: 72-80.
  • 6. MacLennan AH, Wilson DH, Taylor AW. The escalating cost and prevalence of alternative medicine. Prev Med 2002; 35: 166-173.
  • 7. MacLennan AH, Myers SP, Taylor AW. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. Med J Aust 2006; 184: 27-31. <MJA full text>
  • 8. Xue CC, Zhang AL, Lin V, et al. Complementary and alternative medicine use in Australia: a national population-based survey. J Altern Complement Med 2007; 13: 643-650.
  • 9. Nahin, RL, Barnes PM, Stussman BJ, Bloom B. Costs of complementary and alternative medicine (CAM) and frequency of visits to cam practitioners: United States, 2007 (National Health Statistics Reports No. 18). Hyattsville, Md: National Center for Health Statistics, 2009. (accessed Nov 2016).
  • 10. Chan TYK, Chan JCN. Chinese herbal medicines revisited: a Hong Kong perspective. Lancet 1993; 342: 1532-1534.
  • 11. Brazier NC, Levine MAH. Drug-herb interaction among commonly used conventional medicines: a compendium for health care professionals. Am J Ther 2003; 10: 163-169.
  • 12. Stickel F, Patsenker E, Schuppan D. Herbal hepatotoxicity. J Hepatol 2005; 43: 901-910.
  • 13. Vanhaelen M, Vanhaelen-Fastre R, But P, Vanherweghem J-L. Identification of aristolochic acid in Chinese herbs. Lancet 1994; 343: 174.
  • 14. Pittler MH, Ernst E. Systematic review: hepatotoxic events associated with herbal medicinal products. Aliment Pharmacol Ther 2003; 18: 451-471.
  • 15. Sansom L, Delaat W, Horvath J. Review of medicines and medical devices regulation — stage two. Report on the regulatory frameworks for complementary medicines and advertising of therapeutic goods. Canberra: Australian Government Department of Health, 2015.$File/Review%20of%20Medicines%20and%20Medical%20Devices_Stage%20Two%20Report_Accessible.pdf (accessed July 2016).
  • 16. Reid R, Steel A, Wardle J, et al. Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement Altern Med 2016; 16: 176.
  • 17. Gartoulla P, Davis SR, Worsley R, Bell RJ. Use of complementary and alternative medicines for menopausal symptoms in Australian women aged 40–65 years. Med J Aust 2015; 203: 146. <MJA full text>
  • 18. Peng W, Adams J, Hickman L, Sibbritt DW. Complementary/alternative and conventional medicine use amongst menopausal women: results from the Australian Longitudinal Study on Women’s Health. Maturitas 2014; 79: 340-342.
  • 19. Braun LA, Forrester CA, Rawlins MD, et al. Complementary medicine use by people living with HIV in Australia — a national survey. Int J STD AIDS 2016; 27: 33-38.
  • 20. Clinical Oncology Society of Australia. Position statement. The use of complementary and alternative medicine by cancer patients. Sydney: COSA, 2013. (accessed July 2016).
  • 21. Morgan TK, Williamson M, Pirotta M, et al. A national census of medicines use: a 24-hour snapshot of Australians aged 50 years and older. Med J Aust 2012; 196: 50-53. <MJA full text>
  • 22. Barnes J, McLachlan AJ, Sherwin CMT, Enioutina EY. Herbal medicine: challenges in the modern world. Part 1. Australia and New Zealand. Exp Rev Clin Pharm 2016; 9: 905-915.
  • 23. Huang WF, Wen K-C, Hsiao M-L. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. J Clin Pharmacol 1997; 37: 344-350.
  • 24. Lau KK, Lai CK, Chan AYW. Phenytoin poisoning after using Chinese proprietary medicines. Hum Exp Toxicol 2000; 19: 385-386.
  • 25. Ernst E. Adulteration of Chinese herbal medicines with synthetic drugs: a systematic review. J Intern Med 2002; 252: 107-113.
  • 26. Dasgupta A. Review of abnormal laboratory test results and toxic effects due to use of herbal medicines. Am J Clin Pathol 2003; 120: 127-137.
  • 27. Byard RW. The potential forensic significance of traditional herbal medicines. J Forensic Sci 2010; 55: 89-92.
  • 28. Zhao Z, Yuen JPS, Wu J, Huang W. A systematic study on confused species of Chinese Materia Medica in the Hong Kong market. Ann Acad Med Singapore 2006; 35: 764-769.
  • 29. Leung AY. Traditional toxicity documentation of Chinese Materia Medica: an overview. Tox Pathol 2006; 34: 319-326.
  • 30. Awang DVC. Maternal use of ginseng and neonatal androgenization. JAMA 1991; 266: 363.
  • 31. Gilbert JD, Musgrave I, Hoban C, Byard RW. Lethal hepatocellular necrosis associated with herbal polypharmacy in a patient with chronic hepatitis B infection. Forensic Sci Int 2014; 241C: 138-140.
  • 32. Webb AN, Hardiker W, Cranswick NE, Somers GR. Probable herbal medication induced fulminant hepatic failure. J Paediatr Child Health 2005; 41: 530-531.
  • 33. Skoulidis F, Alexander GJM, Davies SE. Ma huang associated acute liver failure requiring liver transplantation. Eur J Gastroenterol Hepatol 2005; 17: 581-584.
  • 34. Kostakis C, Byard RW. Sudden death associated with intravenous injection of toad extract. Forensic Sci Int 2009; 188: e1-e5.
  • 35. Ernst E. Cardiovascular adverse effects of herbal medicines: a systematic review of the recent literature. Can J Cardiol 2003; 19: 818-827.
  • 36. Ernst E. Serious psychiatric and neurological adverse effects of herbal medicines — a systematic review. Acta Psychiatr Scand 2003; 108: 83-91.
  • 37. Ko RJ. Adulterants in Asian patent medicines. N Engl J Med 1998; 339: 847.
  • 38. Muzi G, Dell’omo M, Madeo G, et al. Arsenic poisoning caused by Indian ethnic remedies. J Pediatr 2001; 139: 169.
  • 39. Moore C, Adler R. Herbal vitamins: lead toxicity and developmental delay. Pediatrics 2000; 106: 600-602.
  • 40. Awang DVC, Fugh-Berman A. Herbal interactions with cardiovascular drugs. J Cardiovasc Nurs 2002; 16: 64-70.
  • 41. Ernst E. Risks of herbal medicinal products. Pharmacoepidemiol Drug Saf 2004; 13: 767-771.
  • 42. Dasgupta A, Bernard DW. Herbal remedies. Effects on clinical laboratory tests. Arch Pathol Lab Med 2006; 130: 521-528.
  • 43. Izzo AA, Ernst E. Interactions between herbal medicines and prescribed drugs: a systematic review. Drugs 2001; 61: 2163-2175.
  • 44. Ernst E. The efficacy of herbal medicine: an overview. Fund Clin Pharmacol 2005; 19: 405-409.
  • 45. Hu Z, Yang X, Ho PCL, et al. Herb–drug interactions: a literature review. Drugs 2005; 65: 1239-1282.
  • 46. Lau WC, Welch TD, Shields T, et al. The effect of St John’s wort on the pharmacodynamic response of clopidogrel in hyporesponsive volunteers and patients: increased platelet inhibition by enhancement of CYP3A4 metabolic activity. J Cardiovasc Pharmacol 2011; 57: 86-93.
  • 47. Ang-Lee M, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001; 286: 208-216.
  • 48. Thakor V, Leach MJ, Gillham D, Esterman A. The quality of information on websites selling St. John’s wort. Complement Ther Med 2011; 19: 155-160.
  • 49. Bensoussian A, Lee S, Murray C, et al. Choosing chemical markers for quality assurance of complex herbal medicines: development and application of the Herb MaRS criteria. Clin Pharmacol Ther 2015; 97: 628-640.
  • 50. Therapeutic Goods Administration. Listed complementary medicine compliance reviews [website]. Mar 2015. (accessed May 2016).
  • 51. Sansom L, Delaat W, Horvath J. Expert review of medicines and medical devices regulation. Recommendations. Australian Government Department of Health, 2015.$File/Review%20of%20Medicines%20and%20Medical%20Devices%20-%20Recommendations_Accessible.pdf (accessed May 2016).
  • 52. Gao W, Yang H, Qi LW, et al. Unbiased metabolite profiling by liquid chromatography-quadrupole time-of-flight mass spectrometry and multivariate data analysis for herbal authentication: classification of seven Lonicera species flower buds. J Chromatogr A 2012; 1245: 109-116.


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