Aristolochic acid, AA, is found in a number of herbs that have been used medicinally since antiquity, including many still used today in Traditional Chinese Medicine (TCM) and Ayuvedic medicines of India.
Because AA was believed to have anti-inflammatory properties the German pharmaceutical industry used it to develop drugs in the 1960’s and 70’s. This effort ended in the early 1980s, when researchers discovered that AA was a powerful carcinogen in rats.
Scientists now know that AA is a potent human nephrotoxin (kidney poison) and human carcinogen, causing chronic kidney disease (CKD) and cancers of the upper urinary tract (UUC).
The dual toxicities of AA were highlighted in the 1990’s when operators of a high end spa in Belgium incorporated traditional Chinese herbal remedies into their weight-loss program. Over 100 otherwise healthy women developed CKD, requiring lifelong hemodialysis or kidney transplantation. Several of the women died.
Similar cases appeared in other countries throughout the world including the US.
Alerted by this development, scientists investigated.
Endemic (Balkan) nephropathy (EN) caught their eye, an illness that initially presents with mild symptoms, advancing progressively to chronic renal failure. Upper urinary tract cancer is also strongly associated with EN.
EN occurs only in farming villages in the Balkan countries of Bosnia, Bulgaria, Croatia, Romania and Serbia located near the tributaries of the Danube River. It was first noticed in the late 1950s. Although it often occurs in members of the same family, it is not inherited. Those who develop EN do so after living for a period of time in one of the villages where it is endemic. Scientists searched unsuccessfully for its cause for 50 years. When they noticed the marked similarities between it and aristolochic acid nephropathy (AAN), they hypothesized that aristolochic acid might be the causative agent of EN.
Investigating further, they discovered that Aristolochia clematitis, a plant native to the area where people suffered from EN, grew in local wheat fields and that the seeds were commingled with wheat grain used by local residents to bake bread, a staple of their diet. Being scientists they conducted experiments which showed that AA is a major factor in the development of EN and the associated urothelial cancer.
Knowing that Aristolochia had been used as herbal medicines for centuries throughout the world, the scientists wondered whether or not AA had in the past and was still causing chronic kidney disease and upper urinary tract cancer in individuals who routinely use TCM.
To explore this possibility, the scientists turned to Taiwan which has the highest incidence of UUC of anywhere in the world and where Aristolochia remedies are extensively used. By conducting a molecular epidemiologic study, they concluded that AA “contributes significantly to the incidence of UUC in Taiwan, a finding with significant implications for global public health”.
There was an excellent review of the journal article in Science Daily, much better than mine. If you want to read it, go here: http://www.sciencedaily.com/releases/2012/04/120409164305.htmScience.
Then search for “aristolochic acid”, “April 9, 2012”, “Study Links Toxic Component in Herbal Remedies To Kidney Failure And Cancer”.
Two quotes from Science Daily,
“We believe our latest research highlights the importance of a long-overlooked disease that affects many individuals in Taiwan, and, by extension, in China and other countries worldwide, where Aristolochia herbal remedies traditionally have been used for medicinal purposes,” stated Arthur Grollman, MD of Stony Brook University in NY.
“Marc De Broe, University of Antwerp, an investigator not associated with the study says, ‘From a group of fewer than 200 patients in Belgium, and a geographically confined rural population in the Balkans, the circle of cancer risk due to AA exposure has now grown to potentially global proportions.’”
What other herbal medicines and other “natural remedies” that have been used for centuries have and continue to cause debilitating and potentially fatal diseases? Since very few if any have ever been tested for safety and, in the US, the Dietary Supplement and Health Act (DSHEA) makes such testing unnecessary, we won’t know unless or until something dramatic catches the attention of scientists again.
That is the heart of the matter, the difference between evidence-based medicine and the alternative or folkloric kind. The former investigates and does its best to get the facts. It objectively tests its beliefs, hypotheses, to see if they are correct. The latter believes and assumes, evidence be damned.
While you very definitely can be injured and killed by approved drugs and practitioners of evidence-based medicine and while there definitely may be folk remedies out there that offer major benefits that outweigh the risks they pose even though they have yet to be scientifically shown to be safe and beneficial for specific indications, the only way to substantially increase the odds, the risk/benefit ratio, in your favor is to use evidence-based medicine and avoid the alternatives or folkloric kinds like the plague unless you have nothing left to lose.
As a person who was injured early in life by an incompetent MD who didn’t know enough to look at the evidence, maybe now you can see why alternative medicine and its practitioners terrify me, especially those like NDs who are lobbying hard and successfully to convince the public and politicians that they practice evidence-based medicine when that isn’t true. Maybe now you understand why my fear that they are using “remedies” as lethal as cigarettes that will cause many premature deaths before anyone realizes it are justified. Maybe now you will understand why I put such a high value on evidence-based medicine although I respect the right of adults to use belief-based systems of medicine as long as they are honest and don’t insist that they are evidence-based when they are not. Maybe now you will understand why I am so upset by NDs who insist that they have the equivalent educations of MDs who believe in and practice evidence-based medicine while NDs routinely use folk medicine, remedies and “dietary supplements” before they are ever objectively, much less scientifically, evaluated for safety and efficacy. Maybe now you will understand why I think they are playing Russian roulette with the health and lives of their patients.
There are presently 7 accredited naturopathic schools in North America, 5 in the US and 2 in Canada, whose degrees permit people to be licensed as “primary care physicians” in several states and provinces.
Some of those schools also offer degrees in Chinese Medicine.
Many NDs incorporate it and Ayuvedic medicine into their practices. They also study “botanical medicine” in their schools and use it in their practices even though little of it has ever been scientifically evaluated for safety and efficacy.
NDs believe that a long history of use demonstrates safety and that practitioners over the centuries have learned by experience and observations which remedies work and are safe whereas scientists have learned through extensive investigations and testing that the only accurate way to evaluate the safety and efficacy of a drug or therapy is through the use of objective, scientific tests. What they just discovered about AA in Taiwan is one more example of the things that have led them to this conclusion over the years.
As one ND so elegantly puts it, “Naturopathic Medicine is a distinct approach to wellness which integrates modern science-based knowledge with traditional Western and Eastern diagnostic and treatment methods.” http://www.drhaff.com/Naturopathic-Medicine.html.
What she and her colleagues don’t understand is that when they choose to routinely practice medicine that is supported by solid evidence along side of that which is not, they are not practicing scientific or evidence-based medicine. They are simply choosing what they like, what fits into their philosophy or system of belief and using it on unsuspecting people. What they seem to like the most in scientific medicine is the technology, the image, the white coats, stethoscopes, needles, diagnostic equipment. Well, that is the impression I’ve gotten from listening to them and reading their websites. They’ve missed the heart of the matter, the need to objectively test their beliefs about the safety and efficacy of drugs and therapies to see if they are correct before using them. And that is what terrifies me.
aristolochic acid, Chinese Traditional Medicine, Ayuvedic, alternative medicine, naturopaths, folk medicine, oriental medicine, NDs, deadly medicine
Wow, so informative article, thank you very much for all these links, very cognitive
ReplyDeleteYou are missing the point. AA is toxic in high doses, and can therapeutic in proper dosages, that is why it has been (and it continues to be) used in traditional medicine. The only difference between medicine and poison is the dosage, not the substance, this is at the root of the work greek word pharmakon (which meant both poison and medicine, for even 3000 years ago the greeks understood the differnce was only a matter of dosage) This is not just the case for AA it is the case for *all* medicines, literally. Any medicine in the pharmacy will be become poisonous in high enough dosages, including aspirin which is fairly toxic in moderate doses. If people´s water supplies were accidentally dosed with aspirin (like the bread was with AA in the Balkans) and they didn´t know, and kept drinking many people would die as well. Would you write an article against aspirin then? You are mistaking toxic doses which are a result of accidents (in every case, including the chinese herbal suplements) for something else.
ReplyDeleteJerónimo, please give me references to the toxicology studies that show what the toxic dose of AA is and to studies done by scientists showing that AA offers benefits, what those benefits are and what the dose is that provides those benefits.
ReplyDeleteIn order to convince me that your claims of efficacy are correct, I will have to see a large number of studies done by reputable scientists which consistently give the same results. And in order to convince me that someone knows what a safe dose is, I will have to see toxicology studies done in humans. Based on the evidence already in, I doubt that anyone could ethically do such studies now, unless, of course, they could present overwhelming objective evidence that AA offered benefits that far outweighed those risks.
The difference between evidence-based medicine and the alternative or folkloric kind is that the former doesn't assume that something is true or false. It obtains objective evidence which it draws conclusions from. The latter assumes without testing first to see if its assumptions are correct. Most often they are not.
Incidentally, the government of Taiwan seems to disagree with your assumptions about the safety and efficacy of AA. It banned it, http://www.cmjournal.org/content/3/1/13, although testing has found that some CHP used there still contain it.
Just here from HuffPo. Excellent post, I'll look at the others.
ReplyDeleteComment to Jerónimo:
If the dose needs to be controlled, why is this not done in herbs. Not knowing that something is toxic is barely acceptable, knowing it is toxic and not doing anything about it is inexcusable.
Acleron, be sure to check here: http://rosemaryjacobs.com/naturopaths.html
ReplyDeleteIt's the reason I started my blog.
And prescription drugs aren't nephrotoxic? "Drugs cause approximately 20 percent of community-and hospital-acquired episodes of acute renal failure.1–3 Among older adults, the incidence of drug-induced nephrotoxicity may be as high as 66 percent."
ReplyDeletehttp://www.aafp.org/afp/2008/0915/p743.html
Why is it that when alt med fans who believe that their drugs and therapies are safe are presented with evidence showing that they are not can’t honestly admit that to themselves and their potential victims? Why do they totally ignored the danger and start screaming that pharmaceuticals injure and kill people, something no one who knows anything about pharmaceuticals has ever denied. Actually, the opposite is true. Practitioners of evidence-based medicine routinely point out the risks of the drugs and therapies they use while alt. practitioners routinely insist that theirs are safe even when there is absolutely no way to know that because they haven’t been adequately studied.
ReplyDeleteThe information on drug toxicity is available because drugs must be well studied before they are sold and then closely followed after they hit the market to see if once used by the general population problems not seen in test subjects appear.
ReplyDeleteBefore drugs can be sold, manufacturers have to do studies showing that they offer benefits, the dose that offers the benefits and the dose that is toxic to the average person. With that information doctors and patients can make informed choices as to whether or not the benefits of taking them outweigh the risks.
With "natural" drugs, remedies and supplements, no such studies are required before they are sold so that people cannot make informed decisions about their use. Taking them is like playing Russian roulette with you life and health. I suspect that the women who took AA to lose weight would never have done so if they had realized the risks involved, but because the botanicals hadn't been adequately studied, they didn't have a clue about how dangerous they were.
Life is not risk free. There is no way to be certain that you will always benefit from a substance and never be injured or harmed by it. However, the best way to increase the odds in your favor is to appropriately use adequately studied substances and not those that are untested. And it is about time that proponents of "alt" remedies stopped trying to convince everyone that their "natural" drugs are safe when either they have no evidence to support that.
ReplyDelete