Whats Wrong With These Results?

Amitava Dasgupta, Ph.D, DABCC Professor of Pathology and Laboratory Medicine University of Texas-Houston Medical School

Alternative Medicine: Unexpected Lab Values

Alternative medicines can interfere with clinical laboratory tests. This interference can be either positive or negative. Alternative medicines can cause pharmacological effects or toxicity leading to unexpected lab values. Alternative medicines may interact with therapeutic drugs. Alternative medicines may be adulterated with Western drugs.

Alternative (Herbal) Medicines

Interference in clinical laboratory testing due to direct interference with immunoassays.

Digoxin and Chan Su

One

woman died after taking herbal tea containing Chan Su. She never took digoxin or digitoxin. Her apparent serum digoxin level was 4.9 ng/ml as measured by Fluorescence Polarization Immunoassay (Abbott Laboratories).
Ko et al. West Med J 1996;43: 34-40

Chan Su
Chan

Su is a traditional Chinese medicine prepared from skin glands of Chinese toads. It is used in treating heart diseases as Chan Su can stimulate myocardial contraction. Chan Su contains bufalin which has structural similarity with digoxin. Bufalin is also toxic in animal models.

Structure of Active Components of Chan Su

Chan Su and Digoxin Assay

CLIA: Chemiluminescent Assay (Bayer)
4.5 4

Digoxin, ng/ml

3.5 3 2.5 2 1.5 1 0.5 0 Pool 1FPIA Pool 1 MEIA Pool 1 CLIA

ml of Chan SU added to per ml of Digoxin pool

Dasgupta et al. Am J Clin Pathol 2000;114: 174-179

1.5

3.5

Elimination of Interference

Chan Su interference eliminated by monitoring free digoxin 3.5

Digoxin, ng/ml (FPIA)

3 2.5 2 1.5 1 0.5 0 0 1 2 3.5 5 Total Dig Free Dig

ml of Chan Su added to per ml of digoxin pool

Digoxin and Herbal Medicines

Herbal

medicines potentially interfering with digoxin immunoassays:

Chan

Su Lu-Shen-Wan Danshen Siberian and Asian Ginseng Uzara Roots

Lu-Shen-Wan and Digoxin

Lu-Shen

Wan is another Chinese medicine that contains bufalin. Apparent digoxin activity of 0.88 ng/ml was reported in a volunteer who took one Lu-Shen-Wan Pill. Lu-Shen-Wan interference: Eliminated by monitoring free digoxin
Panesar NS. Clin Chem 1992;38: 2155-2156.

Siberain Ginseng and Digoxin

74

year old male with a therapeutic digoxin level of 0.9-2.2 ng/ml for 10 years presented with a digoxin level of 5.2 ng/ml but showed no evidence of digoxin toxicity. He was taking Siberian ginseng. After discontinuing Siberian ginseng his digoxin level returned to 0.9 ng/ml.
McRae. Can Med Assoc J 1996;155:293-295

Siberian Ginseng: Our Experience

We tested three different Siberian ginseng for potential digoxin-like activity (Sundown, Root to Health, ZT Universal, Shanghai) Analytical methods included:

FPIA, MEIA, EMIT 2000, Randox Digoxin, Beckman, chemiluminescent assay (Bayer).

Two preparations showed modest activity with the FPIA assay in vivo in mice after feeding with Siberian ginseng:

Asian Ginseng and Digoxin

Although both Asian and Siberian ginseng are imported from Asia, the two are chemically distinct:

Asian ginseng is prepared from Panax ginseng root Siberain ginseng is prepared from Eleutherococcus senticosus.

One Asian ginseng (Song Shiu, Shanghai) out of the three products studied also showed modest interference with the FPIA digoxin after feeding in mice.

In Vivo Digoxin Activity in Mice

Herb

Fed Before* Asian Ginseng (Song) ND Asian Ginseng (Song) ND Siberian (ZT) ND Siberian (ZT) ND Siberian (Sundown) ND Siberian (Sundown) ND

After* 0.68 0.50 0.47 0.32 0.26 0.21

*Fluorescence polarization assay (Abbott Laboratories) used

Ginsengs and Digoxin

1.6 1.4 1.2 1 Pool Digoxin, ng/ml 0.8 0.6 0.4 0.2 0 FPIA MEIA EMIT Randox CLIA AG SG

FPIA

MEIA

EMIT

Randox

Bayer

Dan Shen
Dan

Shen is a traditional Chinese medicine prepared from roots of Salvia miltiorrhiza. Dan Shen is used as a heart tonic. More than 20 diterpene quinones known as Tanshinones have been isolated from Dan Shen. These compounds have structural similarity with digoxin.

Dan Shen and Digoxin Assay

1.6 1.4

Digoxin, ng/ml

1.2 1 0.8 0.6 0.4 0.2 0 FPIA MEIA CLIA EMIT Dig Pool +25ulDS +50ulDS

Dasgupta et al Clin Chimica Acta 2002;317:231-234.

Dan Shen: In Vivo Results

Mouse

Apparent Digoxin, ng/ml

Before ND ND ND ND ND ND 1h After 2h After 0.20 0.46 0.23 0.54 ND 0.26 ND 0.36 0.20 0.45 0.21 0.41

Dose:50 mg/Kg

1 2 3 4 5 6

Dasgupta et al. Clin Chimica Acta2002;317:231-234.

Herbs and Digoxin assays.

Drug free serum supplemented with extract of different herbs. Specimen FPIA Chan Su 4.9 ng/ml Lu-Shen-Wan 3.5 ng/ml Dan Shen 0.67 ng/ml Asian Ginseng 0.46 ng/ml Siberian Ginseng 0.32 ng/ml

Herbs and Digoxin Assay

Herb

Interference
High Moderate to High Moderate Low to Moderate Low to Moderate

Chan Su Lu-Shen-Wan Dan Shen Asian Ginseng Siberian Ginseng

Elimination of Interference of Herbs in Digoxin Assays by Measuring Free Dig

Herb Chan

Protein Binding Free Digoxin 80-90% 70-80% 35-45% 30-40% Yes Yes No No

Su Dan Shen Asian Ginseng Siberian Ginseng

Datta P, Dasgupta A. Ther Drug Monit (in press)

Elimination of Interference
EMIT

2000, Randox, Roche, Beckman and Bayer digoxin assays are free from interference by Dan Shen, Asian Ginseng and Siberian Ginseng. Only FPIA and MEIA are affected. All assays except Bayer showed interference with Chan Su and Lu-ShenWan.

Alternative (Herbal) Medicine

Unexpected test results due to pharmacological effect or toxicity directly related to the use of herbal medicine.

Herbs and Abnormally Low Glucose

Herbal Product causing Hypoglycemia
Ginseng Decreased glucose Garlic Ginger Decreased glucose Nettle Chromium Decreased glucose Often found in weight loss products Decreased glucose

Herbs and Bilirubin

Herbal Product causing hyperbilirubinemia
Coptis chinensus/japonicum cause neonatal jaundice Contains berberine Chuen-Lin Artemisia scoparia Wormwood, Green Giger Goldenseal (berberine) Displaces bilirubin from albumin

Chan E. Biol Neonate 1993;63: 201-208.

Licorice (Glycyrrhizin) and Hypokalemia

Licorice

usually induce hypertension. However, 59 cases of licorice induced hypokalemic myopathy have been reported. mean serum potassium - 1.98 mEq/L total CK - 5385 U/L plasma renin activity - 0.17 ng/ml/h (low) 57 patients recovered after stopping Shintani et al. Eur Neurol 1992;32:44-51 licorice.

Alternative (Herbal) Medicine

Interactions between therapeutic drugs and herbals can lead to unexpected low drug levels in patients who were previously therapeutic.

Phenytoin, Phenobarbital and Herbs

Reduced seizure threshold EEvening primrose oil Reduced serum and borage oil both drug concentrations reduce seizure threshold of phenobarbital. SShankhapushpi reduces seizure threshold of phenytoin.
Fugh-Berman. Lancet 2000;355:134-138

St Johns Wort

A 32 year old female 3 year post kidney transplant showed a sub-therapeutic FK 506 (tacrolimus) level of 3.5 ng/ml. Her previous level was 8.3 ng/ml. Repeat testing with a fresh specimen next day (2.9 ng/ml) confirmed the previous result. The patient had started taking St. Johns Wort; 300 mg capsules (0.03% hypericin, Natures Way) tid, ~8 weeks earlier.

Drug Interactions: St Johns Wort

Decreased

serum drug concentrations

metabolism/transport:

carbamazepine, cyclosporine, tacrolimus, HIV protease inhibitors (indinavir, nevirapine), simvastatin, theophylline, amitriptyline, ethinyl estradiol/desogestrel, digoxin, warfarin decreased absorption: iron
Serotonin
SSRIs

excess

(sertaline, paroxetine, nefazodone)

St Johns Wort
CYP3A hyperforin: pregnane X receptor ligand species and organ specific expression / activity
human:

CYP3A4 (hepatic/intestinal) rat: hepatic 3A2 (not intestinal 3A2)

Hennessy. Br H Clin Pharmacol 2002;53:75-82 Durr. Clin Pharmacol Ther 2000;68:598-604 Roby. J Clin Psychopharmacol 2001;21:530-2

St Johns Wort
P-glycoprotein/MDR1 expression / activity
human:

intestinal, hepatic, PBMC rat: intestinal, PBMC (not hepatic) enhanced drug efflux function

rhodamine 123 (PBMCs)

Hennessy. Br H Clin Pharmacol 2002;53:75-82 Durr. Clin Pharmacol Ther 2000;68:598-604 Roby. J Clin Psychopharmacol 2001;21:530-2

Oral Anticoagulants and Herbs

Ginseng,

Danshen, Garlic, Ginkgo Biloba, Garlic, Ginger, Devils Claw, Red Clover and Horse-Chestnut inhibit platelet activity and interfere with extrinsic coagulation pathway. These herbs should be avoided by all patients on warfarin therapy because of the possibility of excessive bleeding.
Miller. Arch Int Med 1998;158:2200-2211

Herbs and Bleeding

Herbs and Abnormal Coagulation Tests platelet aggregation decreased coagulation pathways

Garlic Bleeding Warfarin

Ginger Bleeding Warfarin

Ginkgo Bleeding Warfarin

Ang-Lee and Yuan. JAMA 2001;286:209-216

Dan Shen and Warfarin

Mitral valvuloplasty was performed in a 48 year old female and her INR (international normalization ratio) was 1.5-3.0 (Warfarin dose: 2.5-3.5 mg). She later came to ER. Her coagulation tests were abnormal (PT:>60 s, PTT >120 s, INR 5.62). She was taking Dan Shen causing over-anticoagulation. Dan Shen was discontinued and her coagulation tests returned to normal again (INR:2.5).

Herbs and Surgery

Herbal

Products Effects Garlic, Ginkgo,Ginseng Bleeding Ma Huang, Ephedra Cardiovascular Ginseng Hypoglycemia Kava-Kava, Valerian Prolonged Sedative effect of Anesthetics
Ang-Lee et al JAMA 2001;286:208-216.

Alternative (Herbal) Medicine

Unexpected results due to contamination of herbal products with Western medicines

Chinese Herbs Contaminated with Phenytoin

A patient never on phenytoin was admitted with a phenytoin level of 48.5 mg/ml. The patient was taking valproic acid and carbamazepine but never took phenytoin. However she was taking Chinese herbs (Jue Dian Shen Wan, Nang San Hao, etc). Toxicological analysis confirmed the presence of phenytoin in these two preparations.
Lau et al. Human Exp Toxicol 2000;19:385-386.

Herbal Medicine: Sulfonylurea

A 56 year old male presented to ER with severe hypoglycemia. Despite treatment, hypoglycemia did not improve.

Glucose: 37.8 mg/dL to 52.2 mg/dL.

He was taking Chinese medicine ZhenQi for Type II diabetes. On analysis sulfonyluria (glibenclamide) was found in the herb.

Goudie and Kaye MJA 2001;175:256-257.

Herb and Aplastic Anemia

A 12 year old boy was brought to ER for rash and gum bleeding. His hemoglobin was 8 gm/dL, platelet count 5000/ml. His mother gave him Gan Mao Tong Pian for pain and fever a week ago. Bone marrow biopsy confirmed aplastic anemia. The boy survived after five months of therapy. The herb contained phenylbutazone.
Nelson et al Clin Toxicol 1995;33:467-470.

Herbs and Contamination

Western

drugs like acetaminophen, caffeine, indomethecin, prednisolone, digoxin, phenytoin, phenylbutazone, and hypoglycemic agents have been found in herbal preparations.

Huang Wf et al J Clin Pharmacol 1997;37:344-350

Conclusions

Unexpected digoxin results may be due to ingestion of Chinese herbs. Digoxin levels may be falsely high or low!

Unexpected low levels of therapeutic drugs may occur due to use of St. Johns Wort.
Patients taking drugs with narrow therapeutic ranges should not use any herbal products.

Conclusions
Abnormal

coagulation tests may occur due to use of garlic, ginger, ginkgo etc. results may be related to contamination of herbals with Western medicines.

Unexpected

Amitava Dasgupta: E-mail: Amitava.Dasgupta@uth.tmc.edu