Aristolochic Acids Detected in Some Raw Chinese Medicinal Herbs And

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ARTICLELCLT Aristolochic Acids Detected in Some Raw Chinese Medicinal Herbs and Manufactured Herbal Products – A Consequence of Inappropriate Nomenclature and Imprecise Labelling?

ThomasAristolochic Acids in Some Raw Chinese P. Medicinal HerbsCheung, M.Sc. and Charlie Xue, Ph.D. The Chinese Medicine Research Group, Division of Chinese Medicine, RMIT University, Australia Kelvin Leung, Ph.D. and Kelvin Chan, Ph.D. Research and Development Division, School of Chinese Medicine, Hong Kong Baptist University, HKSAR Chun G. Li, Ph.D. The Chinese Medicine Research Group, Division of Chinese Medicine RMIT University, Australia

aristolochic acids. The confusion in Chinese nomenclature for Background. Certain frequently used Chinese herbal medi- related raw herbs, and imprecise labelling of manufactured prod- cines commonly used for weight control, may contain toxic Aris- ucts may contribute to the inadvertent use of toxic herbal species tolochia species, which have been associated with severe in Chinese medicine practice. Additional measures are needed to nephropathy and urothelial cancer in humans and animals. The ensure the safety of consumers of Chinese herbal medicines. toxic entities in Aristolochia species are aristolochic acid-I (AA-I) and aristolochic acid-II (AA-II). There is a lack of systematic Keywords Aristolochic acid; Chinese herbs; Traditional Chinese For personal use only. information about the aristolochic acid content of Aristolochia medicine; Herbal medicine toxicity species and related genera, including those in Chinese materia medica that are used in the treatment of overweight individuals. Objectives. To determine the content of AA-I and AA-II of commonly used Chinese herbal medicines (raw herbs and manufac- INTRODUCTION tured products) including species of Aristolochia and related In the early 1990s, a weight management clinic in Belgium genera. Methods. Twenty-one raw herbs and seven manufac- formulated a product intended for weight control which con- tured herbal products were purchased from herbal wholesalers and traditional Chinese medicinal herb retailers in Melbourne, tained two Chinese herbs. One of the herbs specified for the Australia in September 2003, after the supply of known aris- product was Stephania tetrandra (Chinese name: Han Fang Ji), tolochic acid-containing herbs and products had been banned in which does not contain aristolochic acids; however, instead of Australia. Six additional raw herbs were sourced from a herbal this species, another was incorporated into the product, Aristolo- teaching museum. These were purchased in 2001, before the pro-

Clinical Toxicology Downloaded from informahealthcare.com by University of Minnesota on 10/17/11 chia fangchi (Chinese name: Guang Fang Ji), which contains hibition. The contents of aristolochic acids of each was determined by high pressure liquid chromatography (HPLC), and aristolochic acids. The unfortunate result of the misformulation confirmed by liquid chromatography–mass spectrometry (LC– was that, in a relatively short time, a substantial number of users MS). Results. Of the samples tested, four of the raw herbs pur- of the product suffered serious renal toxicity. The first occur- chased before the ban and two manufactured products purchased rences were in 1993, when three female users developed sub- after the ban, were found to contain aristolochic acids (16–1002 acute interstitial fibrosis of the kidney (1), and by 1995 ppm). Conclusions. Several Chinese raw herbs and some commercially available manufactured herbal products contain approximately 100 female users had developed severe renal fail- ure, about one-half of whom required a renal transplant (2). The toxic syndrome, which was referred to as “Chinese herb nephr- Received 1 July 2005; accepted 5 October 2005. opathy” was allegedly due to the aristolochic acids present in Address correspondence to Chun G. Li, Ph.D., RMIT Chinese Medicine Research Group, Division of Chinese Medicine, RMIT Aristolochia fangchi. In 1999, two cases of aristolochic acid- University, GPO Box 71, Bundoora 3083 Vic Australia. E-mail: related nephropathy were reported in the United Kingdom (3). In [email protected] both cases, there was extensive atrophy of cortical tubules and

371 372 T.P. CHEUNG ET AL.

interstitial fibrosis. The Chinese herb involved was identified as 27 herbs studied are classified as diuretics, purgatives or anti- Aristolochia manshuriensis (Chinese name: Guan Mu Tong), rheumatics (11), and some of them are often used clinically for which is used for the treatment of eczema. weight control. The seven manufactured products (Table 2) In addition to the herbs mentioned above, aristolochic acids were also collected because according to their labels, they con- have been reported to be present in other herbal species, such tain either Fang Ji, Mu Tong or Xi Xin as part of their formu- as, Asarum splendens, Asarum himalaicum (Chinese name for lae. All herbal samples were ground into powder and stored in both: Xi Xin) (4), and Aristolochia contorta (Chinese name: containers at 4°C for subsequent analysis. Ma Dou Ling) (5). Moreover, there have also been reports of toxicity linked to medicinal herbs containing aristolochic acids from China (6), Japan (7), and Taiwan (8). In some countries, Sample Extraction such as Australia and the United States, the supply of herbal Each herbal sample (1 g of powder) was extracted with products in which aristolochic acid has been detected is prohib- 34 ml of methanol twice under high pressure at 100°C using an ited by therapeutic regulatory authorities (9,10). This prohibi- Accelerated Solvent Extractor ASE-100 (Dionex, Australia); tion also applies to manufactured products that contain any the solvent then evaporated under vacuum in a rotary evapora- such herbs in their patent formulae. tor. The residue was dissolved in 1 ml of methanol and filtered Although the supply of aristolochic acid-containing herbs is through a polytetrafluoroethylene syringe filter (0.2 μm pore banned in certain countries, it is probable that users of CHM, size) (Altech, Australia). even in these countries, may be at risk of exposure to aristolochic acids. Contributing substantially to this risk is the possibility of misidentification of herbal species and of inadvertent Analysis of Aristolochic Acid by HPLC or intentional substitution of herbs in herbal formulae. In The amounts of AA-I and AA-II in the methanol extracts regards to misidentification, many botanically-related species were determined by a modified HPLC method (5) using a Shi- of medicinal herbs have the same or similar Chinese pharma- madzu liquid chromatograph LC 10AD (Shimadzu, Australia) ceutical names, which can lead to errors in prescribing, formu- under the following conditions: column, LiChrospher 100 RP- lation and supply. The situation is further complicated by the 18 reverse-phase, 5 μm, 25 × 0.5 cm I.D. (Supelco, Australia); fact that different species of herbs in their raw state may have mobile phase, a mixture of 0.3% ammonium carbonate solu- similar macroscopic characteristics. Identification of herbal tion and acetonitrile (75:25, v/v, pH 7.5); flow rate, 0.8 ml/min. species is even more difficult after even minimal processing, The detector, a photo-diode-array UV detector, was set at 251 such as thin slicing or drying. In order to assess the extent of nm. Aliquots of 20 μl of the methanol extract and of AA-I and the risk to users of CHM being exposed to aristolochic acid- AA-II standards dissolved in methanol were injected. AA-I and For personal use only. containing herbs, we conducted a study in which we analysed AA-II were identified by their retention times (AA-I = 8.6 min, 27 commonly used Chinese raw herbs and seven popular AA-II = 6.6 min). The total run time was 12 min. The recover- Chinese manufactured herbal products for the presence of aris- ies of the aristolochic acids were determined by spiking 1 g of tolochic acids. The findings of the study give rise to serious Poria cocos (Chinese name: Fu Ling), which does not contain concern for public safety. AA, with various amounts of AA-I and AA-II. All herbal samples were analysed in duplicate. Recovery determinations for each level of AA-I and AA-II were performed in triplicate. The METHODS recovery of both AA-I and AA-II ranged from 88% to 94%. Calibration curves for AA-I and AA-II were established Herbal Materials using methanol solutions of a standard mixture of aris- Twenty-one dried raw herbs (Table 1) and seven manufac- tolochic acids consisting of (w/w) 40% AA-I and 56% AA- Clinical Toxicology Downloaded from informahealthcare.com by University of Minnesota on 10/17/11 tured products were purchased by a method of convenient sam- II (Sigma-Aldrich, Lot: 092k1249). A stock solution of the pling based on traditional Chinese medicine theory in mixture was prepared by dissolving 12.5 mg of the mixture September 2003 from two local herbal wholesalers in Victoria, in 25 ml of methanol (HPLC grade, Aldrich-Sigma). A Australia. Another six raw herbs, Stephania tetrandra (Han range of dilutions of the stock solution was chromato- Fang Ji), Aristolochia fangchi (Guang Fang Ji), Clemantis graphed to construct standard curves for AA-I and AA-II armandii (Chuan Mu Tong), Aristolochia manshuriensis (quadratic fit) over range of 10–280 ppm. The correlation (Guan Mu Tong), Asarum herba (Xi Xin), and Aristolochia coefficient for each standard curve was greater than 0.99. contorta (Ma Dou Ling), were supplied by the herbal teaching The peaks for AA-I and AA-II were well separated with museum of the Division of Chinese Medicine, RMIT Univer- good peak sharpness, symmetry and resolution, as shown in sity. These six herbs were purchased from the same wholesalers Figure 1. AA-I and AA-II in test samples were identified in 2000 to be used for display only prior to prohibition of their from chromatographic peaks corresponding to the retention sale by the Australian Therapeutic Goods Administration (TGA) times of reference standards and were quantified from sam- in July 2001. From a Chinese herbal medicine perspective, the ple/reference peak area ratios. ARISTOLOCHIC ACIDS IN SOME RAW CHINESE MEDICINAL HERBS 373

TABLE 1 Levels of aristolochic acids (AA-I and AA-II) in samples from the three pharmacological classes of raw herbs Herbal Sample Level (ppm) Botanical name Common Chinese name AA-I AA-II AA-I + AA-II Diuretics Aristolochia manshuriensis Guan Mu Tong 41 – 41 Clematis armandii Chuan Mu Tong –– – Aucklandia lappa Decne Mu Xiang –– – Aristolochia contorta Bge. Ma Dou ling 195 33 228 Poria cocos (Schw.) Wolf Fu Ling –– – Pyrrosia lingua (Thunb.) Farw Shi Wei –– – Dioscorea hypoglauca Palif. Bei Xie –– – Coix lachryma jobi L. Yi Yi Ren –– – Plantago asiatica L. Che Qian Zi –– – Polyporus umbellatus (Pers.) Fr. Zhu Ling –– – Alisma plantago-aquatica L. var. orientale Samuels Xe Xie –– – Artemisia capillaries Thunb. Yin Chen Hao –– – Tetrapanax papyriferus (Hook) K. Koch Tong Cao –– – Anti-rheumatics Aristolochia fangchi Wu Guang Fang Ji 943 59 1002 Stephania tetrandra S. Moore Han Fang Ji –– – Asarum sieboldii (either: A.. splendens or A.. himalaicum) Xi Xin trace 28 28 Acanthopanax gracilistylus Wu Jia Pi –– – Viscum coloratum (Kom.) Nakai Sang Ji Sheng –– – Chaenomeles lagenaria (Loisel.) Koidz Mu Gua –– – Clematis chinessis Osbeck Wei Ling Xian –– – Gentiana macrophylla Pall Qin Jiao –– – Angelica pubescens Maxim Du Huo –– – For personal use only. Lysimachia christinae Hance Jin Qian Cao –– – Purgatives Prunus japonica Thunb. Yu Li Ren –– – Rheum palmatum Da Hunag –– – Cassia angustifolia Vahl Fan Xie Ye –– – Aloe vera L. var. chinesis (Haw.) Berger Lu Hui –– –

TABLE 2 Clinical Toxicology Downloaded from informahealthcare.com by University of Minnesota on 10/17/11 Levels of aristolochic acids (AA-I and AA-II) in seven over the counter manufactured products Manufactured product Level (ppm) Chinese proprietary name Pharmaceutical Co. (China) AA-I AA-II AA-I + AA-II (1) Chuan Xiong Cha Tiao Wan Lanzhou Fu Ci 8 8 16 (2) Dao Chi Pian Tian Jin 40 210 250 (3) Xin Yi Wan Lanzhou Minshan – – – (4) Xiao Qing Long Tang Lanzhou Minshan – – – (5) Ba Zheng San Lanzhou Fu Ci – – – (6) Xiao Feng San Lanzhou Fu Ci – – – (7) Long Dan Xie Gan Tang Lanzhou Da Bao – – – 374 T.P. CHEUNG ET AL.

FIG. 1. A typical HPLC chromatogram showing peaks of standards AA-I and AA-II at retention times 8.6 and 6.6 minutes, respectively.

Confirmation of AA by LC-MS the amounts of AA-I being higher than AA-II for both herbs. A LC-MS analytical protocol modified from a protocol in The total aristolochic acids (AA-I and AA-II) in A. Fangchi the FDA Laboratory Information Bulletin (12) was adopted to (1002 ppm) was about fivefold than that in A. contorta (228 confirm findings with the HPLC method. ppm). AA-I (41 ppm) was found mainly in Aristolochia man- The chemical reference standard was purchased from the shuriensis, and AA-II (28 ppm) was found mainly in the National Institute for the Control of Pharmaceutical and Bio- Asarum species tested. logical Products (Beijing, China). HPLC-grade methanol, Of the seven manufactured herbal products tested, the prod- ammonium acetate, formic acid and acetonitrile were used for uct marketed under the Chinese proprietary name Dao Chi Pian the preparation of elution solvents. Water was purified by was found to contain 40 ppm of AA-I. and 210 ppm of AA-II. For personal use only. reverse osmosis (Millipore, Bedford, MA, USA). The liquid- Another proprietary product, Chuan Xiong Cha Tiao San, was chromatography mass spectrometer used was a Perkins-Elmer found to contain low levels of aristolochic acids (8 ppm of each SCIEX API365 LC/MS/MS system. An Alltech C18 column AAI and AAII). (5 μm, 250 × 2.1 mm) was used at room temperature (20°C). The voltages of the electrospray, orifice and ring were main- DISCUSSION tained at 5 kV, 30 V and 170 V, respectively. The flow rate of The recently reported incidences of nephropathy linked to the nebulizing gas was maintained at 1.04 L/min and the colli- ingestion of Chinese herbs containing aristolochic acids raises sion energy was 17 eV (lab. scale). Nitrogen was used as the broader concerns about the safety of Chinese herbal remedies collision gas and its density was maintained at 1.56 × 1015 mol- (3–7). In many countries, there are relatively lax regulatory ecule/cm2. A typical multiple reaction monitoring (MRM) controls on the importation and supply of raw Chinese herbs chromatogram is shown in Figure 2. Clinical Toxicology Downloaded from informahealthcare.com by University of Minnesota on 10/17/11 and manufactured herbal products, with scant regard to their botanical authenticity, quality and toxicity. Under such circum- RESULTS stances, it is inevitable that herb-related adverse events, such as Of the 21 Chinese raw herbs purchased in 2003, none con- those resulting from ingestion of Aristolochia species (1–3), tained aristolochic acids. Of the six raw herbs sourced from the will continue to occur. teaching museum, four contained AA-I and/or AA-II. Two of Species misidentification and confusion about herb nomen- the seven manufactured products purchased in 2003 contained clature are likely to be major factors in the occurrence of both AA-I and AA-II. The findings with the HPLC methodol- adverse events associated with Chinese herbal medicine. Many ogy were confirmed by LC-MS analysis. Chinese herbs have similar morphological characteristics to The levels of AA-I and AA-II in the six positive samples are other herbs and frequently, different species of herb have the shown in Table 1 and 2, respectively. Results are expressed as same Chinese pharmaceutical name, or, more commonly, the μg/g of the herbal material (i.e., ppm). Both AA-I and AA-II first component (stem) of the Chinese name of several species were found in Aristolochia fangchi and Aristolochia contorta, of herb is the same. Often the prefix in the common name ARISTOLOCHIC ACIDS IN SOME RAW CHINESE MEDICINAL HERBS 375 For personal use only.

FIG. 2. A multiple reaction monitoring (MRM) chromatogram of AA-I showing the peaks at retention time of 17.15 min of Aristolochia fangchi that resulted in product ions at m/z 298, 296 and 324 with relative abundances similar to those obtained for the standard.

designates the original region that an herb was grown. The oedema and arthritis. It can be seen that within each group there present study, in which aristolochic acids were detected in two are marked similarities in the Chinese names of the herbs, despite

Clinical Toxicology Downloaded from informahealthcare.com by University of Minnesota on 10/17/11 manufactured Chinese herbal remedies commonly used for each herb being a different species. There are even instances of weight control and the management of arthritis (4,5,11), high- different species having exactly the same common name, i.e., the lights these problems. It is likely that the presence of aris- same stem and the same prefix. tolochic acids in these manufactured products can be explained The problem of two species having Chinese names with the by species misidentification and/or confusion about Chinese same stem, even where they have different prefixes, is compounded herb nomenclature. by the practice of some traditional Chinese medicine practitioners There are many herbs that belong to groups of herbs with sim- omitting the prefixes in their prescriptions. Furthermore, even when ilar Chinese names. The name may consist of a stem common to a unique Chinese name is specified by a practitioner (i.e., both stem all members of the group and a prefix. Table 3 and 4 list exam- and prefix), incorrect herbs may be supplied because of a lack of ples from the Encyclopaedia of Chinese Materia Medica (13,14) precision of botanical labelling by herbal suppliers. Thus, A. trifoli- of the Mu Tong and Fang Ji groups, respectively. From a Chinese ata, A. quinata, A. manshuriensis and Clematis armandii are all medicine perspective, these two groups of herbs have the actions called Mu Tong (see Table 3) by some practitioners, or are often all of promoting diuresis, and are often used in conditions such as traded under this Chinese pharmaceutical name. Indeed, they are 376 T.P. CHEUNG ET AL.

TABLE 3 Some examples of different varieties of Mu Tong in Chinese medicine (13,4) Botanical name Common Chinese name Region of growth in China Genuine/Toxic? Akebia trifoliata San Ye Mu Tong Mainly in Sichuan Both are genuine according to (Thunb.) Decne. ancient record; now rarely Akebia quinata Wu Ye Mu Tong used, except regionally in (Thunb.) Koidz Mainly in Zhejing China; yet Akebiaspecies often labelled in manufactured products Clematis armandii Chuan Mu Tong (also called: Sichuan, Hubei, Jiangxi, Both are not genuine according (Franch.) Xiao Mu Tong) Guizhou, Yunan, Guangdong to ancient record; non-toxic; Clematis montana Chuan Mu Tong Sichuan next most often used in China Buch.-Ham and exported overseas

Aristolochia Guan Mu Tong Jinin, Liaoning, All three are not genuine; manshuriensis Kom. Huai Mu Tong HeilongJiang, Guang Mu Tong is toxic with Aristolochia (also called: Mu Fang Ji) As Huai Mu Tong, the aristolochic acids; yet is most moupinensis Franch. Huai Mu Tong stems rather the roots of these commonly used in China at Aristolochia kaempferi (also called: Mu Fang Ji) two species are used in some present, and sometimes Willd. regions of China, mainly exported overseas Sichuan (compare to Table 4)

TABLE 4 Some examples of different varieties of Fang Ji in Chinese medicine (13,14) Botanical name Common Chinese name Region of growth in China Genuine/Toxic? Stephania tetrandra Fen Fang Ji (also called: Zhejiang, Anhui, Jiangxi, Both are genuine according to For personal use only. S. Moore. Han Fang Ji) Hubei, Guangdong, Guangxi, record in Compendium of Lianjiang &Youxi in Fujian Materia Medica; non-toxic; Province; commonly used in China and Han Fang Ji Kaihua exported Cocculus trilobus Mu Fang Ji (also called: Mainly in Henan, Shaanxi Non-toxic; used locally in some (Thunb.) DC. Qing Teng Xiang) regions of China Aristolochia fangchi Guang Fang Ji Guangdong, Guangxi Guang Fang Ji is toxic containing Aristolochia Mu Fang Ji (Note also As Mu Fang Ji, the roots aristolochic acids (AA), but is moupinensis Franch. called: Huai Mu Tong) rather than the stems of these still used in China and two speciesare used in some sometimes exported overseas; Aristolochia Mu Fang Ji (also called: regions of China, mainly the two Mu Fang Ji and Han Clinical Toxicology Downloaded from informahealthcare.com by University of Minnesota on 10/17/11 kaempferi Willd. Huai Mu tong) Sichuan (compare to Table 3) Zhong Fang Ji have not been analyzed for AA; nevertheless, Aristolochia Han Zhong Fang Ji Han Zhong in Shaanxi, Shaanxi, all Aristolochia species should heterophylla Hemsl. Gansu, Guizhou be used with great caution

often erroneously regarded as equivalent and are frequently used for 2003, were found to be free of aristolochic acids. The second a therapeutic purpose without regard to their botanical, chemical group of six banned raw herbs were included in the study because and consequently, toxicological, differences. There are similar of the potential for them to be supplied to wholesalers, retailers or problems with the Fang Ji group (Table 4). to patients as a result of nomenclature confusion between the toxic In the present study, three groups of herbal medicines were and non-toxic species that share the same stem name. The banned analysed. The first group of 21 raw herbs purchased in Victoria in herbs were purchased prior to prohibition of their sale, and were ARISTOLOCHIC ACIDS IN SOME RAW CHINESE MEDICINAL HERBS 377

obtained from the herbal teaching museum of the Division of Chi- Pian. Chuan Xiong Cha Tiao Wan contains eight different Chi- nese Medicine, RMIT University. Of these six herbs, four were nese herbs and is manufactured by Fu Ci Pharmaceutical Com- found to contain aristolochic acids. There were differences in the pany in Lan Zhou province, China. One of the constituent herbs chemical form and levels of aristolochic acids found in the herbs is Xi Xin, which on the product label was referred to as Asari tested. The sample of Aristolochia contorta (Ma Dou Ling) con- herba. Therefore, it is likely that a toxic species, either A. splen- tained both AA-I and AA-II, with a total aristolochic acid concen- dens or A. himalaicum, was used to manufacture the product. tration of 228 ppm. Aristolochic acids were not detected in Another product tested, Xiao Qing Long Tang, did not have a Stephania tetrandra (Han Fang Ji), the species that was specified detectable level of aristolochic acids, despite its label listing Asari for incorporation into the Belgian slimming formulation (see herba as a constituent. This product, produced by Mian San Phar- Introduction). However, the species substituted in the formula, maceutical Company in Lan Zhou, China, would appear to use a Aristolochia fangchi (Guang Fang Ji) had a total aristolochic acid non-toxic Asarum species. These findings again point to the prob- level of 1002 ppm. Aristolochic acids have also been detected in lems of inadequate and inaccurate labelling of herbal materials in Aristolochia fangchi in other studies. Thus, Lee et al. (5) found regard to botanical names. Frequently, only the genus of the levels between 581–1082 ppm, and Hashimoto et al. (4) reported herbs is provided, making it impossible to precisely identify the levels between 1070–2440 ppm. species used during the manufacturing process. Regarding the two other herbs tested, which have the same The problems mentioned above for Chuan Xiong Cha Tiao Chinese stem name Mu Tong, aristocholic acids were detected Wan were also reflected in the findings with Dao Chi Pian, a in only one. Thus, Aristolochia manshuriensis (Guan Mu Tong) formula often prescribed by Chinese medicine practitioners to had 41ppm of AA-I, whereas no aristocholic acids were detected promote diuresis. One of the four herbal ingredients of the for- in Clematis armandii (Chuan Mu Tong). The sample of Aris- mula is Mu Tong. The label on the product tested in the present tolochia manshuriensis was imported from China by a herbal study listed the botanical name Caulis Akebia. As shown in wholesaler. The area in China in which it was harvested is not Table 3, the two herbs Akebia trifoliata and Akebia quinata are known. The relatively low level of aristolochic acids found in regarded as genuine Mu Tong and are not toxic. The Mu Tong our sample contrasts with the much higher levels (1690 to 8820 used in the product tested is likely to be derived from a toxic ppm) reported by Hashimoto et al. (4) for specimens of Guan Mu Tong species, such as Aristolochia manshuriensis or Aris- Mu Tong harvested in various provinces of China. The discrep- tolochia moupinensis, rather than from the Akebia species as ancy may be due to different agronomic conditions or, more labelled. This appears to be another example of inaccurate likely, to different species being tested. botanical labeling. Herbs of the Asarum species are commonly used to treat pain, The seven Chinese medicinal formulae studied are probably such as headache and toothache. The botanical identity of the the only formulae available in the State of Victoria that include For personal use only. Asarum sample (Xi Xin) tested in the present study is not known. It Fang Ji, Mu Tong, or Xi Xin. However, we only sampled one was imprecisely labeled as Asarum herba, and was found to contain brand of each formula. Many other proprietary brands of each 28 ppm of AA-II. In another study (4) in which six different species formula are available. Four of the products tested were of the Asarum genus were analyzed, aristolochic acids were included in the list of 14 products banned by the Australian detected in trace amounts in only two species; specifically, the TGA. The other 10 products banned are not available in Victo- Asarum splendens and Asarum himalaicum, both collected from the ria, and presumably, not throughout Australia. Note that the Sichuan province in China. Aristolochic acids were not detected in name of a specific formula may end with “Wan” or “Pian” (i.e. A. sieboldii Miq., A. heterotropoides, A. sieboldii Miq. Var. seou- pills), “Tang” (i.e. decoction) or “San” (i.e. granules). lense, and A. forbesii, which had been collected in either China or We also attempted to obtain samples of the herbs Tian Xin Korea. In another study, three North American species of Asarum Teng, Ma Dou Ling and Qing Mu Xiang, and of formulae con- were analyzed (15). Samples of one of the species Asarum taining them, these herbs being derived from the toxic Aris- Clinical Toxicology Downloaded from informahealthcare.com by University of Minnesota on 10/17/11 canadense, was found to contain differing amounts of AA-I tolochia species (Aristolochia contorta Bge or Aristolochia depending on where the samples had been purchased. Asarum debilis Sieb. Et Zucc). We were unable to obtain such samples canadense has been proclaimed as a prohibited herb by the U.S. after these herbs were banned by the Australian Therapeutic Food and Drug Administration (9). The positive AA result in the Goods Administration (TGA) in 2001. However, it seems to us present study suggests that the Asarum species analyzed in the that the possibility of substitution of a non-toxic herb with a present study may have been either Asarum splendens or Asarum toxic one, due to incorrect or inadequate labelling, is more himalaicum, possibly sourced from the province of Sichuan in likely to occur with the commonly used herbs Fang Ji, Mu China. Again, the presence of aristolochic acids in some but not all Tong and Xi Xin, as discussed above. Asarum species illustrates the risks associated with ambiguity or lack of precision regarding botanical identification of Chinese herbs. Of the third group of herbal medicines investigated, the seven CONCLUSION manufactured herbal products, two were found to contain In the present study, some clinically related Chinese aristolochic acids: Chuan Xiong Cha Tiao Wan and Dao Chi herbs and manufactured herbal products were screened for 378 T.P. CHEUNG ET AL.

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