Drugs to Avoid

Avoiding Certain Medications:

Patients with cirrhosis should not take Non-Steroidal Anti-Inflammatory Drugs (NSAID) such as Advil (Ibuprofen), Motrin (Ibuprofen), or aspirin-type drugs. Tylenol (Acetaminophen) is safe if you take less than six 325 mg tablets each day (2,000 mg per day).

Because cirrhosis patients are at increased risk of ulcer disease, you should discuss with your doctor about taking an anti-ulcer drug. View a list of medications that can harm the liver, and a list of herbal medications you should avoid.

For patients with liver disease, the ingestion of everyday drugs may cause further damage as the liver breaks down these toxic substances from the bloodstream. Because the length of time for liver injury to occur may vary from days to months, frequent blood tests are necessary to monitor possible damage.

Following is a list of hepatotoxic drugs. Patients who take these medications (regularly or daily) should undergo monthly laboratory testing for the first three months of therapy and then every three to six months because of the association between these medications and liver disease.

acetominophen, particularly hazardous when taken with alcohol or anti-seizure medications

alpha-methyldopa (Aldomet)

amiodarone

carbamazapine

chlorzoxazone, Parfon-forte

dantrolene

diclofenac, voltaren

fluconazole or ketoconazole

flutamide

hydralazine

ibuprofen

imuran/azathioprine/6-MP

isoniazid (INH)

Ketek

long-acting nicotinic acid

luekotriene synthase inhibitors (asthma medications) Zafirlukast Accolate and zileuton (Zyflo)

methotrexate

nitrofurantoin (Macrodantin)

perihexilene maleate

phenylbutazone

phenytoin

pravastatin, fluvastatin, simavastatin, lovastatin,

quinidine

rifampin

sulfa medications (especially Septra or Bactrim)

tacrine

Tasmar (tolcapone) Parkinson’s Disease

Ticlid

troglitzone (Rezulin)

vitamin A (in doses greater than 5,000 Units/d; beta carotene is safe at all doses)

According to the April 1996 New England Journal of Medicine, the most common cause of acute liver failure in the United States is the negative interaction between acetaminophen (Tylenol) and alcohol. In addition, there are interactions that are less common but equally as serious. Research suggests individual genetic variations in liver enzymes may be the cause.

For information on cytochrome P450 drug interactions or to order a pocket reference card, visithttp://medicine.iupui.edu/flockhart/

Herbal medications are a part of standard eastern medicine. Today, more patients and an increasing number of physicians are using single herbs and combinations in western medicine. Although these preparations are believed to have some medicinal value, there is also a risk of toxicity.

The following herbs have been described to cause a variety of liver problems ranging from hepatitis to liver failure and should not be consumed if you have liver disease (1,2). If you are being treated with interferon, herbs should not be taken unless under strict supervision. Make sure you discuss the potential reactions and interactions with both Western and Chinese medicine practitioners before taking any medication or herbal remedy. Although universally liver-toxic substances are identifiable in the laboratory, liver hypersensitivity problems are not predictable. One person may experience no negative side effect from a medicinal substance; another may have organ failure. Although you cannot predict hypersensitivity in all cases, some indicators may offer clues as to who is vulnerable and who is not.

Risk factors include:

You have multiple allergies and have had previous adverse reactions to drugs or herbs.

You have a history of chronic skin rashes.
You have liver disease — although herbs that benefit the liver are not harmful, it is recommended that if you have another, unrelated medical condition in addition to liver disease and you are going to treat it with herbs, you exercise extreme caution and monitor all posible adverse reactions carefully.

You should discontinue taking any herb if you experience a skin rash, substantial nausea, bloating, fatigue and/or aching in the area of your liver, yellowing of the skin or pale feces.

Additionally, you should discontinue taking any herb if you experience a skin rash, substantial nausea, bloating, fatigue, aching in the liver area, yellowing of the skin (jaundice) or pale feces.

Herbal Medications to Avoid (Latin Names)

Atractylis Gunnifera

Azadirachza indica  

Berberis vulgaris

Calliepsis laureola

Cassia angustifolia

Chelidonium majus

Corydalis

Crotalaria

Ephedra

Eupatorium

Ginseng radix

Glycyrrhizae radix

Hedeoma pulegoides

Heliotropium

Larrea tridentate

Lycopodium serratum

Mentha pulegium

Morinda citrifolia

Pinelliae tuber

Piper methysticum

Sassafras albidum

Scutelleria

Scuterarie

Senecio longilobus (senecio species)

Serrenoa serrulata

Stephania

Stephaniae Sinica

Symphytum officinale

Teucrium chamaedrys/polium

Tussilago farfara

Valeriana officinalis

Viscum album

Zingeberis rhizoma

Zipiphy fructus

 Herbal Medications and Mushrooms to Avoid (Western Names)

 

    Amanita mushroom

    Chaparral (creosote bush, greasewood)

    Comfry – taken internally

    Eupatorium

    Germander (mint family) – this toxic herb is often substituted for skullcap, and skullcap is not toxic in well-formulated herbal remedies. However, always insist that any ingredient identified as skullcap be the genuine article and not germander.

    Groundsel (senecio longilobus)

    Heliotropium

    Jin Bu Huan (Lycopodium serratum)

    Mentha pulegium

    Mistletoe

    Pennyroyal (squawmint) oil or Hedeoma pulegoides

    Sassafras

    Senicio species

    Senna

    Sophora

*It appears that St. John’s Wort and milk thistle (silymarin) do not have significant liver toxicity potential.

Asian Herbal Preparations (Herbs to Avoid)

Herbal patent medicines, tonics, elixirs and prepackaged solutions are particularly risky for anyone, whether they have liver disease or not. Far too often ingredient labels are incomplete or mistranslated. Herbs are mistakenly used in the concoctions that are dangerous or inappropriate in combination with other herbs. Toxic herbs are substituted for beneficial ones. And herbal ingredients that are generally harmless can cause liver damage in a very small group of allergic or intolerant individuals.

The best advice is to avoid all premixed preparations. Rely on the best-trained and most experienced herbalist available to individualize your herbal therapy and monitor your reactions.

Following is a list of contaminated formulas containing heavy metals, poisons and other potentially liver-toxic substances identified by the Oriental Herbal Association:

The above are premade formulations that are contaminated with toxins, but when herbalists make them up, the proper versions of the formulas can be salutory.

Common Toxic Ingredients in Asian Herbal Preparations

The following list, provided by the Oriental Herbal Association, identifies harmful ingredients for which patients with liver disease should be on guard:

        Amanita mushroom

        Lepiota helveola

        An Gong Niu Huang Wan – contains arsenic and mercury

        Bi Tong Pian – contains chlorpheniramine, an antihistamine

        Bi Yan Pian (Chung Lian Brand) – contains acetaminophen

        Da Huo Luo Wan – contains mercury

        Dendrobum Moniliforme

        Farfunoeminkam Wan – contains chlorpheniraminean antihistamine

        Gan Mao Ling (Yang Chen) – contains chlorpheniramine, caffeine, acetaminophen

        High-Strengh Yin Cheng – contains chlorpheniramine, acetaminophen, pulegone (it can trigger seizures, cerebral edema and liver failure)

        Huang Lien Shang Ching Pian – contains pulegone

        Ma Hsing Zhe Ke Pian – contains ephedrine which can cause heart irregularities and convulsion

        Marguerite Acne pills – contains sophoridane, an unknown medication

        Night Sight pills – contains mercury

        Niu Huang Chiang Ya Wan – contains mercury and/or lead in formlations from various companies

        Pe Min Kan Wan (Chu Kiang, Yan Jiang) – contains acetaminophen, chlorpheniramine and phenylpropanolamine hydrochloride (increases blood pressure)

        Shen Ling Bai Zhu Pian – contains isoborneol, a synthetic isomer of borneol, a camphor-related compound

        Ta Huo Lo Tan – contains mercury and lead

        Tsai Tsao Wan – contains mercury

        Yin Chiao Chieh Tu Pian (Yang Cheng, Plum Flower) – contains pulegone

        Zhi Suo Ding Chuam Wan – contains ephedrine and pseudophedrine (stimulants that can raise blood pressure and cause seizures)

        Zhong Gan Ling – contains aminopyrine and dipyrone that can lead to fatal bone marrow toxicity and agranulocytosis, an acute blood disease.

        Aconite or Aconitum – Causes paralysis and death if not highly processed before use

        Acorus – Causes convulsions and death

        Borax – Triggers severe kidney damage

        Borneal – Triggers internal bleeding and death

        Bufonis – can paralyze the heart muscle and lungs

        Buthus – Causes paralysis of the heart and death

        Calomel – A mercury compound

        Cinnabar – A mercury compound

        Litharge – Contains lead oxide

        Minium – Contains lead oxide

        Myiabris – Can trigger convulsions, vomiting and death

        Orpiment – Contains arsenic

        Realgar – Contains arsenic

    Licorice – A mainstay of Chinese formulas, licorice is used in very small quantities to balance herbal action and often appears as glycyrrhizin (licorice root). However, licorice produces well-documented side effects such as hyperaldosteronism (an increase in levels of the adrenal hormone aldosteron, triggering imbalance of electrolytes) when taken in doses of more than 50 grams a day or for six weeks or longer. However, no side effects have been seen in smaller doses over 30 days or in higher doses for a very short period of time.

    Skullcap – Also called scutelleria, this herb is used in many formulas to good effect. However, it appears that the toxic substance, germander, often is substituted for skullcap in formulas without being properly identified. As a result, skullcap looks like the offending substance. Whenever skullcap appears in a formula make sure that it, not germander, is in fact being used. If you cannot be sure, do not take the formula or herb.

There has been one mention of toxicity in the literature for the following herbs. Further research is needed.