《杏林探宝——认知中药》是由上海中医药大学推出的一门关于中药学的慕课课程，由上海中医药大学杨柏灿教授主讲。 上海中医药大学（Shanghai University of Traditional Chinese Medicine）的前身是上海中医学院，创建于1956年，是新中国诞生后国家首批建立的四所中医药高等院校之一，也是上海市属高校中唯一的一所医科类重点特色院校。 中药学根植于中华文化，是中医药学的重要组成部分，也凝聚着中华文明的精髓。其悠久的历史，卓越的防病治病效果，较少的毒副作用，成为中华民族防病治病不可或缺的选择。同时，中药的作用也日益引起国际社会的关注和重视。但不可否认，对中药的认识和应用存在着一些不容忽视的误区与盲区，非常有必要采取一定的方式，通过合适的平台传播、普及中药知识，使人们对中药有一个更为全面准确的认识，并能合理应用，让中药为人类的健康保健发挥更大的作用。
5-3 用药安全性的影响因素
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杏林探宝——认知中药
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安全合理应用中药
用药安全性概念及影响因素。以具体实例从组方配伍、用量用法、病证禁忌等方面，强调医患配合在确保中药既有效又安全上的重要性。提出如何应用一定的方法确保一些有毒药物在疾病治疗中的作用与安全，使之由毒物变宝物。
介绍中药：马钱子、朱砂、砒石等。
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杨柏灿教授，博士生导师
上海中医药大学中药学教研室
We've just mentioned three poisonous herbs.
Now I'd like to introduce
factors that affect drug safety.
Actually,
drug safety
involves multiple factors.
These include
people who use the drugs,
people who prescribe the drugs
and what conditions the drugs are used for.
In other words,
factors affecting the drug safety
() are associated with the materia medica;
(2) are associated with doctors who prescribe;
(3) are associated with patients.
So I'd like to explain
from these three aspects.
First, let's take a look at the materia medica
this is an objective factor,
especially for poisonous herbs.
The main active components,
sometimes the active component and toxic component
are the same substance.
We need to exert its efficacy
but avoid its toxicity.
You need to be
ver cautious to
choose herbs.
As for poisonous herbs,
we mentioned that some are highly poisonous.
To be honest,
the chances of using these herbs
are slim.
As a result, there is no need to
worry about their risk,
because they are under strict regulation.
Undoubtedly,
safety issue is highlighted for
products under regulation.
This is one aspect.
For some herbs that are
mildly toxic
but popular in the market,
we need to pay much more attention
because inappropriate use
may cause toxicity.
Of course this may not severely harm the body.
This is one aspect.
The second aspect,
the materia medica itself is not toxic,
however it becomes toxic
when it's contaminated.
The use of contaminated materia medica
involves with the administration
and dispensary.
This is about contaminated materia medica.
Now let's give you an example.
We know that years,
or more than 10 years ago,
during the spread of SARS in 2003,
all Chinese people took Chinese medicine.
This indicates that
Chinese medicine is effective for
disease prevention and treatment,
even for acute contagious diseases,
which have been recognized and approved.
Another aspect,
it also indicates some people just take blindly.
At that time, Guan Zhong (Rhizoma Cyrtomii)
was in short supply.
It's believed that it can defend against SARS
and prevent SARS.
As a result, this herb was rarely used for
an extended period of time,
or even forgotten.
All of a sudden, it became so effective that
people rushed to buy this herb.
In Chinese medicine,
for Chen Pi (Pericarpium Citri Reticulatae): the older, the better; for Guan Zhong: the fresher, the better.
That's to say,
older Guan Zhong
have poorer effect.
Since it has not been used for a long time,
all of a sudden, people realized it's good
and rushed to buy,
including contaminated one
in the market.
It was reported that
some people had their liver and kidney damaged
after taking Chinese herbs to prevent
SARS,
one of the herbs is Guan Zhong.
This is the issue regarding the materia medica.
Thirdly,
it's related to the type of the herb.
Previously we mentioned Long Dan Xie Gan Wan (Gentian Liver-Draining Pill),
in which an ingredient
that can damage the kidney function
is Guan Mu Tong (Caulis Aristolochiae Manshuriensis).
However, there are many subtypes of Mu Tong (Caulis Akebiae),
such as Mu Tong, Chuan Mu Tong (Caulis Clematidis Armandii),
and Guan Mu Tong is just one subtype.
If you choose randomly before
getting to know the types,
safty issues may emerge.
This is the factor related to the materia medica.
The second factor
is related to doctors.
We think doctors should
play a leading role in this issue,
because it is the doctor who
choose the herbs,
decide the
dosage
educate the patients to
use in a correct way.
So doctors are
key to
drug safety.
In this regard,
we'd like to mention
the following aspects.
First,
the herb needs to match with the syndrome.
Whether it's
symptom-oriented
or pattern-oriented,
the prescription needs to be directed at the syndrome.
I've mentioned that
not many safety issues
result from
really toxic herbs,
most safety issues are related to atoxic or mildly toxic herbs,
for example, inconsistency bewteen prescription and syndrome.
We've mentioned once
about in the case of yang excess, swallowing Gui Zhi (Ramulus Cinnamomi) can be fatal.
Since Gui Zhi is very warm and hot in property,
it's undoubtedly indicated for cold syndrome.
If you use Gui Zhi for warm-heat syndrome
instead of cold syndrome,
side effects will surely occur.
Therefore it may sound easy
to say the prescription shall match with the syndrome;
it's not so easy in clinical practice.
This is the factor related to doctors.
Secondly,
about the dosage.
Even if a herb is toxic,
a well-controlled dose
can tranform toxicity into treasure
and benefit the treatment.
So in many cases,
whether a herb is toxic
or there is a safety risk
largely depends on
the dosage.
As a result, toxicologically,
a classical saying goes,
medicine itself is not toxic,
whereas the dosage is the culprit.
Let me tell you a true story.
A senior doctor
that supervises students
prescribes Yang Jin Hua (Flos Daturae) for a patient.
We know that Yang Jin Hua has anesthetic effect
and can be used to relieve coughing and asthma.
Generally the daily dose is
no more than 1.5g;
however, his student neglected
the decimal point,
turning 1.5g into 15g.
It turned out that the patient
lost consciousness after taking the formula.
This event does not need to go to court,
it's the doctor's fault.
Although the doctor himself didn't do it,
his student was not entitled to prescribe
the supervisor
shall be fully responisble for the event.
So the dosage is extremely important.
Thirdly,
instead of one single herb,
our prescription
contains several herbs.
In this case, we need to
consider the compatibility,
which is closely related to
whether the formula is effective,
highly effective
and safe.
I'd like to say
a few words
about compatibility.
The purposes of compatibility:
(1) to strengthen the therapeutic efficacy:
one herb can be effective but not enough potency,
a similar herb can be
used in combination,
achieving the effect of "1+1>2'.
(2)
To counteract:
one herb is necessary but may cause
side effects;
and other herbs can be
used in combination
to prevent the side effects
to counteract.
Additionally, sometimes
it's necessary to reduce or
weaken its potency.
However,
combination of herbs
may
cause side effects.
About compatibility,
there is 'compatibility among seven conditions'
in Chinese medicine...
single herb, mutual reinforcement, mutual assistance, mutual restraint, mutual suppression, mutual inhibition and antagonism.
These seven combinations
may result in four possible outcomes:
(1) strengthen the efficacy,
mainly through mutual reinforcement and mutual assistance;
(2) counterbalance
through mutual restraint and mutual suppression;
(3) weaken the efficacy
through mutual inhibition;
(4) result in or strengthen toxic reactions
through antagonism.
For treatment, we hop
the combination can strengthen the efficacy
sometimes by counteracting
or mutual inhibition
in special occasions.
For example,
we all know ginseng tonifies qi,
and usually we do not eat raddish
when we
take ginseng.
Why?
Because raddish disperses qi.
Raddish
Raddish can neutralize the qi-tonifying action of ginseng.
When you used ginseng by mistake
or used too much ginseng,
you can
eat a little raddish
or raddish seeds called
Lai Fu Zi (Semen Raphani)
to neutralize.
However, it is
absolutely prohibited to
use antagonism,
which has been stipulated in the national pharmacopoeia.
The main contents
have been generalized in the form of rhymes
by ancient people.
Ban Wei Bei Lian Ji Gong Wu,
meaning that Ban Xia (Rhizoma Pinelliae), Gua Lou (Fructus Trichosanthis), Bei Mu (Bulbus Fritillaria), Bai Lian (Radix Ampelopsis) and Bai Ji (Rhizoma Bletillae)
cannot be used in combination with Wu Tou,
including Chuan Wu (Radix Aconiti), Cao Wu (Radix Aconiti Kusnezoffii)
and Fu Zi (Radix Aconiti Lateralis), etc.
It clearly states that the aforementioned drugs cannot be used together.
Also the rhyme goes 'Zao Ji Sui Yuan Ji Zhan Cao',
meaning that Hai Zao (Sargassum), Da Ji (Radix Euphorbiae Pekinensis), Gan Sui (Radix Kansui) and Yuan Hua (Flos Genkwa)
cannot be used in combination with Gan Cao (Radix et Rhizoma Glycyrrhizae).
Also, Zhu Shen Xin Shao Pan Li Lu,
'Shen' here
includes Ren Shen (Radix et Rhizoma Ginseng), Dang Shen (Radix Codonopsis), Xi Yang Shen (Radix Panacis Quinquefolii), Tai Zi Shen (Radix Pseudostellariae),
Dan Shen (Radix et Rhizoma Salviae Miltiorrhizae), Xuan Shen (Radix Scrophulariae), Sha Shen (Radix Adenophorae seu Glehniae)
all these cannot be used in combination with Li Lu (Radix et Rhizoma Veratri Nigri),
neither can Xi Xin (Radix et Rhizoma Asari), Chi Shao (Radix Paeoniae Rubra) and Bai Shao (Radix Paeoniae Alba).
Our ancestors learned these with a price
and we should keep in mind.
These contents are listed
as combination contraindications
in the pharmacopoeia.
That's why we say the safety issue
is more
related to the doctors.
Of course there are some special periods,
for example, women during period, childbirth and pregnancy
cannot use some herbs.
In addition, this is also related to the route of administration.
So
Doctors are the key in this process.
Finally, the patient-related factor.
It's actually still related to doctors.
As doctors, you have to remind, correct and instruct
how to use herbs appropriately.
When you realize patients have wrong ideas or
misunderstandings,
you have to
correct and
educate them.
These include the decoction,
administration
cautionary notes,
and
dietary habits, etc.
Some herbs need to be decocted for a long time
but you failed to do so
or have no idea;
some herbs only need to be decocted for a while,
but you decocted for a long time;
some herbs need to be wrapped up during decoction,
for example,
Pi Pa Ye (Folium Eriobotryae)
needs to be wrapped up in a gauze bag,
otherwise,
it floats in the decocted water and
may cause vomiting
as soon as you swallow.
All these information shall be informed
by doctors.
The patients then follow
the doctors'
instrucdtions.
Some safety issues
are inevitable.
What?
Individual differences.
As for doctors' prescription,
even if the dose, method
and syndrome
are all correct,
patients' still
experienced side effects,
which is related to patients' constitutional differences.
We need to keep a close look
at these issues as well.
In this class,
I talked about some factors affecting the drug safety,
involving the patient, doctor and materia medica,
especially the doctor.
So much for this session.
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