What's Wrong With These Results

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What’s Wrong With These Results? Amitava Dasgupta, Ph.D, DABCC Professor of Pathology and Laboratory Medicine University of Texas- Houston Medical School

Transcript of What's Wrong With These Results

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What’s Wrong With These Results?

Amitava Dasgupta, Ph.D, DABCC

Professor of Pathology and Laboratory Medicine

University of Texas-Houston Medical School

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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.

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Alternative (Herbal) Medicines

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

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Digoxin and Chan SuOne 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

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Chan SuChan 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.

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Structure of Active Components of Chan Su

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Chan Su and Digoxin AssayCLIA: Chemiluminescent Assay (Bayer)

0 1.5 3.5 5

l of Chan SU added to per ml of Digoxin pool

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Pool 1FPIAPool 1 MEIAPool 1 CLIA

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oxin

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

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Elimination of Interference Chan Su interference eliminated by monitoring free digoxin

l of Chan Su added to per ml of digoxin pool

0

0.5

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Total DigFree Dig

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oxin

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Digoxin and Herbal MedicinesHerbal medicines potentially interfering

with digoxin immunoassays: Chan Su Lu-Shen-Wan Danshen Siberian and Asian Ginseng Uzara Roots

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Lu-Shen-Wan and DigoxinLu-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.

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Siberain Ginseng and Digoxin74 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

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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:

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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.

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In Vivo Digoxin Activity in MiceHerb Fed Before* After*Asian Ginseng (Song) ND 0.68Asian Ginseng (Song) ND 0.50Siberian (ZT) ND 0.47Siberian (ZT) ND 0.32Siberian (Sundown) ND 0.26Siberian (Sundown) ND 0.21

*Fluorescence polarization assay (Abbott Laboratories) used

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Ginsengs and Digoxin

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Digoxin, ng/ml

FPIA MEIA EMIT Randox CLIA

Pool

AG

SG

FPIA MEIA EMIT Randox Bayer

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Dan ShenDan 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.

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Dan Shen and Digoxin Assay

0

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FPIA MEIA CLIA EMIT

Dig Pool

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+50ulDS

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

Dig

oxin

, ng/

ml

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Dan Shen: In Vivo ResultsMouse # Apparent Digoxin, ng/ml

Before 1h After 2h After1 ND 0.20 0.462 ND 0.23 0.543 ND ND 0.264 ND ND 0.365 ND 0.20 0.456 ND 0.21 0.41Dose:50 mg/Kg

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

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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

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Herbs and Digoxin AssayHerb Interference Chan Su High

Lu-Shen-Wan Moderate to High

Dan Shen Moderate

Asian Ginseng Low to Moderate

Siberian Ginseng Low to Moderate

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

Herb Protein Binding Free Digoxin

Chan Su 80-90% YesDan Shen 70-80% YesAsian Ginseng 35-45% NoSiberian Ginseng 30-40% No

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

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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-Shen-Wan.

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Alternative (Herbal) Medicine

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

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Herbs and Abnormally Low Glucose

G in sengD e creased g lu co se

G a rlicG ing er

D e creased g lu co se

N e ttleD e creased g lu co se

C h ro m iumO ften fo un d in w eig ht

lo s s p ro d uc tsD e creased g lu co se

H erbal P roduct causing H ypoglycem ia

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Herbs and Bilirubin

C o ptis ch in en sus /jap o nicum cause neo nata l jau nd ice

C o nta ins berb erineC h uen-L in

A rtem isia sco pariaW o rm w oo d,G reen G ig er

G o ld en seal(b erberin e)

D isplaces b iliru b infro m alb um in

H erbal P roduct causing hyperb ilirub inem ia

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

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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/Lplasma renin activity - 0.17 ng/ml/h (low)

57 patients recovered after stopping licorice.

Shintani et al. Eur Neurol 1992;32:44-51

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Alternative (Herbal) Medicine

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

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Phenytoin, Phenobarbital and Herbs Reduced seizure

threshold Reduced serum

drug concentrations

•EEvening primrose oil and borage oil both reduce seizure threshold of phenobarbital.

•SShankhapushpi reduces seizure threshold of phenytoin.

Fugh-Berman. Lancet 2000;355:134-138

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St John’s 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. John’s Wort; 300 mg capsules (0.03% hypericin, Nature’s Way) tid, ~8 weeks earlier.

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Drug Interactions:St John’s 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: ironSerotonin excess

SSRI’s (sertaline, paroxetine, nefazodone)

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St John’s Wort

CYP3Ahyperforin: 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

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St John’s Wort

P-glycoprotein/MDR1 expression / activity

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

rhodamine 123 (PBMC’s)

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

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Oral Anticoagulants and Herbs

Ginseng, Danshen, Garlic, Ginkgo Biloba, Garlic, Ginger, Devil’s 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

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Herbs and Bleeding

G arlicBleedingW arfarin

G ingerBleedingW arfarin

G inkgoBleedingW arfarin

Herbs and Abnorm al Coagulation T estsplatelet aggregation decreased

coagulation pathw ays

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

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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).

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Herbs and SurgeryHerbal Products EffectsGarlic, Ginkgo,Ginseng BleedingMa Huang, Ephedra CardiovascularGinseng HypoglycemiaKava-Kava, Valerian Prolonged

Sedative effect of Anesthetics

Ang-Lee et al JAMA 2001;286:208-216.

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Alternative (Herbal) Medicine

Unexpected results due to contamination of herbal products with Western medicines

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Chinese Herbs Contaminated with Phenytoin

A patient never on phenytoin was admitted with a phenytoin level of 48.5 g/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.

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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.

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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.

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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

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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. John’s Wort.

Patients taking drugs with narrow therapeutic ranges should not use any herbal products.

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Conclusions

Abnormal coagulation tests may occur due to use of garlic, ginger, ginkgo etc.

Unexpected results may be related to contamination of herbals with Western medicines.

Amitava Dasgupta: E-mail: [email protected]

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