Lesson 4: Cautions and contraindications according prescription situations

Allergy

Allergy-related problems are not given in the database as a disorder, except for allergic asthma and allergic rhinitis (Respiratory Disorders), urticaria (Skin Disorders), and food intolerances Digestive Disorders).

Allergy to specific plants or plant groups
However, there are concerns that a small number of people may be allergic to the following plants, although I have not yet seen cases of allergy to any of these.

If the practitioner is worried about this, then they can ask the patient, for example:
“Do you have allergy to yarrow (Achillea), or plants in the Daisy (Asteraceae) family?”

If the patient does not know, and most patients do not, and if the practitioner is worried, they can start the patient at a lower dose for 1-3 days, and then, if there are no allergy symptoms, raise the dose to normal level.

Practitioner’s judgement
Some of these herbs are listed as contraindicated by some texts. For example, Aloe gel is contraindicated for persons with known sensitivity by M&B Safety.

However, whether the herb is classed as ‘contraindicated’, or ‘to be used with caution’, may depend on whether the previous allergy to the herb was mild or severe, and on the judgment of the practitioner.

The practitioner may, with the patient’s consent, wish to try a low dose of the herb to determine if there is any sensitivity reaction, and if there is not, or if it is minimal, and there is benefit, practitioner and patient may decide to continue with the herb.

Achillea contraindicated or caution: allergy to Asteraceae
Aloe gel contraindicated or caution: allergy to Aloe gel
Apium contraindicated or caution: allergy to birch or mugwort families (M&B Safety)
Arnica  contraindicated or caution: allergy to Asteraceae
Artemisia abs. contraindicated or caution: allergy to Asteraceae
Calendula contraindicated or caution: allergy to Calendula oficinalis
Chamomilla contraindicated or caution: allergy to Asteraceae
Commiphora contraindicated or caution: allergy to Commiphora
Echinacea contraindicated or caution: allergy to Asteraceae
Foeniculum contraindicated or caution: allergy to Apiaceae
Grindelia contraindicated or caution: possible contact dermatitis from this plant (M&B Safety)
Hedera  contraindicated or caution: fresh leaf and leaf sap can cause allergic contact dermatitis (ESCOP)
Marrubium contraindicated or caution: juice of the (fresh) plant can cause contact dermatitis (M&B Safety)
Myrica contraindicated or caution: allergy to Myrica pollen, caution especially if used as snuff
Petroselinum contraindicated or caution: rare contact allergy to this plant
Pimpinella contraindicated or caution: occasional allergic reactions (BHC2)
Solidago contraindicated or caution: allergy to this herb
Stellaria contraindicated or caution: allergy to this herb
Tanacetum contraindicated or caution allergy to Tanecetum or other Asteraceae
Thuja contraindicated or caution: allergy to this herb
Tilia contraindicated or caution: rare allergy to this herb (M&B Safety)

Alterative Herbs

Alteratives are cleansing herbs that can release toxins from the tissues into the blood stream. If toxins are released at a rate faster than the body, and especially the liver, can detoxify them, then there may be temporary nausea, diarrhea, fever, restlessness, irritability, or depression. Most important, there may be aggravation of skin rashes, or arthritis, that may be severe. This is especially likely in patients with a high load of toxins in the body, or in patients with contraindicateduced liver detoxification function.

Potential problem herbs
Arctium seeds contraindicated or caution
Taraxacum root contraindicated or caution 
Iris contraindicated or caution 
Rumex contraindicated or caution 

Practitioner precautions 
For combinations containing strong alterative herbs, the practitioner can add anti-inflammatory herbs such as Glycyrrhiza to the prescription, or include heptoprotective bitters such as Silybum.

▶ Alterative herbs in Hepatic disorders.

Patient precautions 
The patient should be advised to:

• start with 1 ml or even 1 drop doses of tincture in susceptible patients, and gradually increase the dose
• if there is intolerance of alcohol, combination can be prescribed as decoction or capsules rather than tincture
• drink more water every day whilst taking the prescription
• contraindicateduce intake of food and drink likely to generate toxins, eg. alcohol, coffee, strong tea, and rich and spicy food

Severe alterative reactions 
If there is severe aggravation of skin, muscle, or joint disorders, despite the precautions above, then the patient can be prescribed Silybum 2 for 1-2 months before alteratives are given. Silybum 2 is specifically designed to strengthen the liver detoxification function, as a preparation for the use of alteratives.

Aromatic Oil

The use of some plants as aromatic oils is contraindicated, either at all times, or in specific circumstances, eg. pregnancy.
A few examples are given here, but the user is recommended to check in:

• Essential Oil Safety Tisserand R and Young R. 2nd ed, Churchill Livingstone 2014
• European Medicines Agency (EMA) ▶ monograph on the specific herb oil www.ema.europa.eu/en

Examples
Mentha pul. contraindicated: at all times
Pimpinella contraindicated: during pregnancy
Ruta contraindicated: during pregnancy
Syzygium contraindicated: during pregnancy, except for short-term topical use for toothache
Thuja contraindicated: at all times

External use only

Some plants are for topical use only, and their internal use is contraindicated.

Arnica contraindicated

Fresh herbs

The following herbs are best used as dried material, and avoided as fresh material, until more data is available.

Anemone contraindicated
Hedera contraindicated
Iris contraindicated
Phytolacca contraindicated or caution: there is an American tradition of use of the fresh root, but more caution should be used than with the dried root, and its use is outside the scope of this database

Phototoxicity

There is the theoretical concern that constituents of the following plants may result in photosensitization, so it may be prudent to avoid prolonged exposure to UV light whilst taking these herbs.

Angelica arc. caution
Apium (seeds) caution
Citrus species caution
Hydrastis caution: avoid exposure to UV when Hydrastis is used in the eyes
Hypericum caution: avoid exposure to UV if taking high doses of Hypericum
Ruta caution: history of phototoxic reactions to furanocoumarins

Prolonged use

The following herbs are best used in the acute stage only, or during acute episodes, and should not be taken continuously long-term.

Ephedra contraindicated
Isatis leaf (Da Qing Ye) contraindicated

Sensitivity to herbs

Some patients, may be very sensitive to treatment with herbs or conventional drugs. Especially those with liver disorders

▶ Hepatic disorders, or with severe general weakness, eg. chronic fatigue syndrome fibromyalgia, or MCS (multiple chemical sensitivities)
▶ Exhaustion.

Start on very low dose 
Therefore, start such patients on a very low individual dose of the main prescription, such as 1-5 drops, and increase the dose slowly as required, unless there are side effects.

Separate dropper bottles 
It is my experience that herbs to which such patients may be sensitive are best prescribed in separate dropper bottles, and not included in the main herbal prescription.

If prescribed in dropper bottles, separate from the main prescription, then, a specific number of drops, eg. 1-20 drops, of the separate herb can be added to each dose of the main prescription.

This is because some patients may be sensitive to these herbs, and too high a dose may produce side effects.

Depression and exhaustion
For example, a small minority of patients may feel more depressed with a large dose of Humulus or Sanguinaria, or more exhausted with large doses of Humulus or Valeriana.

Capsicum shock
As another example, whilst Mexicans, and English people who habitually eat very hot Indian curries, have no problem with hot Capsicum (chilli pepper), most German and Austrian patients, who do not eat chilli pepper, and only use sweet paprika in cooking, find that really hot Capsicum is a shock to the system, and need to start with only a few drops, until their bodies adjust to the experience.

Headache
A few people who have headache or migraine, may have their headache aggravated by Astragalus or by Cimicifuga, because, in terms of Chinese medicine, both herbs can help to raise Qi and Yang.
If the practitioner has concerns about this, it is prudent to start with a low dose of either of these herbs, and slowly increase it, if there is no aggravation of the headache. One convenient way of doing this is to put the Astragalus, or the Cimicifuga, in a dropper bottle separate from the main prescription.

Chronic fatigue syndrome (CFS)
It has been my experience that some patients with CFS, fibromyalgia syndrome (FMS), or multiple chemical sensitivities (MCS), are very sensitive to herbs or medicines. I found that some of these patients can be oversensitive to Panax ginseng, or even Schisandra, so that normal doses of Schisandra can aggravate or cause mental restlessness.

The answer, again, is to put these herbs in dropper bottles separate from the main prescription, so that the patient can find the number of drops of Panax or Schisandra that increase energy and mental performance, without increasing restlessness.

Menopausal hot flushes
Sometimes, herb combinations prescribed for hot flushes make the patient too cold.

Zanthoxylum, at normal doses, would aggravate hot flushes. But if prescribed in a separate dropper bottle, the right number of drops of Zanthoxylum, when added to each dose of the main prescription, will stop the main prescription making the patient too cold, without aggravating the hot flushes.

The patient finds the right number of drops by starting with one drop of Zanthoxylum, and the slowy increasing the number of drops.

Changing needs
For example, either or both Humulus and Valeriana can be prescribed for emotional stress, such as anger, fear, anxiety, or panic attacks. But for many patients, the stress levels may change according to what is happening in their work or home situation.

So they need to be able to vary the dose, or the number of drops, of Humulus and/or Valeriana, according to changing stress levels in their environment, and this is easy to do if these herbs are in a dropper bottle separate from the main prescription.

Caution
Too high a dose of Humulus and/or Valeriana may make the patient sleepy or mentally dull. This can be a problem in the daytime if the patient needs a clear mind to do their work, or if they are driving or operating machiners.

So the patient should initially experiment to find the number of drops that maximally helps the emotional stress without affecting their ability to work or drive.