Lesson 6: Cautions and contraindications according disorders

Arthritis and Rheumatism

Some alterative (blood cleansing) herbs may occasionally aggravate arthritis and rheumatism, by release of accumulated toxins from the cells into the blood, at a faster rate than the detoxificatory and eliminative processes can clear them from the body.

These herbs should be initially given in small doses, and the dose should gradually be increased if there are no aggravations.

They can be preceeded by hepatoprotectives, eg. Silybum, or combined with hepatoprotective anti-inflammatories, eg. Glycyrrhiza, to moderate adverse alterative effects.

Arctium lappa seeds caution
Iris versicolor caution
Rumex crispus  caution
Taraxacum officinale root caution

Problems are less likely with Arctium seeds or Taraxacum if these are initially given in low dose.

Cancer

see also “Chemotherapy side-effects”

Lymphocytic leukemia
Phytolacca contraindicated: avoid until more is known

Oral leukoplakia
Sanguinaria contraindicated: avoid until more is known

Cardiovascular Disorders

Angina pectoris
Ephedra contraindicated: until more is known

Arrhythmia
Ephedra contraindicated: until more is known
Cinchona caution
Convallaria caution
Sarothamnus caution

Risk of arrhythmia with Cinchona, Convallaria and Sarothamnus can be reduced by:

• starting initially at a lower dose
• never using as a single herb, in a balanced herb combination, especially with Crataegus and Leonurus, which have stabilizing effect on heart rhythm
• monitoring the patient

Ventricular tachycardia
Scrophularia nodosa contraindicated?: contraindicated by BHP, but no research evidence found for this

Bradycardia
Piscidia contraindicated

Cold Extremities
The following herbs may have a cooling effect, and aggravate existing cold sensations. But this effect can be contraindicateduced or avoided, and these herbs can be safely used, in some cases, if the herb is prescribed with a little Capsicum, Zanthoxylum, or Zingiber, as appropriate.

Anemone caution
Asclepias caution
Humulus caution
Isatis leaf (Da Qing Ye) caution
Piscidia caution
Sanguisorba caution: according to Chinese medicine, use caution in patients with Cold from Deficiency or Blood stasis
Scutellaria baicalensis caution: according to Chinese medicine, contraindicated for Cold from Spleen Deficiency, but can be used if combined with a little Zingiber
Taraxacum root caution

Heart Failure
Ephedra contraindicated 
Piscidia contraindicated 

Hypertension
Ephedra contraindicated
Sarothamnus scoparius contraindicated 
Glycyrrhiza contraindicated or caution: contraindicated for severe hypertension, caution in mild to moderate hypertension and use lower doses

Stroke, tremors, spasms
Ephedra contraindicated

Varicose veins
Capsicum caution: caution if heat sensations

Digestive Disorders

Colic, intestinal
The following herbs may initiate intestinal colic, especially in higher doses, so are often combined with spasmolytics, eg. Foeniculum or Zingiber, to prevent or contraindicateduce this effect.
Rhamnus caution
Rheum caution

Colitis
Capsicum   caution: especially if there are heat signs

Constipation
High-tannin herbs: The following herbs have high tannin levels (15-20%), making them strong astringents, and so are contraindicated for constipation.
Polygonum contraindicated
Potentilla contraindicated
Quercus contraindicated

Tannins, but % unknown
Sanguisorba caution

Laxative abuse: Rhamnus and Rheum should not be used as single herbs in high doses, but only as part of a balanced herb combination, eg. Rheum 2.

Diarrhea
Rhamnus  contraindicated or caution: contraindicated at high doses
Rheum  contraindicated or caution: contraindicated at higher doses (1-4 g/day), but can be used at lower doses (100-300 mg/day) as an antidiarrheal, in some circustances
Taraxacum caution: in Chinese medicine, caution for loose stools related to Spleen Deficiency with Cold; adverse effects unlikely if Taraxacum is given with a little Zingiber

Children’s diarrhea
Juglans bark contraindicated or caution: large doses contraindicated for children, and contraindicated for children with diarrhea and weakness

Digestive weakness (reduced appetite)
Cooling bitters: Cooling bitter herbs may be unsuitable for persons with weak digestion and cold sensations (Spleen Deficient Qi + Interior Cold), but adverse efects are unlikely if the se herbs are given together with a little Zingiber.
Berberis caution
Hydrastis caution
Isatis leaf (Da Qing Ye) caution
Taraxacum caution

Moistening herbs: The following herbs may aggravate heavy sensations and mental dullness due to damp (Spleen Qi Deficiency + Spleen Damp), unless these are given together with aromatic carminative herbs, eg. Elettaria or Citrus.

This caution is for the use of strong decoction: the problem is unlikely with tincture or fluid extract.
Althaea caution
Lycium  caution
Ophiopogon caution

Food intolerances
Gluten allergy
Avena semen caution adverse effects unlikely at therapeutic doses

Gastritis and Peptic Ulcers
Capsicum caution
Phytolacca caution
Polygala caution
Zingiber officinale (dried) caution

Hemorrhoids
Capsicum contraindicated for both oral and topical use, especially if hemorrhoids are with heat sensations

Irritable bowel syndrome (IBS)
Ephedra contraindicated especially for IBS associated with anxiety
Rhamnus contraindicated or caution unless in a prolonged constipated phase, and then only use at low dose
Rheum  contraindicated or caution unless in a prolonged constipated phase, and then only use at low dose

Nausea and Vomiting
Convallaria caution
Lobelia  caution nausea is avoided or contraindicateduced if Lobelia is given together with a little Zingiber, and if lower doses are used; stop Lobelia if nausea persists
Phytolacca caution

Obesity and Weight gain
Althaea caution: unlikely unless large doses of strong decoction are taken long-term

Ear Disorders

Oil infusions  Drops of suitable oil infusions can be used as a topical treatment for ear disorders, when appropriate. The following precautions should be taken:

• liquid preparations should not be introduced into the ear if there is perforation of the eardrum, except on the advice of an ear, nose, and throat specialist
• preparations should not be introduced to the ear unless at body temperature
• preparations should be completely clear of particles
• neither the dropper nor the bottle neck should touch the ear

Examples ▶ the topical combinations for the ear: Verbascum 2 and Anemone 13.

Warning: Oil infusions should not be confused with pure essential oils. The essential oils are highly concentrated and should not be given into the ear, unless they are very dilute, and only on the recommendation of an expert.

Capsicum contraindicated

Eye Disorders

Eyewashes or eyedrops  Finely powdecontraindicated dried herbs can be made into an infusion, and then used with an eyebath to bathe the eyes, or as eyedrops.

Examples ▶ the topical combinations for the eye: Euphrasia 8, Hydrastis 3, Hydrastis 5, and Viola 3.

Precautions 
The eyes are more sensitive than the ears, unless the eardrum is perforated, and the following precautions should be taken:

• preparations introduced into the eyes should be sterile, so infusions must be freshly made for each application
• infusions should be filtecontraindicated until completely clear of particles
• practitioners are advised not to prescribe infusions to be used as eyewash or eyedrops, that are prepacontraindicated by the patient, unless they are sure that the patient is capable of accurately following written instructions
• preparations should not be introduced to the eye unless at body temperature
• preparations containing alcohol should not be put in the eyes

Capsicum contraindicated

Exhaustion

The following applies to all Main disorders in the Exhaustion Disorder group.

Exhaustion: stimulant herbs
Stimulant herbs may be appropriate for some types of exhaustion, such as collapse from exhaustion due to severe acute blood loss (Collapse of Yang).

But stimulant herbs can have big disadvantages for exhaustion with physical, mental, or emotional stability due to lack of reserves of energy (severe Kidney Qi Deficiency + Kidney Yin Deficiency + Heart Spirit Disturbance), because stimulants can:

• further deplete reserves of Kidney Qi and Yi, aggravating exhaustion
• increase Kidney Yin Deficiency and increase Deficiency Heat sensations
• destabilize heartbeat, blood pressure, mind, and emotions (Heart Qi Distrurbance, Heart Spirit Disturbance, Liver Yang Hyperactivity, Liver Wind)

Exhaustion: stabilizing tonic herbs
It is safer, and more productive, to avoid strong stimulants for patients with low energy reserves and energy instability, for example, exhaustion due to burnout or to chronic fatigue syndrome. It is better to use less powerful stimulants that also tonify Yin, such as Panax quinquefolium, or to use nourishing, stabilizing, slower-acting tonic herbs eg. Avena, Lycium, and Serenoa.

Burnout: stimulant herbs
It is tempting for patients with mental, physical, or sexual burnout to overdose with stimulant herbs, such as Ephedra, contraindicated Panax ginseng, or Turnera, but this usually results in overstimulation, restlessness, insomnia, anxiety, and risk of hypertension and myocardial infarction.

Ephedra contraindicated
Panax ginseng  contraindicated or caution: depending on dose
Turnera contraindicated or caution: depending on dose

Burnout: sedative herbs
Exhausted patients who force themselves to work, and who do not realise or admit to the degree of their exhaustion, may initially feel very ticontraindicated on taking large doses of Humulus, Lavandula, Piscidia, or Valeriana. This is usually temporary while their body takes the rest necesary for recovery, but it may alarm the patient if this is not previously clearly explained to them.

It is best therefore to start these herbs in lower doses with burnout patients.

If the initial exhaustion following taking these herbs does not improve, they should be stopped.
The following herbs may aggravate exhaustion and weakness, but their use may be possible if used low dose, and combined with a little circulatory stimulant eg. Capsicum or Zingiber

Humulus contraindicated or caution
Lobelia  caution
Piscidia caution
Valeriana caution

Chronic fatigue syndrome (CFS): stimulant herbs
▶ Sensitivity to herbs.

Ephedra, contraindicated Panax ginseng, and Turnera are generally unsuitable for patients with very weak or unstable energy, such as CFS, or related disorders such as fibromyalgia (FMS). They are too stimulant and liable to cause restlessness.

White Panax ginseng and Schisandra, if used for CFS, are best prescrribed in separate dropper bottles.

Ephedra contraindicated
Turnera contraindicated or caution: depending on dose
Panax ginseng (red) contraindicated or caution: depending on dose
Panax ginseng (white) caution
Schisandra caution

Gallbladder Disorders

Curcuma longa    contraindicated ? or caution: contraindicated by Commission E for obstruction of bile passages, but no reasons or references were given Chelidonium caution: only use after specialist diagnosis, and monitor
Taraxacum caution 
Zingiber caution: according to Commission E, only use after specialist diagnosis, but no reasons or references were given

Gynaecological Disorders

Premature thelarche
Premature thelarche is not listed as a disorder in this database. One study reported 4 cases of premature breast formation Foeniculum, but another study reported that no adverse results are expected in children from short-term use of fennel (▶ Foeniculum in database). However, prolonged intake should be avoided (B&M).

Infertility treatment
Vitex contraindicated or caution: depending on dose
It may be prudent to avoid prescribing Vitex when the patient is taking medications for infertility, or for IVF, that are intended to alter hormone levels. The exception to this would be the use of Vitex by a gynecology specialist, trained in herbal medicine, who thoroughly understood the hormonal effects of both the medications and Vitex.

Jaundiced neonates
Berberis caution
Hydrastis caution

Hormone replacement therapy
Vitex contraindicated or caution: One text recommended that in general Vitex should not be taken by patients using progesterone medications or HRT (B&). This is presumably a theoretical concern about the possibility that Vitex may increase progesterone levels.

Estrogen-dependent tumors
Cimicifuga caution especially at higher doses; practitioner should make their own decision on the basis of available evidence, but there seems to be no significant evidence to link Cimicifuga with breast or uterine cancer cell  proliferation

Vaginal dryness
Myrica contraindicated: as vaginal douche
Potentilla contraindicated: as vaginal douche
Quercus contraindicated: as vaginal douche

Headache and Migraine

In terms of Chinese medicine, herbs with a tendency to increase Liver Yang Hyperactivity have potential to aggravate or initiate headache.

Astragalus caution or contraindicated: depending on dose, and on degree of sensitivity
Panax gin. (red) caution or contraindicated: depending on dose, and on degree of sensitivity
Panax gin. (white) caution

Heat Sensations

Heat sensations is not given in the database as a disorder, but cautions are necessary for this situation, which may be considered contraindicated ‘normal’ in some situations, eg. menopause.
The following herbs are warming and therefore should be used with caution for those with mild to moderate heat sensations, and avoided for those with severe heat sensations.

Exceptions: Capsicum
There are exceptions to this rule, for example, the use of Capsicum to relieve heat stroke and normalize the body temperature is well known.

The following herbs can all be graded as contraindicated, contraindicated or caution, or caution, depending on dose, and on the severity of the patient’s heat sensations. 

Capsicum contraindicated or caution
Cinnamomum bark contraindicated or caution
Ephedra contraindicated or caution
Panax gin. (red) contraindicated or caution
Rosmarinus contraindicated or caution
Sanguinaria contraindicated or caution
Schisandra contraindicated or caution
Syzygium contraindicated or caution
Turnera contraindicated or caution
Zanthoxylum contraindicated or caution
Zingiber oficinale (dried) contraindicated or caution
Zingiber oficinale (fresh) contraindicated or caution
Myrica caution: unless combined with a cooling herb, eg. Hydrastis
Panax gin. (white) caution

Heavy Sensations and Mental Dullness due to Damp

Heavy sensations is not given in the database as a disorder, but Altheaea, Lycium, and Ophiopogon may aggravate this condition.

▶ Contraindicateduced appetite: moistening herbs (Digestive weakness).

Hepatic Disorders

Reduced Liver Function If there is merely mild to moderate contraindicateduction of liver function, the herb or combination can be taken as 1–2.5 ml of tincture, in quarter of a glass of water, 3 times per day, starting with 1 ml, and slowly increasing the dose to 2.5 ml only if necessary.

Risk patients
If the patient has pre-existing liver damage, liver carcinoma, or is taking potentially hepatotoxic conventional medication, and the practitioner wants to use herbal medicine, the practitioner may wish to take one or more of the following precautions:

• regular liver tests
• monitor for signs that may indicate hepatotoxicity, which include: yellowing of the eyes or skin, nausea or vomiting, abdominal pain or unusual ticontraindicatedness
• start with lower herb dose
• use decotions rather than alcohol-based tinctures or fluid extracts

Cimicifuga contraindicated: for cirrhosis or hepatitis until more is known
Sanguinaria contraindicated: for severe pre-existing liver disorders until more is known
Chelidonium contraindicated or caution: contraindicated for severe pre-existing liver disorders; until more is known, do not take for >1 month without breaks in treatment; liver testing may be appropriate

Sensitivity to alcohol
Decoctions or capsules: Apart from avoidance of alcohol for religious reasons, there are patients who cannot physically tolerate it. For these patients, herbs should not be supplied as tinctures or fluid extracts that are alcohol-based. The herbs can be prescribed either as decoctions of dried chopped herbs, or as powdecontraindicated herbs in capsule form.

Examples of this are the combinations Silybum 1, Silbum 2, Silybum 3, and Silybum 4, supplied as capsules, which are used to treat contraindicateduced liver function.

Alterative herbs
Alterative herbs may release toxins from the tissues into the bloodstream, which may put a strain on the detoxification capacity of a weak or damaged liver.
In my opinion, the use of standard doses of alterative herbs, such as Arctium seeds, Rumex, and Taraxacum, is contraindicated in cases of severe liver damage, unless the following precautions are observed.

The first step is to strengthen the liver by the use of small quantities of:

• bitter tonics with hepatoprotective effects, but no alterative action, such as Artemisia species, Gentiana, Rosmarinus, and especially, Silybum
• sour-astringent hepatoprotective herbs, eg. Schisandra
• sweet tonics with hepatoprotective and detoxicant effects, eg. Glycyrrhiza
• acrid herbs with hepatoprotective and detoxicant effects, such as Zingiber

Once the use of such herbs has begun to improve liver function, it may then be appropriate to add very small amounts of alteratives to the combination.

Hyperthyroidism

Hyperthyroid is not in the database as a disorder.

Ephedra contraindicated
Fucus caution

Neurological Disorders

These are not in the database as specific disorder.

Epilepsy
Thuja caution: theoretical concern due to thujone

Psychological Disorders

Anger, irritability
Ephedra contraindicated or caution: contraindicated in severe anger, may be possible to use in mild irritability, if combined with anxiolytic herbs, eg.  Anemone
Panax gin. contraindicated or caution: contraindicated in severe anger, may be possible to use in mild irritability if combined with anxiolytic herbs, eg. Anemone, Passiflora

Anxiety
Ephedra contraindicated or caution: contraindicated in severe anxiety, may be possible to use in mild anxiety if combined with anxiolytic herbs, eg. Anemone
Panax gin.  contraindicated or caution: contraindicated in severe anxiety, may be possible to use in mild anxiety if combined with anxiolytic herbs, eg. Anemone

Attention, concentration
The following herbs should be avoided, or used with caution, and in lower dose, if the patient is:

• driving or using machinery
• taking an important test or exammination

Humulus contraindicated or caution
Lavandula  contraindicated or caution
Piscidia contraindicated or caution
Valeriana contraindicated or caution

Morning mental dullness
Large doses of these herbs (> 5 ml), taken after 4 am, can result in mental dullness after rising for susceptible persons.

Bipolar Disorder or Mania
Ephedra contraindicated
Panax gin. contraindicated or caution: contraindicated in mania, may be possible to use in mild bipolar if combined with anxiolytic herbs, eg. Anemone
Hypericum caution: use with caution if tendency to mania or bipolar, since may aggravate this (B&M)
Rosmarinus   caution 
Turnera caution

Depression
Humulus contraindicated or caution: should be avoided for severe depression, and if used for patients with mild to moderate depression, should be used with a little Zingiber
Hypericum caution: Hypericum alone may not be enough by itself for severe depression, especially with suicidal thoughts, but may be a valuable adjunct to medication, but check for herb-drug interactions
Panax gin. caution: in cases of depression associated with emotional constraint and feelings of obstruction or fullness in the chest (Heart Qi Stagnation), since Panax ginseng may increase the sensations of pressure and discomfort in the chest
Piscidia caution: should be avoided for severe depression, and if used for patients with mild to moderate depression, should be used with a little Zingiber
Sanguinaria caution: in rare cases may aggravate depression, so best to prescribe in a separate dropper bottle from the main combination, and to start with a few drops, and sloly increase dose if there are no adverse effects

Hyperactivity
Ephedra contraindicated
Panax gin. contraindicated or caution: contraindicated in severe hyperactivity, may be possible to use in mild hyperactivity if combined with anxiolytic herbs, eg. Anemone
Rosmarinus caution
Turnera caution

Insomnia
Ephedra contraindicated or caution: contraindicated in severe insomnia, may be possible to use in mild insomnia, if used in the daytime only, eg. for acute asthma, and if combined with anxiolytic herbs, eg. Anemone
Panax gin. contraindicated or caution: contraindicated in severe insomnia, may be possible to use in mild hyperactivity if combined with anxiolytic herbs, eg. Anemone, or if, in terms of Chinese medicine, insomnia is due to Heart Deficient Qi
Rosmarinus contraindicated or caution: this herb is best avoided after about 4 pm, or it may aggravate insomnia
Turnera contraindicated or caution: best not taken after 3 pm for patients with insomnia and restlessness
Schisandra caution: some very weak patients, eg with chronic fatigue syndrome, may get restlessness or insomnia unless Schisandra is used at a very low dose.

Respiratory Disorders

Dry cough The following drying herbs should be used with caution for dry coughs (Lung Dryness or Lung Yin Deficiency in Chinese medicine), especially if there are also heat sensations.
Angelica arc. caution
Myrica caution

Moist phlegmy cough
Decoctions of the following herbs should be used with caution for patients with moist or phlegmy coughs Lung Phlegm Damp or Lung Phlegm Fluids in Chinese medicine), but the problem is unlikely with tincture or fluid extract.
Althaea caution
Lycium caution
Ophiopogon caution

Early-stage Infections
Schisandra contraindicated: in Chinese medicine, contraindicated for patients with Exterior Wind
Astragalus caution
Panax gin. caution in Chinese medicine, use caution for patients with Exterior Wind

Recurring Infections
In Chinese medicine, for the following herbs, use caution for patients with recurring respiratory infections (Retained Pathogen). Avoid use as a single herb, especially in the acute stage of the recurrence, or they may trap the pathogen in the body.
It may be possible, in some cases, to use one or more of these herbs if they are in combination with herbs that clear Retained Pathogen.
Astragalus caution
Panax gin. caution
Schisandra caution

Nasal Dryness
Myrica powder caution: Myrica snuff should be followed with nasal douche with saline, to prevent nasal dryness

Sweating

Sweating is not listed as a separate disorder in the database, but if it is chronic and due to weakness, and is spontaneous, on minimal exertion, or during an acute infection but does not relieve the condition, it is important to avoid the use of herbs, or dispensing methods of acupuncture, that further aggravate sweating.

Ephedra contraindicated
Zingiber contraindicated or caution: in acute Wind Cold or Wind Heat invasion, fresh Zingiber may be used to initiate sweating and relieve the condition, but in acute infection in which sweating does not alleviate the condition, Zingiber should be avoided or used with caution
Achillea caution: large amounts of hot Achillea infusion are excellent to break a fever, but should be stopped as soon as sweating is initiated and continuous, and should not be used if sweating does not relieve the condition

Skin Disorders

See “Alterative Herbs” in Lesson 4

Urinary Disorders

Hypokalemia
Convallaria contraindicated or caution: can be combined with Taraxacum leaves, which are high in potassium
Rhamnus contraindicated or caution: may result from flud and electrolyte loss following prolonged laxative abuse
Rheum contraindicated or caution: may result from flud and electrolyte loss following prolonged laxative abuse
Glycyrrhiza caution: avoid very high doses of Glycyrrhiza

Renal inflammation (‘irritation’)
Petroselinum contraindicated: theoretical concern about apiole, especially with the seeds
Juniperus caution: if the practitioner is concerned about this, then Juniperus can be combined with demulcent anti-inflammatories eg. Zea mays