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Identification number: DOI: 10.1016/j.imr.2014.05.001
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Eprints ID: 11989
To cite this version:
Kamsu Foguem, Bernard and Foguem, Clovis Adverse drug reactions in some
African herbal medicine: literature review and stakeholders’ interview. (2014)
Integrative Medicine Research, vol. 3 (n° 3). pp. 126-132. ISSN 2213-4220
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Adverse
drug
reactions
in
some
African
herbal
medicine:
literature
review
and
stakeholders’
interview
Bernard
Kamsu-Foguem
a,∗,
Clovis
Foguem
baLaboratoryofProductionEngineering(LGP),ENIT-INPTUniversityofToulouse,TarbesCedex,France bCenterforSmeel,TasteandFoodScience(CSGA),UMR6265CNRS,UMR1324INRA,UniversityofBurgundy,
Dijon,France
Keywords:
alternativemedicines complementarytherapies pharmacovigilancepractice toxicologicalriskassessment traditionalmedicine
Background:In viewofthelarge consumptionofherbalmedicineinAfricacountries,it islikelythatmanyadversedrugsreactionsgounrecordedwitheitherpatientsfailingto presenttohealthservices,ornopharmacovigilanceanalysisbeingmade,ortheanalysis notbeingreportedcentrally.Thisproblemisofinterestespeciallyforthosewhoare work-inginthegeneralareaofadversedrugreactionsorstakeholdersinthedomainofherbal medicineforconsideringsafetyissues.
Methods:Weareparticularlyinterestedinthewaythattheuseofverywell-knownandhighly valuedplantsislinkedtotheobservationofadversedrugreactionsinAfricancountries.We investigated,throughaliteraturereviewandusingtheInternet(withasemanticsearch strategy),somewell-knownorpopularmedicinalplantsusedinAfricanherbalmedicine (AHM).Otherinformationonthepropertiesrelatedtouse,andcharacteristicsofmedicinal plantswascomplementedbysomeinterviewswithstakeholders.
Results:Althoughsubstantialprogresshasbeenmadeinelucidatingthemechanismsof actionofmanydrugs,thepharmacologicalactionsofmanymedicinalplantsaregenerally notwellunderstood.Theresultsofaliteraturereviewsuggestthatthereportedadversedrug reactionsofherbalremediesareoftenduetoalackofunderstandingoftheirpreparation andappropriateuse.Theresultsofstakeholders’interviewssuggestthatthereisagrowing needtoprovidepatientswithcorrectinformationabouttheherbalmedicinestheyconsume.
Conclusion:Animportantaspectofherbalmedicineisthecorrect,timely,andintegrated communicationofemergingdataonriskasanessentialpartofpharmacovigilance,which couldactuallyimprovethehealthandsafetyofpatients.Thiscallsforimproved collabo-rationbetweentraditionalpractitionersandmodernhealthcareprofessionals,researchers, anddrugregulatoryauthorities.Inaddition,thereisaneedforanadversedrugreaction reportingsystemtofacilitatethecollection,monitoring,andevaluationofadversedrug events.
∗Correspondingauthor.LaboratoryofProductionEngineering(LGP),EA1905,ENIT-INPTUniversityofToulouse,47Avenued’Azereix,
BP1629,65016,TarbesCedex,France.
E-mailaddresses:Bernard.Kamsu-Foguem@enit.fr(B.Kamsu-Foguem),cfoguem@yahoo.fr(C.Foguem).
1.
Introduction
Medicinalplantsareimportantmaterialsforthe pharmaceu-ticalandcosmeticindustries.Neglectedsincethediscovery ofsyntheticdrugs,whichcanbeproducedinawiderscale, therehasbeen aresurgence ofinterest inplantmedicines inrecentyears.Itisestimatedthatapproximatelyhalfofall syntheticdrugshaveanaturalorigin.1Anysubstancewitha
healinginfluencecanalsogenerateunwantedoradverseside reactions.Aswithsyntheticdrugs,thequality,efficacy,and safetyofmedicinalplantsmustalsobeassured.Thereisa non-negligiblecontributionofAfricatotheworld’smedicinal plants’stock.Ineffect,Africaprovidesapproximately60,000 oftheworld’shigherplantspeciesandyetcontributes<8%of the1100drugsplacedonthemarketworldwide.2Manyplants
usedinherbalmedicineprovidevaluablepromisingmedical solutionstosomediseases[pathologiesandinfections],since many medicinalplantsare asourceofnewmedicines and thereforethey haveanessential role inmedicalresearch.3
African traditional medicine is “the most economical and available system of health carefor a large number of the Africanpopulationinruralandsemi-urbanareas.”4African
herbalmedicine(AHM)isafundamentalelementofAfrican traditionalmedicinepractices.
However,therearesomechallengesandopportunitiesin the improvement ofherbal medicine.The various adverse drugreactionsofherbalmedicinecarrywiththemspecificrisk factorswhichcanleadtoincreasedvulnerabilitytohuman health difficulties. In recognition of the increasing possi-bilities of purchasing medicinal products on the street or onlineworldwide,improvementmeasuresareneededto bet-terinformpeopleabouttheefficiencyandvulnerabilitiesof purchasingmedicines.Anadversedrugreactionisdefinedby EdwardsandAronsonas“anharmfulortroublesomereaction, duetointerventionrelatedtotheuseofahealingsubstance, whichenvisagesriskfromfutureadministrationandrequires prevention or explicit treatment, or alteration ofposology andmethodofadministration,orwithdrawalofthemedical substance.”5Thelatencyperiodbetweentheuseofadrugand
theoccurrenceofanadversereactioncanhelpinitscausality assessmentinpharmacovigilancemanagement.6Such
infor-mationcanbeinvaluableintheinterpretationofdrugsafety signals,andfacilitatedecisionsonfurtherprotectiveactions beingtakenthenandthetypeoffurtherinvestigationsabout alterationintheposology,orremovalofthesubstance.
2.
Methods
Weresearchedsomewell-knownor popularAHM products byusingaliteraturereviewandthroughtheInternet(usinga semanticsearchstrategy).
A thorough literature search was made by referring to books,peer-reviewedpapers,scientificdatabasessuchas Sco-pus,ScienceDirect,PubMed,andGoogleScholar.Keywords suchasadversedrugreactions,Africantraditionalmedicine, herbalornaturalproducts,alternativetherapy,surveillance, phytotherapyinrelationtomedicinalplantsweretheterms employed in the different semantic investigations. Other
Development of a trust-based relationship with African traditional health practitioners for effective communication and knowledge elicitation
Contact with African traditional health practitioners
Reported medicinal uses of the plants, substances isolated, and observed pharmacological effects (medicinal properties and adverse effects)
Literature survey
Type of plant (tree, herb, parasite, shrub, liana or aqueous plant), preparation of remedy (plant part, fresh, dried), dose and regimen, disease or symptoms treated
Collection of information about herbal practices
Fig.1–Theadoptedinformation-gatheringprocessfor herbalpractices.
informationonthepropertiesofmedicinalplantswas com-plementedbyinterviewswithstakeholders.Medicinalplants were identified based on their traditional use in different aspectsofAfricantraditionalmedicine.
In ourapproach,the information-gatheringprocess was basedbothonthedetailsofstakeholders’interviewsandthe outcomesoftheliteraturereview.Morespecifically,inorder toobtaininformationaboutherbalpracticesandtheir associ-atedeffects,wewentthroughthefollowingprocesswiththree phasesadaptedfromKamsu-Foguemetal7(Fig.1):
• ContactwithAfricantraditionalhealthpractitioners: develop-mentofatrust-basedrelationshipwithAfricantraditional health practitioners for effective communication and knowledgeelicitation.Trustisespeciallynecessaryforopen and operativecommunication, sincehealth practitioners keeptheirknowledgesecretanddonotwishtosharetheir know-howoutsidethefamilyenvironment.
• Collection of information about herbal practices: the infor-mation iscollected throughquestionnaires or structured interviews withstakeholders.Theformincludesthe fol-lowinginformationforconsideredherbalmedicines:type ofplant(tree,herb,parasite,shrub,lianaoraqueousplant), preparationofremedy(plantpart,fresh,dried),doseand regimen,diseaseorsymptomstreated.
• Literature survey with monographs, chemical abstracts and MEDLINE:weinvestigatedthepreviouslydescribed medic-inalusesoftheplants,substancesisolatedandidentified pharmacologicaleffects(medicinalproperties,alternative optionsfortheuseoftheplant,andadverseeffects).
3.
Results
Ourreviewassuchwaslimitedtohighlightingthepotential foradverse drug reactions inAHM.Thus,we have consid-ered thatit is essential toclearly delimitthe scope ofthe study,whichhasbeenrestrictedtocertainwell-knownand highly appreciated plants inAHM. Therich floraofAfrica (e.g.,thePaleotropicalnaturalenvironmentofCentralAfrica andtheCapensisnaturalenvironmentofSouthAfrica) con-tainsnumeroustoxicplantswithethnopharmacologicaluses (e.g.,parasitic,bacterial,fungalorviraltreatments,treatment ofcentral nervous system-relatedconditions, aphrodisiacs,
andformaternalhealthcare,miscellaneousconditionssuch ascancer,arthritis,andheartconditions).Toxicconstituents (e.g., neurotoxins, cytotoxins, and metabolic toxins) from theseplantscanharmthemajorsystemsofthehumanbody (cardiovascularsystem,digestivesystem,endocrinesystem, urinarysystem,immunesystem,muscularsystem,nervous system,reproductivesystem,andrespiratorysystem).8
Severalcausalityassessmentmethodshavebeenproposed toassesstherelationshipbetweendrugsandtheappearance ofadverseevents.Thosemethodsbelongtothreecategories: expertjudgment, probabilistic methods, and algorithmsor scales.9 In view of their attractive characteristics
(succes-siveevaluationofcriteria,sumofscoresor decisiontrees), scalesandalgorithmsareusuallyusedforoperational assess-mentsofadversedrugreactionsandtheyenableaneasyand convenienthandlinginvarioussituations.Forinstance,the CouncilforInternational OrganizationsofMedicalSciences (CIOMS)scale,alsoreferredtoastheRousselUclaf Causal-ityAssessmentMethod(RUCAM),10 isusedbymanyexpert
hepatologists,researchers,andregulatoryauthoritiesto eval-uatethepossibilityofsupposedunderlyingcausesofadverse drugreactions.Particularly, theCIOMSprovidesadvantages [standardized scale (chronology, risk factors, concomitant drug(s)orherbs(s),searchfornondrug/herbcauses,previous informationonhepatotoxicityofthedrug/herb,responseto unintentionalreadministration),validationforhepatotoxicity withexcellentsensitivity,specificity,andpredictivevalidity] fordrug-induced liverinjury and herbinduced liverinjury (HILI) causality assessment.11 Meanwhile, the CIOMS scale
hascertainweaknesses(e.g.,retrospective use,dechallenge criteria,qualitativelygradedriskfactors,andlimited exclu-sionofalternativecauses).Somechallenges(e.g.,thequality ofadversereactionreports)influencetheaccuracyin causal-ityassessmentofherbalmedicinalproducts.Theexploration ofomicstechnologies(genomics/transcriptomics,proteomics, and metabolomics) applied to toxicology (toxicogenomics, toxicoproteomics,andtoxicometabolomics)isavaluableway ofprovidingadditionalinformationrelatedtopredictivesafety assessment ofherbal medicinal products.12 Thepredictive
toxicityofherbalconstituentsgeneratesemerging opportu-nitiesthatareessentialtoimprove theknowledgebasefor integratedsafetyassessment.
Theresultsarepresentedintwosegments,oneonthe lit-eraturereviewandtheotheronthestakeholders’interview. Weobtained100reportsfromtheliteraturereviewand>50 stakeholders’interviews.Thisresearchtookplaceovera 2-yearperiodfromDecember2012toJanuary2014.
• TheliteraturereviewconductedintheareaofAHMonly reportedadversedrugreactionsoftenanegligible impact onthe globalhealth issuesinacountry orregion. How-ever,people areveryoftensubjecttosafety risksrelated toherbalmedicine whichaffect ormay affecttheir vital organs(e.g.,kidneys,lungs,liver,gastrointestinaltract)and couldcauseseriousdamagetoothervulnerableareasofthe humanbody.Thesurveyrevealsthatadversedrugreactions maybecausedbylogisticalandtechnicalproblemsor ques-tionabledecisionsbythetraditionalhealthpractitioners. The logistical and technical problems include poor har-vest,theinadequateidentificationofcomplexproperties,
inappropriatepreparation,improperconservationor incor-rectpackingofnaturalproducts.Theconsideredproblems arenotpeculiartotheselectedplantsalone,butexistalso inotherherbalmedicineproductsthatarenotincludedin thisstudy,becauseofthenonexhaustivenatureofthelistof productsencounteredinAHM.Furthermore,acertain con-trolrangecanbemadetomonitorthewidespreadpractice ofcombiningmanydifferentcompoundclassesandherbal typesorcreatingheterogeneousproductclassmodelsfor useintherapeuticprocedures.
• Thestakeholders’interviewresultsinsignificant informa-tion that hashighlighted (in additionto managerialand someregulatoryproblems)insufficientcommunicationin relationtoincreasedconsumptionofproductsfromAHM. Traditional health practitioners are capable of identify-ing simpleadverse drug reactions andtaking preventive actionsbylearningideaswithexperiencedfeedback pro-cesses.Meanwhile,forcomplexadversedrugreactions,the lackofapparentsymptoms,coupledwiththepotentialto causeseveredamagetokeyorgans,meansthateducational assistanceforcarefulandsafeuseofherbalmedicinal prod-uctsmust beencouraged,withspecialcareforhigh-risk patients. Theproblemistypicallymanifested bythe fact that informationisofteneitherinaccessible,incomplete, oroflowqualityaboutpotentialadversedrugreactionsof usedherbalproducts.Themanagerialandregulatory bar-riersarepresentinmanyAfricancountriesbythelackof clearenforcedrulesforbearingandsharingvarious expe-riencedfeedback processes,aswell asbythe absenceof systemsthatcanhelptopromoteintegrativepoliciesand implementation.
Examples of potential adverse effects of some herbal medicines with theirtraditionaluse and their countriesof originarepresentedinTable1.
4.
Discussion
Qualityofherbalmedicinesisamatterthataffectsthewhole worldtoday,witharequirementforthesafetymonitoringof herbalremedies,andthereisagrowingnecessitytoprovide consumerswiththecorrectinformationaboutthemedicinal productstheyconsume.Inthisperspective,qualitycontrolof herbalmedicineandgoodpracticesareindispensableforthe advancementoftheherbalmedicinesystem.24Quality
prob-lemsofherbalmedicinescanbecategorizedintotwoclasses: internal factors arisingfrom thedrug and externalfactors inclinicaluse.25 Theinternalsafety factorsrelatedtodrug
qualityinclude:rawherbals(speciesandorigin,placeof ori-ginandcollection,naturalenvironment,processing,storage), inactiveingredients,manufacturing,defectsofthe prescrib-inginformation/packageleaflet,limitationsofpremarketing safety studies,and adulterated and counterfeit drugs. The externalsafetyfactorsinclinicalusecomprise:lackof tradi-tionalmedicinetheoreticalguidance,failuretoadheretothe prescribinginformation,inappropriatecombinationwith allo-pathicmedicines,inappropriaterouteanddosingandtiming, incorrectpreparation,andindividualfactors.
Table1–Examplesofmedicinalplantswiththeirpotentialadversedrugreactions.
Medicinalplants Traditionaluses Potentialadverseeffects Origin
Pygeumafricanum (Prunusafricana)
Prostatecancer,prostatitis, benignprostatichyperplasia, otherurinarytractinfections, andaphrodisiac
Gastrointestinalupsets13 Cameroon,SouthAfrica, andMadagascar
Wildwisteria,violettree (Securidaca
longepedunculata)
Laxative,nervoussystem ailments(epilepsy),wounds, sores,coughs,venereal diseases,snakebites, bilharzias,headaches,fever relatedtomalaria,erectile dysfunctionoraphrodisiac, dysmenorrhea,andabortion induction
Acutekidney(corticalnecrosis, acuteinterstitialnephritis),injury, diarrhea,dehydration,and collapse14
Tanzania,Malawi, Soudan,BurkinaFaso, Congo,Zambia,and Zimbabwe
Madagascarrosy periwinkle (Catharanthusroseus)
Cancerchemotherapy Medullaryaplasia,leucopoenia, incoordinationofmovements, convulsions,fatigue,mucositis, constipation,andneutropeniaof shortduration15
Madagascar
RoundleafBuchu (Agathosmabetulina)
Diureticandurinarytract antiseptic,arthritis,treatment ofcellulite,cystitis,diarrhea, flatulence,kidneyinfections, nausea,rheumatism,and wounds
Gastrointestinalirritation,and centrilobularhepaticor hepatocellularnecrosis16 SouthAfrica UmckaloaboorSouth AfricanGeranium (Pelargoniumsidoides)
Coughs,upperrespiratorytract irritationsandinfections (bronchitis,sinusitis,and pneumonia,tonsillitis,and rhinopharyngitis),
gastrointestinaldisorders,and pain
Gastrointestinalcomplaints (nausea,heartburn,diarrhea),skin rashes,andallergic
(hypersensitivity)reactions17
SouthAfrica
Hoodiacactus (Hoodiagordonii)
Appetitesuppressantand anorecticaction
Potentiationofdiabetesmellitus (hyperglycemia),sometimes hypoglycemiaandconfusions18
SouthAfricaand Namibia Redspinach(also
knownasChinese spinach,Hon-toi-moi, Yinchoy,Hsientsai) orSpleenamaranth (Amaranthusdubius)
Diuresis[highbloodpressure, kidneyinfections,obesity,and theedemaassociatedwith premenstrualsyndrome(PMS) ortraumaticinjuries]
Hypotension,skinirritations,to extensiveorganandtissue damagewithdeathinduction19
Africa(e.g.,Ethiopia, SouthAfrica,Kenya, andUganda),Asia, India,Europe,West Indies,NorthAmerica, andSouthAmerica Birdflower(Crotalaria
laburnifolia)
Dysmenorrheaandabortion induction20
Acutekidneyinjury,hepatic veno-occlusivedisease,pulmonary injury,andthrombocytopenia
Africa(e.g.,Zimbabwe) andAsia(e.g.,SriLanka) Impila,ox-eyedaisy
(Callilepislaureola)
Impotence,evilspirits,and gastrointestinalcomplaints21
Chronicrenaldisease,acute kidneyinjury,hyperkalemia, abdominalpain,vomiting, diarrhea,adisturbedlevelof consciousness,convulsions,and liverfailure
NorthandSouthAfrica, andMediterranean Basin
Khatleaf(Cathaedulis) Centralstimulantaction(e.g., managementofobesityand depression)22
Chronickidneydisease,acute kidneyinjury(acutetubular necrosis),hepatotoxicity, cardiovasculardiseases (hypertension,cerebrovascular ischemia,dilatedcardiomyopathy, myocardialinfarction,and thromboembolism),diabetes, sexualdysfunction,duodenal ulcer,andhepatitis
EastAfrica,Yemen
Licorice(Glycyrrhiza
glabra)
Sorethroat,cough,arthritis, andweightlossinduction23
Acutekidneyinjury(hypokalemic nephropathy),amenorrhea, pseudoaldosteronism, hypertension,heartfailure,and rhabdomyolysis
Africanregionsareparticularlyconcernedbytheseissues requiringanadversedrugreactionreportingsystemtoreduce therisksofAHM.However,fewAfricancountries(e.g.,South Africa,Nigeria,andCameroon)havesubsequentlyintroduced herbal/traditionalmedicineaspartoftheirpharmacovigilance system. South Africa has a well-built plant biotechnology community, as well as the thorough implementation of a legal and operational framework for the guideline of the manipulationoflocalbotanicresources,and of genetically-modified organismsto improvehuman health.26 Nigeria is
ina positionto introduceadvanced investigations (assess-ment oftraditionalmedicine practitioners’ disposition and doctors’attitudes)whicheffectivelyexploretheopportunities fortheintegrationofherbalmedicineintothenationalhealth systemwithapplicableregulations.27,28InCameroon,the
gov-ernment,incollaborationwiththeWorldHealthOrganization (WHO),hassetupastrategicplatformfortheharmonization oftheAHMpracticeswithanorganizationalframeworkthat hasintegratedanationalcommissionspecializingin pharma-covigilanceandtraditionalpharmacopoeia.3
There are also other regions of the world (e.g., China, South Pacific, and India) with some problems related to herbal adverse drug reactions. Thecharacteristics of tradi-tionalChinesemedicinedrugsandtheirassociatedadverse drug reactions require an accurate understanding of local culturalandsocialrealitiesinordertoestablishastringent qualitycontrolandariskmanagementmodeladaptedtothe pharmacovigilancesystem(currentpractice,riskfactors,risk control,andfuture)inChina.29Inthiscontext,arecent
tox-icityevaluation(risk–benefitanalysis,severityoftoxiceffects, andclinicalandpreclinicaldata)ofChineseherbalmedicines hasledtothepropositionoffourregulatoryclasses:prohibited formedicinalusage(e.g.,aristolochia);restrictedformedicinal usage,(e.g.,ephedra);requiredwarninglabel(e.g.,coltsfoot); andover-the-counterherbs(i.e.,safetoxicityprofiles).30Inthe
SouthPacific,wefoundthekavaplant(Pipermethysticum) con-sumedworldwideforitsrelaxingpropertiesandusedtotreat generalanxiety.Traditionalaqueousextractsofthispacific herbusedinNewCaledonia,Australia,theUSA,andGermany areassociatedwithrarehepatotoxicity.Theprimarycauseof thekavaproblemwiththistoxicitycanbetracedtopoor qual-ityoftherawmaterialtriggeredbymoldhepatotoxins.31–33
Intheworldwidecases,theorgansmostnotablyaffected by herbal medicine consumption are the liver and kid-neys,astheyfunctionallydetoxifyandexcreteseveraltoxic substances including metabolic wastes. Many renal syn-dromes havebeen reportedfollowingthe use ofmedicinal plants,includingtubularnecrosis,acuteinterstitialnephritis, Fanconi’s syndrome, hypokalemia or hyperkalemia, hyper-tension, papillary necrosis, chronic interstitial nephritis, nephrolithiasis,urinaryretention,andcanceroftheurinary tract.34ArecentUnitedStatesresearchstudy,completedby
theEinsteinMedicalCenter,Philadelphia,reportedthatthe useofherbalanddietarysupplements(HDS)hasadevastating impactonconsumers’qualityoflife,astheybegintodamage theliverirreversiblyandthisrequiresarelevantclinical per-spectivetothediagnosisofHDS-inducedliverinjury(HILI).35
Infact,herbalanddietarysupplementsaregenerallyused throughouttheworld.Thereisalargeandvariedquantityof herbalmedicinalproducts(e.g.,AyurvedicandChineseherbs,
blackcohosh,chaparral,germander,greatercelandine,green tea, Herbalife, Hydroxycut, kava, pennyroyal, pyrrolizidine alkaloids, skullcap, and usnic acid), which are associated with a range of hepatotoxicity events.36–42 Progress inthe
understandingoftheepidemiologyofinducedcellandorgan injuries,thepathogenesis,clinicalobservations,and conse-quencesis requiredtobeableto advanceherbalmedicine safety.
5.
Conclusion
Inbothdevelopedanddevelopingcountries,self-medication and consulting community networks for many herbal medicines tendtodecreasemonitoringoftreatment adher-ence,asdoadverseeffects,whichpatientsmaynotalways mention.Morespecifically,theAfricanrealityclearlyshows thatnaturalproductsareperceivedassafeandsecurewith herbalmedicinesatsustainablelowprices.Ingeneral,AHM productshavesomepotentialsideeffects(dose-related, time-related, or failure of therapy) that can damage a basic structural, functional, and biological unit ofthe organism, such as a cell (cytotoxicity) or an organ such as the kid-ney(nephrotoxicity)ortheheart(cardiotoxicity)ortheliver (hepatotoxicity).Particularly,thestudiedmedicinalplantscan causeproblemsinsomesystemsofthehumanbody(e.g., car-diovascular system,digestivesystem,and nervoussystem). Thus,withourresearchsample(Pygeumafricanum,wild wis-teria, Madagascarrosyperiwinkle,roundleafBuchu,South African geranium,Hoodia cactus, red spinach, bird flower, Impila,ox-eyedaisy,khatleaf,andlicorice),wehavenoticed someadverse drugreactions withseveral clinical manifes-tationsoftoxiceffectsofplantsthatcausegastrointestinal, respiratory,cardiovascular,andneurologicaldisorders.
Despite their lackofknowledgeofphysiopathologyand physiomolecular processes,traditional medicine practition-ers often possess information and experienced knowledge thatisnotyetwidelyoruniversallyknownandinsufficiently used.However,thesepractitionersshouldbeequippedwith adequate knowledge of the pharmacological properties of medicinal plantstobeabletoserveasaguideforthemto easilyidentifytheinformationneededfortheinterpretation ofadversemedicaleffectsandcounsellingpatients.Although manyimportantplantsofAfricawithethnopharmacological usescouldhavepotentialbiologicalactivities,therearea num-beroftheactiveprinciples(e.g.,alkaloids,cardiacglycosides, phorbolesters, lectins,and cyanogenicglycosides)inthese medicinal plants that are extremely toxic. Finally, medic-inal substances in the African traditional pharmacopoeia mustcomplywiththeinternationalPharmacopoeiaandWHO recommendations, tooffer good quality products and safe services. These improvements would have a considerable compactonthephysical,mental,andsocialbenefitsof tra-ditional medicine indevelopmentofbothpreventativeand therapeutichealthcareservicestopatientsinthefieldof inte-grativemedicine.
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