This image depicts Yunnan Baiyao capsules along with the so-called “red hit pill” reserved for extreme hemorrhage. The exact contents remain a classified secret; some have speculated that the red hit pill may contain a higher concentration of aconite. Photo courtesy Dr. Narda G. Robinson Veterinary medicine has a critical thinking problem. Across the country, from universities to private practices, veterinarians are dispensing a Chinese remedy originally named “Qu-huan-zhang-ying-bai-bao pill,” with limited knowledge of its contents. Developed by a Chinese medicine doctor in 1902, this putative hemostatic agent from the Yunnan province enjoys widespread popularity for the treatment of hemorrhage, bruises, swelling, and pain.1 Oncologists, general practitioners, and Chinese herbal practitioners incorporate it into their treatment regimens, hailing its value for everything, from hemangiosarcoma to post-surgical hemostasis. They may cite its antimicrobial, anti-inflammatory, and anti-cancer characteristics, as well, even though evidence supporting its benefits and safety in veterinary species seems marginal, at best.2 What might they have sacrificed in the process? Veterinary medical ethics, scientific standards of research, and intellectual honesty with themselves, their colleagues, and their clients. Let me explain. I have covered previously the ways in which prescribing proprietary Chinese formulations violates the American Veterinary Medical Association (AVMA) ethics. However, when veterinarians promote, sell, prescribe, dispense, and use this proprietary mixture,3 they are exposing patients to even more risk. Why? Because, years ago, the company revealed that those innocent-looking capsules harbor one of the most potent plant poisons, (i.e. aconite). What we know In the Chemistry World article titled, “The dead of aconite,”4 we learn that aconitine, an aconite alkaloid, is 100 times more lethal than strychnine. A 2 mg dose can kill a human. How much would kill a cow, cat, dog, or bird? For that matter, how much aconitine resides in a single capsule? That’s the problem. You can’t know. The Chinese government bought into the Yunnan Baiyao Group, Ltd., years ago; now, it has become the “most valuable TCM (traditional Chinese medicine) enterprise” in China.5 Obviously, this proverbial cash cow heightens the State’s commitment to keeping the lid on its ingredients and manufacturing processes. In fact, we would still be in the dark if the United States Food and Drug Administration (FDA) had not mandated at least minimal disclosure as a requirement for entry into the U.S. market. A 2014 write-up in the Beijing Review noted, “A hemostatic powdered medicine famous for stopping bleeding and relieving pain was thrown in the spotlight as its manufacturer admitted the medicine contains aconitum, a toxic herbal ingredient that, if used improperly, could cause discomfort like numbness of the mouth and limbs, nausea, and even life-threatening conditions such as breathing difficulties and cardiac arrhythmia. Yunnan Baiyao Group Co. Ltd., announced it has improved its product information disclosure as required and claimed its products are safe as its special processing technology has greatly reduced the toxicity of the aconitum. However, it still did not disclose the full formula of Yunnan Baiyao on the grounds that it is classified as a national-level secret recipe.”6 China’s President Xi Jinping’s forceful promotion of TCHM and his heavy-handed suppression of criticism have made researchers and practitioners fearful of expressing concerns about the dangers of Chinese herbal medicine.7 Now, with mounting reports of research fraud from China, Iran, India, and elsewhere, it is becoming even harder to have confidence in the safety of TCHM.8-10 San Qi, otherwise known as notoginseng, or Panax notoginseng, the main constituent in the popular hemostatic formula. Photo courtesy Dr. Narda G. Robinson The threat of poisoning Not all Chinese herb companies continued to sell Yunnan Baiyao after reports of problems began to mount, even before the “secret” about aconite emerged. The president of Mayway, a herb company founded in 1969, stopped its sale in June 2013. She wrote, “Dear Customers, there have been recent news reports surrounding Yunnan Baiyao (a.k.a. Yunnan Pai Yao). Reports include injuries related to its use, potential contamination, and undeclared ingredients. Mayway has decided to discontinue the sale of Yunnan Baiyao in oral form for internal use until which time the quality and safety have been assured.”11 While Mayway still does not carry the product, several traditional Chinese veterinary herbal medicine websites do; they promote it and typically fail to mention the special secret. A paper from Hong Kong called “Aconite poisoning in camouflage” delivers a sobering account of this exact issue (i.e. the problem of “hidden” aconite in Chinese herbal mixtures).12 It states: “As is the case with western pharmaceuticals, some herbs are toxic and must be used with caution. Generally, herbal poisoning is more difficult to manage. This is in part due to inadequate knowledge about the safety and efficacy of Chinese medicine. In Taiwan, it was reported that 47 percent of the potentially toxic effects of Chinese traditional medicines were either unknown or could not be found in the literature. Hence, toxicological problems associated with the use of herbal medicines may not be readily recognized.” Regarding aconite specifically: “In Hong Kong, aconite herbs are the most common cause of severe herbal poisoning. Aconite herb poisoning has been known since ancient times. In western countries, aconite poisoning usually occurs after ingesting the wild aconitum plant. In Asia most aconite poisoning cases are related to the use of aconitum rootstocks in traditional medicines…Aconitum alkaloids are the active ingredients and the source of toxicity. The amount and type of aconitum alkaloids are the main factors determining the severity of intoxication. For the same plant, the level of active ingredient is affected by the time of harvest and method of processing.” The paper also describes the public health significance of hidden aconite in herbal mixtures and the clinical challenge of diagnosing aconite poisoning. “When a patient presents with unexplained numbness, weakness, and cardiovascular symptoms, the possibility of aconite intoxication should be considered.” They conclude, “The frequent occurrence of “hidden” aconite poisoning has a public health significance for our community…Our report only represents the tip of the iceberg…It also highlights the importance of quality assurance in herbs with low margins of safety.” Yet, lacking a high index of suspicion, veterinarians are unlikely to even consider aconite toxicity in their differentials. Cao Wu, a processed form of aconite that owes its toxicity to a high content of aconitine alkaloids. Photo courtesy Dr. Narda G. Robinson Looking for solutions How do we avoid the risk of aconite toxicity in our patients? One option is to stop prescribing any Chinese remedy that includes it. China is not going to disclose the amount they put in their state-classified formula and likely will not switch to a policy of transparency. What other options exist? Rigorous research might be a start, but to accomplish this, those performing the testing would need substantially more awareness of the challenges of botanical medicine research.13 In fact, the number of unknowns involved in testing a proprietary formula might prove to be nearly impossible to overcome. Given the majority of currently available clinical trials on Chinese herbs in general lack factual, independently derived data on potency and purity, none of us know what the research subjects actually received.14-16 Compare this to the transparency standards instituted by the cannabis industry. Certificates of analyses, produced by licensed analytical testing laboratories, show potency and purity, listing pharmacologically active constituents (e.g. cannabinoids, terpenes, etc.) and reporting findings of pesticides, microbials, mold, and other contaminants.17 What is the way forward? Do we continue to violate veterinary medical ethics, maintain a childlike dependence on the advice of “masters” of Chinese medicine, act as distributors for their mystery mixtures and sell them to unsuspecting clients, and hope nothing bad happens? Or do we first independently analyze Chinese herbs and publish a complete accounting of their actual ingredients? Personally, I would prefer the latter. I’d love to know what each one of them contains and, furthermore, what makes up that tiny red pill in the famous hemostatic agent that’s supposedly reserved for life-threatening hemorrhage. Don’t we, and our clients, deserve to know? Narda G. Robinson, DO, DVM, MS, FAAMA, practices osteopathic medicine and veterinary medicine. Dr. Robinson taught science-based integrative medicine at the Colorado State University College of Veterinary Medicine and Biomedical Sciences for 20 years. In 2016, Robinson established her own academy in Fort Collins, Colo., where she teaches medical acupuncture, integrative rehabilitation, medical massage, and other integrative medical approaches. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News. References . Yao Q, Chang B-T, Chen R et al. Research advances in pharmacology, safety, and clinical applications of Yunnan Baiyao, a Traditional Chinese Medicine formula. Front Pharmacol. 24 November 2021. Volume 12 - 2021 | https://doi.org/10.3389/fphar.2021.773185 Gruenstern J. Yunnan Baiyao – miracle herb for your clinic. Innovative Veterinary Care. December 23, 2013. Accessed at https://ivcjournal.com/yunnan-baiyao-miracle-herb-for-your-clinic/ on January 2, 2024. American Veterinary Medical Association Website. Principles of veterinary medical ethics of the AVMA. Accessed at https://www.avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma#:~:text=Veterinarians%20shall%20not%20promote%2C%20sell,do%20not%20know%20the%20ingredients on January 4, 2024. Burks R. The dead of aconite. Chemistry World. October 22, 2021. Accessed at https://www.chemistryworld.com/opinion/the-dead-of-aconite/4014423.article on January 4, 2024. Zhang W. Most valuable TCM raw material companies in China 2022. Statista website. Accessed on January 4, 2024 at https://www.statista.com/statistics/1243633/china-market-capitalization-of-tcm-raw-material-companies/ Anonymous. Should recipes for Chinese medicine be open? Beijing Review. No. 22, May 29, 2014. Accessed at http://www.bjreview.com.cn/forum/txt/2014-05/26/content_620815.htm on January 4, 2024. Cyranoski D. China to roll back regulations for traditional medicine despite safety concerns. Nature. 2017;551:552-553. Accessed at https://www.nature.com/articles/nature.2017.23038 on January 2, 2024. Gaby AR. Is there an epidemic of research fraud in natural medicine? Integr Med (Encinitas). 2022;21(2):14-18. Jarry J. No, Traditional Chinese Medicine has not been vindicated by science. McGill Office for Science and Society website. November 10, 2023. Accessed at https://www.mcgill.ca/oss/article/medical-critical-thinking-health-and-nutrition/no-traditional-chinese-medicine-has-not-been-vindicated-science on January 2, 2024. Wong S-S and Sing M. Beijing mulls law banning ‘defamation’ of Traditional Chinese Medicine. Radio Free Asia. June 10, 2020. Accessed at https://www.rfa.org/english/news/china/tcm-defamation-06102020112400.html on January 4, 2024. Lau Y. Yunnan Baiyao Discontinued. June 6, 2013. Accessed at https://www.mayway.com/yunnanbaiyao/ on January 2, 2024. Poon WT, Lai CK, Ching CK, et al. Aconite poisoning in camouflage. Hong Kong Med J. 2006;12:456-459. Shipkowski KA, Betz JM, Birnbaum LS et al. Naturally complex: Perspectives and challenges associated with botanical dietary supplement safety assessment. Food Chem Toxicol. 2018;118:963-971. Lee A, Boysen SR, Sanderson J, et al. Effects of Yunnan Baiyao on blood coagulation parameters in beagles measured using kaolin activated thomboelastography and more traditional methods. International Journal of Veterinary Science and Medicine. 2017;5:53-56. Ness SAL, Frye AH, Divers TJ, et al. Randomized placebo-controlled study of the effects of Yunnan Baiyao on hemostasis in horses. Am J Vet Res. 2017;78(8):969-976. Murphy LA, Panek CM, Bianco D, et al. Use of Yunnan Baiyao and epsilon aminocaproic acid in dogs with right atrial masses and pericardial effusion. J Vet Emerg Crit Care (San Antonio). 2017;27(1):121-126. Leafly website. Certificate of analysis. Accessed at https://www.leafly.com/learn/cannabis-glossary/certificate-of-analysis on January 4, 2024.
