Chinese Herbs With Known Safety Concerns: Aristolochia, Ephedra, Aconite and Others

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Most Chinese herbs used with care cause no serious harm, but a few have caused documented injury. This page covers three well-documented cases with regulator or review sources, then points to other pages. It is information only. If you or someone else has taken a herb and has severe symptoms, such as trouble breathing, chest pain, fainting, seizure, confusion or an irregular heartbeat, call local emergency services (911 in the US). In the US, Poison Help is 1-800-222-1222 (poison help by country). Do not stop prescribed medicines on your own; speak to your prescriber.

Aristolochic acid (Aristolochia, Guan Mu Tong and related plants)

What happened. Aristolochia plants contain aristolochic acid. The FDA's import alert says several outbreaks of renal failure were traced to Chinese herbal products containing it, because the plant ingredient was misidentified or confused with a look-alike product through similar traditional Chinese names. [1]

What it does. The FDA calls aristolochic acid a potent carcinogen and nephrotoxin (a substance that damages kidneys) and warns that a product with a small amount could be used for years with no apparent effects until serious, irreversible kidney damage occurs. [1] A 2018 nephrology review lists kidney manifestations including acute kidney injury, chronic kidney disease and urothelial (urinary tract) cancer, and says exposure may call for later cancer screening. [2] A 2023 review states there is no effective treatment for delaying or reversing the kidney deterioration, and that the true number of cases is unknown and probably underestimated. [3]

What regulators did. In the US, FDA Import Alert 54-10 (published 10 December 2020) allows detention without examination of dietary supplements and other products containing Aristolochia and certain Asarum, Cocculus and Thottea species. [1] More detail: aristolochic acid and kidney injury.

Ephedra (Ma Huang)

Ephedra has a long history of medicinal use in China and India for colds, congestion and wheezing. [4] The FDA banned dietary supplements containing ephedrine alkaloids in a final rule effective 12 April 2004, after concluding they present an unreasonable risk of illness or injury. [5] The US National Center for Complementary and Integrative Health says that even at low doses and short term, ephedra has been linked to high blood pressure, heart attack, seizure, stroke and psychosis, and that use in pregnancy and by children is considered unsafe. [4] Do not assume a product is safe because it is labeled traditional; read Ma Huang Tang and ephedra safety.

Aconite (processed aconite roots)

Aconite roots contain alkaloids described as highly toxic cardiotoxins and neurotoxins. [6] In traditional Chinese practice the roots are used only after processing to reduce the toxic alkaloid content, and poisoning has followed larger-than-recommended doses and inadequate processing. [6] The Hong Kong Department of Health issued alerts in 2015 and 2018 about patients who developed numbness of the lips and limbs, dizziness, shortness of breath, nausea and vomiting after taking processed aconite herbs that they bought or took without a practitioner. It notes that poisoning can be fatal in severe cases and advises people not to self-prescribe Chinese medicines. [7][8] The 2018 alert listed no practitioner's consultation, inadequate decoction and overdose as suspected factors. [8] Because both overdose and inadequate processing have caused poisoning, this page gives no preparation guidance.

Other herbs and products to read about

• Liver injury reports: He Shou Wu and liver injury from Chinese herbs.
• Warfarin interaction reports: Danshen. Also see Licorice (Gan Cao).
• Toxic minerals and endangered animals: animal and mineral ingredients.
• Contamination and hidden drugs: Chinese herbal products: quality and interactions and undeclared drugs in patent medicines.
• A general review of nephrotoxic herbs notes that kidney harm can also come from incorrect processing or storage, adulteration, heavy-metal contamination, wrong dosing and herb-medicine interactions. [2]

Practical steps

• Tell every clinician what herbs you use, especially before surgery, with kidney or liver disease, in pregnancy, or with blood thinners or heart medicines.
• Use a licensed practitioner and ask what is in each product. Do not buy herbs for self-treatment of serious conditions.
• Report a problem: reporting a problem with a Chinese herbal product.