OVERVIEW

PRODUCT INFORMATION

REPRESENTATIVE TRADE NAMES

Nux vomica – Generic

DRUG CLASS

Herbal and Dietary Supplements

CHEMICAL FORMULA AND STRUCTURE

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DRUG	CAS REGISTRY NUMBER	MOLECULAR FORMULA	STRUCTURE
Brucine	357-57-3	C23-H26-N2-O4
Strychnine	57-24-9	C21-H22-N2-O2

ANNOTATED BIBLIOGRAPHY

References updated: 03 March 2023

Abbreviations: HDS, herbal and dietary supplements.

• Zimmerman HJ. Unconventional drugs. Miscellaneous drugs and diagnostic chemicals. In, Zimmerman, HJ. Hepatotoxicity: the adverse effects of drugs and other chemicals on the liver. 2nd ed. Philadelphia: Lippincott, 1999: pp. 731-4.

  (Expert review of hepatotoxicity published in 1999; several herbal medications are discussed, but not Nux vomica).
• Liu LU, Schiano TD. Hepatotoxicity of herbal medicines, vitamins and natural hepatotoxins. In, Kaplowitz N, DeLeve LD, eds. Drug-induced liver disease. 2nd ed. New York: Informa Healthcare USA, 2007, pp. 733-54.

  (Review of hepatotoxicity of herbal and dietary supplements [HDS] published in 2007; no mention of Nux vomica).
• Nux vomica. In, PDR for Herbal Medicines. 4th ed. Montvale, New Jersey: Thomson Healthcare Inc. 2007: pp. 607-9.

  (Compilation of short monographs on herbal medications and dietary supplements).
• O'Callaghan WG, Joyce N, Counihan HE, Ward M, Lavelle P, O'Brien E. Unusual strychnine poisoning and its treatment: report of eight cases. Br Med J (Clin Res Ed). 1982;285(6340):478. [PMC free article: PMC1499293] [PubMed: 6809135]

  (Eight persons developed acute strychnine poisoning within 30 minutes of inhaling a white powder thought to be cocaine; one patient dying of cardiac arrest, the others with varying degrees of muscle spasms and convulsions all having raised CPK levels; no mention of liver injury or serum aminotransferase levels).
• Boyd RE, Brennan PT, Deng JF, Rochester DF, Spyker DA. Strychnine poisoning. Recovery from profound lactic acidosis, hyperthermia, and rhabdomyolysis. Am J Med. 1983;74:507–12. [PubMed: 6829597]

  (42 year old man ingested strychnine and developed progressive muscle spasms, respiratory arrest, metabolic acidosis, renal failure, hyperthermia and muscle injury [CPK 8218 U/L] and was treated with paralysis, artificial ventilation, fluid replacement, treatment of acidosis and he eventually recovered; no mention of liver injury or serum aminotransferase levels).
• Katz J, Prescott K, Woolf AD. Strychnine poisoning from a Cambodian traditional remedy. Am J Emerg Med. 1996;14:475–7. [PubMed: 8765115]

  (58 year old Cambodian woman developed dizziness, abdominal pain, muscle spasms, and “awake” seizures shortly after ingestion of “slang nut” and was admitted with lactic acidosis, recovering with supportive therapy, testing of the product revealed it to be seeds from the Strychnos nux-vomica tree).
• Chan TY. Herbal medicine causing likely strychnine poisoning. Hum Exp Toxicol. 2002;21:467–8. [PubMed: 12412642]

  (A 42 year old woman treated with “magianzi” prepared from dried and processed Nux Vomica seeds developed tonic contractures of the limb muscles, perioral numbness, chest tightness and difficulty breathing within hours of drinking a second bowl of a herbalist prescribed herbal decoction, ultimately recovering with supportive therapy; liver function tests were said to be normal).
• Barquero Romero J, Redondo López JM, Galeano Díaz F, Pérez Miranda M. Med Clin (Barc). 2004;122:318–9. [Fatal acute pancreatitis in a patient who received an homeopathic treatment] [PubMed: 15030747]

  (67 year old man with type 2 diabetes developed severe epigastric pain and nausea 2 weeks after starting a homeopathic medication that included Nux vomica and Rhys Toxicodendron [Atlantic poison oak], evaluation revealed an acute hemorrhagic and ultimately fatal pancreatitis despite absence of history of clinical evidence of alcohol use, gallstones or liver injury [ALT 38 U/L, AST 27 U/L]).
• Jacobsson I, Jönsson AK, Gerdén B, Hägg S. Spontaneously reported adverse reactions in association with complementary and alternative medicine substances in Sweden. Pharmacoepidemiol Drug Saf. 2009;18:1039–47. [PubMed: 19650152]

  (Review of 778 spontaneous reports of adverse reactions to herbals to Swedish Registry found no cases attributed to Nux vomica).
• Reuben A, Koch DG, Lee WM., Acute Liver Failure Study Group. Drug-induced acute liver failure: results of a U.S. multicenter, prospective study. Hepatology. 2010;52:2065–76. [PMC free article: PMC3992250] [PubMed: 20949552]

  (Among 1198 patients with acute liver failure enrolled in a US prospective study between 1998 and 2007, 133 [11%] were attributed to drug induced liver injury of which 12 [9%] were due to herbals, including several herbal mixtures, usnic acid, Ma Huang, black cohosh, and Hydroxycut, but not Nux vomica).
• Parker AJ, Lee JB, Redman J, Jolliffe L. Strychnine poisoning: gone but not forgotten. Emerg Med J. 2011;28:84. [PubMed: 20810461]

  (49 year old woman developed acute agitation followed by muscle spasms within hours of suicidal ingestion of strychnine with progressive respiratory failure, lactic acidosis and CK levels rising from normal to 6262 U/L by day 2, but ultimate recover; no mention of liver injury or serum aminotransferase elevations).
• Achappa B, Madi D, Babu YP, Mahalingam S. Rituals can kill – A fatal case of brucine poisoning. Australas Med J. 2012;5:421–3. [PMC free article: PMC3442185] [PubMed: 23024715]

  (29 year old man developed intractable and ultimately fatal convulsions within hours of drinking a decoction that he made from the bark of a strychnine tree that he had mistaken for a Alsonia scholar tree, which had been used by his family in a yearly celebration; no mention of liver test abnormalities).
• Teschke R, Wolff A, Frenzel C, Schulze J, Eickhoff A. Herbal hepatotoxicity: a tabular compilation of reported cases. Liver Int. 2012;32:1543–56. [PubMed: 22928722]

  (A systematic compilation of all publications on the hepatotoxicity of specific herbals identified 185 publications on 60 different herbs, herbal drugs and supplements but does not list or mention Nux vomica).
• Björnsson ES, Bergmann OM, Björnsson HK, Kvaran RB, Olafsson S. Incidence, presentation and outcomes in patients with drug-induced liver injury in the General population of Iceland. Gastroenterology. 2013;144:1419–25. [PubMed: 23419359]

  (In a population based study of drug induced liver injury from Iceland, 96 cases were identified over a 2 year period, 15 of which [16%] were attributed to HDS products, but none were listed as containing Nux vomica).
• Bunchorntavakul C, Reddy KR. Review article: herbal and dietary supplement hepatotoxicity. Aliment Pharmacol Ther. 2013;37:3–17. [PubMed: 23121117]

  (Systematic review of literature on HDS associated liver injury does not mention Arnica montana).
• Navarro VJ, Seeff LB. Liver injury induced by herbal complementary and alternative medicine. Clin Liver Dis. 2013;17:715–35. [PubMed: 24099027]

  (Review of the epidemiology, regulatory status, diagnosis, pathogenesis and causes of liver injury from herbal products with specific discussion of conjugated linoleic acid, ephedra, germander, green tea, usnic acid, flavocoxid, aloe vera, chaparral, greater celandine, black cohosh, comfrey, kava, skullcap, valerian, noni juice, pennyroyal and traditional herbal remedies).
• Navarro VJ, Barnhart H, Bonkovsky HL, Davern T, Fontana RJ, Grant L, Reddy KR, et al. Liver injury from herbals and dietary supplements in the U.S. Drug-Induced Liver Injury Network. Hepatology. 2014;60:1399–408. [PMC free article: PMC4293199] [PubMed: 25043597]

  (Among 839 cases of liver injury from drugs collected in the US between 2004 and 2013, 130 were due to HDS products, including 45 from body building agents [probably anabolic steroids] and 85 from diverse HDS products but no case was attributed specifically to Nux vomica).
• Prat S, Hoizey G, Lefrancq T, Saint-Martin P. An unusual case of strychnine poisoning. J Forensic Sci. 2015;60:816–7. [PubMed: 25702781]

  (A 69 year old Canadian man was found dead at home, apparently after suicidal ingestion of rat poison with high levels of strychnine).
• Ponraj L, Mishra AK, Koshy M, Carey RAB. A rare case report of Strychnos nux-vomica poisoning with bradycardia. J Family Med Prim Care. 2017;6:663–665. [PMC free article: PMC5787976] [PubMed: 29417029]

  (39 year old Indian man made a concoction with 6 leaves of the Strychnos nux-vomica tree, and rapidly developed vomiting, agitation, muscle twitches and muscle tenderness followed by bradycardia and electrocardiographic changes, but with normal blood tests and full recovery within a few days).
• Singhapricha T, Pomerleau AC. A case of strychnine poisoning from a Southeast Asian herbal remedy. J Emerg Med. 2017;52:493–495. [PubMed: 27856027]

  (40 year old Cambodian woman presented with jaw pain and muscle spasms and strychnine detected in plasma and urine a few hours after drinking from a bottle that she thought was vodka but was actually “slang nuts”, a local preparation of Nux vomica seeds; recovering with supportive care; no mention of hepatic injury).
• Brown AC. Liver toxicity related to herbs and dietary supplements: Online table of case reports. Part 2 of 5 series. Food Chem Toxicol. 2017;107:472–501. [PubMed: 27402097]

  (Description of an online compendium of cases of liver toxicity attributed to HDS products, does not list or discuss Nux vomica).
• Medina-Caliz I, Garcia-Cortes M, Gonzalez-Jimenez A, Cabello MR, Robles-Diaz M, Sanabria-Cabrera J, Sanjuan-Jimenez R, et al. Spanish DILI Registry. Herbal and dietary supplement-induced liver injuries in the Spanish DILI Registry. Clin Gastroenterol Hepatol. 2018;16:1495–1502. [PubMed: 29307848]

  (Among 856 cases of hepatotoxicity enrolled in the Spanish DILI Registry between 1994 and 2016, 32 were attributed to herbal products, the most frequent cause being green tea [n=8] and Herbalife products [n=6], no mention of Nux vomica).
• Lu L, Huang R, Wu Y, Jin JM, Chen HZ, Zhang LJ, Luan X. Brucine: A review of phytochemistry, pharmacology, and toxicology. Front Pharmacol. 2020;11:377. [PMC free article: PMC7145893] [PubMed: 32308621]

  (Review of the chemistry, pharmacology and toxicity of brucine, a major component found in Nux vomica seeds which has antineoplastic and antiinflammatory activities in vitro but a narrow therapeutic window; “although brucine has an impressive preclinical profile in pharmacology research, serious toxicity limits its clinical applications” ).
• Downs J, Wolf CE, Williams G, Cumpston KL, Kershner E, Wills BK. Negligible Nux vomica: homeopathic Nux vomica remedies don't contain strychnine? Toxicon. 2021;200:1–2. [PubMed: 34181973]

  (None of a number of Nux vomica products purchased from homeopathic medicine and nutrition stores tested positive for strychnine or brucine using sensitive high-pressure liquid chromatography assays).
• Abhilash KP, Murugan S, Rabbi AS, Pradeeptha S, Pradeep R, Gunasekaran K. Deliberate self-poisoning due to plant toxins: verdant footprints of the past into the present. Indian J Crit Care Med. 2021;25:392–397. [PMC free article: PMC8138652] [PubMed: 34045805]

  (Among 150 patients seen over a 2 year period in an emergency room in South India with deliberate self-poisoning with plant products, the mortality rate was 9%, most were due to oleander [59%] or aduvanthalai [31%], but 4 were due to Nux vomica, all of which survived).
• Ballotin VR, Bigarella LG, Brandão ABM, Balbinot RA, Balbinot SS, Soldera J. Herb-induced liver injury: Systematic review and meta-analysis. World J Clin Cases. 2021;9:5490–5513. [PMC free article: PMC8281430] [PubMed: 34307603]

  (Systematic review of the literature on herb induced liver injury identified 446 references describing 936 cases due to 79 different herbal products, the most common being He Shou Wu [91], green tea [90] Herbalife products [64], kava kava [62] and greater celandine [48]; Nux vomica is not discussed).
• Bessone F, García-Cortés M, Medina-Caliz I, Hernandez N, Parana R, Mendizabal M, Schinoni MI, et al. Herbal and dietary supplements-induced liver injury in Latin America: experience from the LATINDILI Network. Clin Gastroenterol Hepatol. 2022;20:e548–e563. [PubMed: 33434654]

  (Among 367 cases of hepatotoxicity enrolled in the Latin American DILI Network between 2011 and 2019, 29 [8%] were attributed to herbal products, the most frequent being green tea [n=7], Herbalife products [n=5] and garcinia [n=3], while Nux vomica is not mentioned).