Atropin by Pflueger USA

POSSIBLY EFFECTIVE

• Poisoning. Oral activated charcoal taken after ingestion of certain drugs reduces systemic drug exposure. However, it is unclear if it affects clinical endpoints such as morbidity or mortality. Details: Taking activated charcoal orally appears to be effective when used as part of standard treatment for some, but not all, acute poisonings (12392,12393,93198,93606,93607,93613,94730). Single doses of activated charcoal, 25-100 grams in adults (10-50 grams in children, depending on age), are effective for preventing absorption of some drugs, including acetaminophen, aminophylline, amiodarone, aspirin, atenolol, carbamazepine, digoxin, fluoxetine, indomethacin, phenytoin, valproate, and verapamil, especially if taken within one hour of ingestion (93602,93610,93612,93613,94730,108852). A single dose reduces drug exposure by 38% to 52% when given within 1 hour, by 21% to 35% when given 2-4 hours after ingestion, and by about 14% when given 6 hours after ingestion. These late effects, occurring after oral absorption is complete, are due to enhanced elimination via interruption of enterohepatic circulation and binding of drug that has been actively or passively transported back into the gastrointestinal tract (105543). Multiple-dose activated charcoal, 50-100 grams initially followed by doses of 25 grams every 2 hours or 50 grams every 4 hours, or 10-25 grams per dose in children, is recommended for patients who ingest life-threatening amounts of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. This is based on clinical, animal, and in vitro research showing increased elimination of these drugs (12392,105543). This increased elimination can also reduce levels of drugs that have been given intravenously, with the median half-life being decreased by an average of 45% and the median area under the concentration/time curve (AUC) by an average of 47% (105543). Additional research suggests that multiple-dose activated charcoal may be useful for increasing the elimination of amitriptyline, digoxin, imipramine, moxifloxacin, nadolol, phenytoin, piroxicam, and sotalol. Evidence supporting the use of multiple-dose activated charcoal in aspirin, doxepin, tobramycin, valproate, or vancomycin overdose is limited or conflicting (12392,105543). While activated charcoal may reduce absorption of some toxic agents, there is contradictory evidence about whether it improves clinical outcomes (12392,93200,93601,93613,94730). Administering activated charcoal 50 grams every 6 hours for carbamazepine poisoning decreases the duration of coma by 9 hours, the duration of mechanical ventilation by 12 hours, and the length of hospital stay by 9 hours. However, activated charcoal does not reduce the duration of hospitalization, intensive care admission, vomiting, or mortality when compared with control after oral overdose of benzodiazepines, acetaminophen, or selective serotonin reuptake inhibitors (93200). Other preliminary clinical research in patients with phenytoin toxicity shows that taking activated charcoal 50 grams orally every 4 hours reduces the time to return to therapeutic levels by about 22 hours when compared with control, but without reducing symptoms (93609). In patients with pesticide or yellow oleander seed toxicity, neither single-dose nor multi-dose regimens of activated charcoal reduce mortality, seizures, or the need for intubation when compared with control (93601).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Celiac disease. Although there is interest in using activated charcoal for acute gluten exposure in those with celiac disease, there is insufficient reliable information about the clinical effects of activated charcoal for this purpose.
• Chemotherapy-induced diarrhea. It is unclear if oral activated charcoal is beneficial in patients with chemotherapy-induced diarrhea. Details: Preliminary clinical research in children treated with irinotecan shows that taking activated charcoal 250 mg the night before the first infusion and every 8 hours thereafter until the end of the cycle reduces the risk of diarrhea by 60% when compared with no treatment. Activated charcoal also appears to reduce the risk of severe diarrhea by 92% and to decrease chemotherapy discontinuation by 87% in these patients (93608).
• Cholestasis. It is unclear if oral activated charcoal is beneficial in patients with pregnancy-induced cholestasis. Details: Preliminary clinical research in pregnant patients with cholestasis shows that taking activated charcoal 50 grams orally three times daily for 8 days decreases bile acid levels by about 50%, compared with an increase in those not taking activated charcoal. However, itching was not significantly improved with activated charcoal when compared with control (126).
• Constipation. Oral activated charcoal has only been evaluated in combination with other ingredients; its effects when used alone are unclear. Details: A clinical study in patients with chronic constipation shows that a specific combination product (Nucarb; Wilshire Laboratories Ltd) containing activated charcoal 180 mg, calcium sennosides 50 mg, peppermint oil 0.5 mg, fennel oil 0.5 mg, rhubarb extract 250 mg, and sulfur 50 mg, taken as two tablets at bedtime for one week, followed by 1 tablet at bedtime for 1 week, reduces passing gas, abdominal pain, and sensation of bloating by 81%, 73%, and 72% respectively, when compared with baseline. Sensation of straining, severity of constipation, and feeling of incomplete evacuation were reduced by 69%, 67%, and 54% respectively, when compared with baseline (108853). The validity of this finding is limited by the lack of a comparator group.
• Dyspepsia. Oral activated charcoal has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in adults with functional dyspepsia shows that taking a specific combination product containing activated charcoal 280 mg, simethicone 90 mg, and magnesium oxide 180 mg (Carbosymag, Laboratoires Grimberg) three times daily for one month reduces symptoms of dyspepsia, such as postprandial fullness, epigastric pain, and abdominal bloating, when compared with placebo (93199). Other preliminary clinical research in patients with dyspepsia shows that taking another specific combination product containing activated charcoal 280 mg and simethicone 90 mg (Carbosylane, Laboratoires Grimberg) three times daily for 3 months does not improve overall symptoms of dyspepsia or nausea, but does improve abdominal fullness by 20%, bloating by 20%, and slow digestion by 30%, when compared with placebo (93604).
• Flatulence. It is unclear if oral activated charcoal is beneficial for reducing the occurrence of flatulence. Details: Some preliminary clinical research shows that taking activated charcoal (Requa Charcocaps) 582 mg after a gas-producing meal significantly decreases the number of flatus events when compared with placebo. On average, subjects taking activated charcoal reported less than 3 flatus events over 8 hours, compared with more than 14 flatus events in those taking placebo (12395). However, other preliminary clinical research shows that taking activated charcoal 520 mg at breakfast, lunch, dinner, and bedtime for 7 days does not significantly reduce excessive gas or total flatus events when compared with baseline (12396).
• Hangover. There is no reliable evidence that activated charcoal prevents or treats hangover. Details: Activated charcoal is included in some hangover remedies. However, ethanol adsorbs poorly to activated charcoal (12400).
• Hypercholesterolemia. It is unclear if oral activated charcoal is beneficial in patients with hypercholesterolemia. Details: Some preliminary clinical research in patients with hypercholesterolemia shows that taking activated charcoal 4-32 grams daily for 3 weeks decreases total cholesterol by up to 29% and low-density lipoprotein (LDL) cholesterol by up to 41% when compared with control. The effects of activated charcoal appear to be dose-dependent. Additional clinical research shows that taking activated charcoal 20 grams twice daily for 3 weeks is as effective as cholestyramine 8 grams twice daily for treating hypercholesterolemia (12398), but the combined use of activated charcoal and cholestyramine does not appear to confer additional benefit when compared with either agent alone (12397). However, other research suggests that activated charcoal is not effective for treating hypercholesterolemia (12399). Reasons for the discrepancies are unclear but may relate to the small size of the latter study, and the inclusion of some patients without hyperlipidemia.
• Hyperphosphatemia. Oral activated charcoal might reduce the incidence of hyperphosphatemia in patients with kidney disease. Details: Preliminary clinical research in a small number of patients with stage 3 or 4 chronic kidney disease (CKD) shows that taking activated charcoal 0.6-1.2 grams three times daily for 12 months reduces the risk of hyperphosphatemia by 64% when compared with placebo. Additionally, in CKD patients who develop hyperphosphatemia, use of activated charcoal at the same dose for up to 24 months seems to delay the development of vascular calcification when compared with calcium carbonate, but not when compared with lanthanum carbonate (103193). Other preliminary clinical research in patients on hemodialysis shows that taking activated charcoal for 24 weeks, at a starting dose of 600 mg three times daily, increasing by 300 mg three times daily every 4 weeks until the goal phosphate level is reached, reduces phosphate levels to the goal in over 90% of patients when compared with baseline (93611). The lack of a control group limits the validity of these findings.
• Tooth whitening. It is unclear if toothpaste containing activated charcoal is beneficial for tooth whitening. Details: A small clinical study in adults with dental stains due to factors such as coffee or tobacco use shows that using a toothpaste containing activated charcoal (Blanx Black, Coswell SpA) twice daily for 3 months reduces visible staining, dental plaque, and bleeding when compared to baseline, but not when compared with a micro-cleaning crystal toothpaste (Sensation White, Colgate) (111718).
• Wound healing. Research on the use of activated charcoal-containing dressings for wound healing is limited and conflicting. Details: One preliminary clinical study shows that treating chronic venous leg ulcers with activated charcoal-containing dressings (Actisorb, Systagenix) for 6 weeks reduces ulcer size by 17% when compared with control occlusive or semi-occlusive dressings containing antibacterial or antiseptic agents (94731). However, other preliminary clinical research shows that treating pressure ulcers or venous leg ulcers with activated charcoal-containing dressings (Actisorb and Actisorb Silver 220, Systagenix) for 4 weeks does not significantly improve wound healing when compared with a hydrocolloid dressing (93603). More evidence is needed to rate activated charcoal for these uses.

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There is insufficient reliable information available about the effectiveness of clubmoss.

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There is insufficient reliable information available about the effectiveness of Ignatius bean.

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INSUFFICIENT RELIABLE EVIDENCE to RATE

• Chemotherapy-induced peripheral neuropathy. A very small study in patients with bortezomib-induced peripheral neuropathy shows that taking 0.2-0.4 grams of nux vomica three times a day, providing no more than 18 mg strychnine daily, for 30 days improves self-reported neuropathy scores by about 15% when compared to baseline. The validity of this study is limited by the lack of comparator group (104775). More evidence is needed to rate nux vomica for this use.

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There is insufficient reliable information available about the effectiveness of star of Bethlehem.

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LIKELY SAFE ...when used orally, short-term (12392,12393,93200,93609,93610,93611,93613). ...when activated charcoal-containing wound dressings are used topically (93603,94731).

POSSIBLY SAFE ...when used orally, long-term. Activated charcoal has been used with apparent safety in doses up to 1.2 grams three times daily for up to 3 years (103193).

PREGNANCY AND LACTATION: POSSIBLY SAFE
when used orally short-term. Activated charcoal 50 grams three times daily for 8 days has been used with apparent safety in pregnancy (126).

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POSSIBLY UNSAFE ...when used orally. Clubmoss contains toxic alkaloids, but no poisonings have been reported (18).

PREGNANCY AND LACTATION: POSSIBLY UNSAFE
when used orally; avoid using.

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UNSAFE ...when used orally due to its toxic strychnine constituent. The US Food and Drug Administration (FDA) banned strychnine from nonprescription drug products in 1989 (18).

PREGNANCY AND LACTATION: UNSAFE
when used orally due to toxic effects (18).

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UNSAFE ...when used orally (2,13,18,505). Nux vomica in doses of 30-50 mg contains approximately 5 mg of strychnine, and can cause severe adverse effects. 1-2 grams of nux vomica contains 60-90 mg of strychnine, and can be fatal (13,18,65345). Chronic ingestion of lesser amounts can cause death after a period of weeks (18).

PREGNANCY AND LACTATION: UNSAFE
when used orally (2,13,18,505); avoid using.

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LIKELY UNSAFE ...when used orally. Star of Bethlehem contains toxic cardiac glycosides (15330,15331,15332,15333). Ingestion of star of Bethlehem could result in serious adverse effects including cardiac arrhythmia and death.

PREGNANCY AND LACTATION: LIKELY UNSAFE
when used orally. Star of Bethlehem contains toxic cardiac glycosides (15330,15331,15332,15333). Ingestion of star of Bethlehem could result in serious adverse effects.

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ALCOHOL (Ethanol) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = D The binding action of activated charcoal may be reduced by alcohol.  Details Alcohol may lower the adsorptive capacity of activated charcoal (12400).

CONTRACEPTIVE DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Activated charcoal may reduce the clinical effects of oral contraceptives.  Details Activated charcoal, taken in a dose of 5 grams four times daily for 3 days, may bind to, and reduce the absorption of, oral contraceptives, thereby limiting their effectiveness and increasing the risk of contraceptive failure. However, some clinical research shows that the risk for this interaction is minimal when activated charcoal is taken either 3 hours after or at least 12 hours before oral contraceptives (103192).

ORAL DRUGS Interaction Rating = Major Do not take this combination. Severity = High •  Occurrence = Probable •  Level of Evidence = B Activated charcoal reduces systemic exposure to many drugs, including those that undergo enterohepatic recirculation, regardless of the route of administration.  Details Activated charcoal adsorbs various drugs and may reduce their absorption and/or half-life. Examples of affected drugs include acetaminophen, aminophylline, amiodarone, atenolol, carbamazepine, dapsone, digoxin, disopyramide, fluoxetine, indomethacin, moxifloxacin, nadolol, phenytoin, phenobarbital, piroxicam, quinine, sotalol, theophylline, tricyclic antidepressants, valproate, and verapamil (12392,12400,93198,93602,93610,93612,93613,94730,105543). Avoid co-administration, except after drug overdose.

SYRUP OF IPECAC Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = C Syrup of ipecac is inactivated by activated charcoal.  Details Activated charcoal adsorbs and inactivates syrup of ipecac (12394). Avoid co-administration.

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CORTICOSTEROIDS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking star of Bethlehem with prolonged corticosteroid therapy might increase the risk of toxicity.  Details Star of Bethlehem contains cardiac glycosides (15330,15331). Concomitant use of corticosteroids with star of Bethlehem can increase the therapeutic and adverse effects of long-term corticosteroid use due to potassium depletion and electrolyte imbalance.

DIGOXIN (Lanoxin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking star of Bethlehem in combination with digoxin might have additive effects and increase the risk of toxicity.  Details Star of Bethlehem contains cardiac glycosides with effects similar to digoxin (15330,15331).

DIURETIC DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking diuretics with star of Bethlehem might increase the risk of toxicity.  Details Star of Bethlehem contains cardiac glycosides (15330,15331). Theoretically, concomitant use of potassium-depleting diuretics and star of Bethlehem can increase the risk of cardiac glycoside toxicity due to potassium depletion (506).

MACROLIDE ANTIBIOTICS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking macrolide antibiotics with star of Bethlehem might increase the risk of cardiac glycoside toxicity.  Details Star of Bethlehem contains cardiac glycosides (15330,15331). Macrolide antibiotics appear to increase the gastrointestinal absorption of oral digoxin. Theoretically, concomitant use of macrolide antibiotics might increase the absorption of the cardiac glycosides found in star of Bethlehem and increase the risk of adverse effects (17).

QUININE Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking quinine with star of Bethlehem might increase the risk of cardiac glycoside toxicity.  Details Star of Bethlehem contains cardiac glycosides (15330,15331). Quinine may reduce the clearance of oral digoxin. Theoretically, concomitant use of quinine might reduce the clearance of cardiac glycosides found in star of Bethlehem and increase the risk of adverse effects (2).

STIMULANT LAXATIVES Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, excessive use of stimulant laxatives with star of Bethlehem might increase the risk of toxicity.  Details Star of Bethlehem contains cardiac glycosides (15330,15331). Excessive use of stimulant laxatives can cause diarrhea, resulting in potassium depletion. This might increase the risk of cardiac glycoside toxicity.

TETRACYCLINE ANTIBIOTICS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking tetracycline antibiotics with star of Bethlehem might increase the risk of cardiac glycoside toxicity.  Details Star of Bethlehem contains cardiac glycosides similar to digitalis (15330,15331). Tetracycline antibiotics appear to increase the gastrointestinal absorption of oral digoxin. Theoretically, concomitant use of tetracycline antibiotics might increase the absorption of the cardiac glycosides found in star of Bethlehem and increase the risk of adverse effects (17).

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General ...Orally, activated charcoal is generally well tolerated.
Most Common Adverse Effects:
Orally: Abdominal pain, black stools, bloating, constipation, and flatulence.
Serious Adverse Effects (Rare):
Orally: Gastrointestinal obstruction and pulmonary aspiration.

Gastrointestinal ...The most common adverse reactions reported with activated charcoal are gastrointestinal in nature. Constipation appears to be the most frequent complaint, but is typically transient. Black stools, abdominal pain, bloating, and flatulence have also been reported (12392,12398,93611,103193). Rarely, activated charcoal may lead to gastrointestinal obstruction (12392).

Pulmonary/Respiratory ...Rarely, pulmonary aspiration has been reported in patients taking activated charcoal orally. This may happen if activated charcoal is regurgitated or if a misplaced nasogastric tube delivers activated charcoal to the lungs rather than the stomach (12392).

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General ...Orally, no adverse effects have been reported; however, a thorough evaluation of safety outcomes has not been conducted. Additionally, clubmoss contains toxic alkaloids, which could cause serious adverse effects (43721). When fir club moss (Lycopodium selago) is mistaken for clubmoss, cholinergic toxicity has been reported. This toxicity is due to huperzine A, which is not present in clubmoss (13193).
Airborne exposure to clubmoss spores might cause symptoms of asthma (43721).

Pulmonary/Respiratory ...Occupational exposure to clubmoss spores, including cases associated with facilities that use the spores to coat condoms, has been reported to cause asthma (43721).

Other ...Clubmoss (Lycopodium clavatum) might be mistaken for fir club moss (Lycopodium selago), which contains huperzine A, a constituent with strong inhibitory activity against acetylcholinesterase. In two case reports, fir club moss was mistaken for clubmoss and ingested as tea. This caused cholinergic toxicity with symptoms of sweating, nausea, dizziness, cramping, and slurred speech (13193).

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General ...Orally, Ignatius bean is generally regarded as unsafe for use. Any benefits of therapy may not outweigh the risk of toxicity. Ignatius bean 30-50 mg, which contains approximately 5 mg of strychnine, can cause restlessness, anxiety, heightened sense perception, enhanced reflexes, equilibrium disorders, painful back and neck stiffness, twitching, spasms of jaw and neck muscles, myoglobinuric renal failure, rhabdomyolysis, extreme muscle tension, and agitation and difficulty breathing after respiratory spasms (55854). Seizures have been reported to occur within 15 minutes of Ignatius bean ingestion (17). Taking Ignatius bean at a dose of 1-2 grams can be fatal (18). Most deaths occur within 3-6 hours of ingestion and are due to respiratory and subsequent cardiac arrest, anoxic brain damage, or multiple organ failure secondary to hyperthermia (18,505).
Long-term consumption of Ignatius bean can cause strychnine accumulation, particularly in individuals with liver damage. Chronic use can cause death after a period of weeks (18).
By inhalation, Ignatius bean has been reported to cause seizures (17).

Cardiovascular ...Orally, Ignatius bean 1-2 grams has been reported to cause fatal cardiac arrest within 3-6 hours of ingestion (55853,55855).

Endocrine ...Orally, Ignatius bean 1-2 grams has been reported to cause hyperthermia resulting in multiple organ failure within 3-6 hours of ingestion (18,505).

Musculoskeletal ...Orally, Ignatius bean 30-50 mg, which contains approximately 5 mg of strychnine, has been reported to cause rhabdomyolysis, painful back and neck stiffness, spasms of jaw and neck muscles, and extreme muscle tension (55854).

Neurologic/CNS ...Orally, Ignatius bean 30-50 mg, which contains approximately 5 mg of strychnine, has been reported to cause restlessness, anxiety, heightened sense perception, enhanced reflexes, and twitching. It has also been reported to cause seizures within 15 minutes of ingestion (55854). Taking 1-2 grams of Ignatius bean has been reported to cause death due to anoxic brain damage (18,505).
By inhalation, Ignatius bean has been reported to cause seizures within 5 minutes (17).

Pulmonary/Respiratory ...Orally, Ignatius bean 30-50 mg, which contains approximately 5 mg of strychnine, has been reported to cause respiratory acidosis and difficulty breathing due to respiratory spasms (55854).

Renal ...Orally, Ignatius bean has been associated with myoglobinuric renal failure (55854).

Other ...Orally, Ignatius bean 1-2 grams can be fatal. Most deaths occur 3-6 hours after exposure and occur from respiratory and cardiac arrest, anoxic brain damage, or multiple organ failure due to hyperthermia (55853). Chronic use of lower doses of Ignatius bean has been reported to cause death after a period of weeks (55853).

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General ...Orally, 30-50 mg nux vomica (5 mg strychnine) can cause restlessness, feelings of anxiety, heightening of sense perception, enhanced reflexes, equilibrium disorders, painful neck and back stiffness, followed later by twitching, tonic spasms of jaw and neck muscles, painful convulsions of the entire body triggered by visual or tactile stimulation with possible opisthotonos, muscle hypertonicity and agitation. Dyspnea may follow spasm of the respiratory muscles (18). Seizures occur within 15 minutes of ingestion (or 5 minutes of inhalation) and may result in hyperthermia, metabolic and respiratory acidosis, rhabdomyolysis, and myoglobinuric renal failure (17,65345). Nux vomica can be fatal (13,505); most deaths occur 3-6 hours post-ingestion from respiratory and subsequent cardiac arrest, anoxic brain damage, or multiple organ failure secondary to hyperthermia (18,505). Strychnine accumulates with extended administration (2).

Neurologic/CNS ...Orally, 30-50 mg nux vomica (5 mg strychnine) can cause restlessness, feelings of anxiety, heightening of sense perception, enhanced reflexes, equilibrium disorders, painful neck and back stiffness, followed later by twitching, tonic spasms of jaw and neck muscles, painful convulsions of the entire body triggered by visual or tactile stimulation with possible opisthotonos, muscle hypertonicity and agitation. Dyspnea may follow spasm of the respiratory muscles (18). Seizures occur within 15 minutes of ingestion (or 5 minutes of inhalation) and may result in hyperthermia, metabolic and respiratory acidosis, rhabdomyolysis, and myoglobinuric renal failure (17). In one case report, a 58-year old woman developed dizziness with abdominal and leg pain following a seizure, after ingestion of one nux vomica fruit. Her muscles were tense and hyper-reflexive and she had lactic acidosis and nystagmus (65345). Most deaths occur 3-6 hours post-ingestion from respiratory and subsequent cardiac arrest, anoxic brain damage, or multiple organ failure secondary to hyperthermia (18,505). Strychnine accumulates with extended administration, particularly in individuals with liver damage (2).

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General ...Star of Bethlehem contains cardiac glycosides, which can cause serious adverse effects.
Serious Adverse Effects (Rare):
Orally: Star of Bethlehem contains toxic cardiac glycosides that can cause cardiac arrhythmia and death.

Cardiovascular ...Orally, the cardiac glycosides in star of Bethlehem can cause cardiac arrhythmias (2).

Gastrointestinal ...Orally, the cardiac glycosides in star of Bethlehem can cause nausea and vomiting (2).

Neurologic/CNS ...Orally, the cardiac glycosides in star of Bethlehem can cause headache and stupor (18). Visual color disturbances can also occur (18).

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