Zusammenfassung
Unter verschiedenen Risiken, die bei einer Arzneitherapie in der Schwangerschaft zu beachten sind, ist auch das der Gentoxizität. Die Problematik ist keineswegs nur für die Schwangerschaft von Bedeutung, hat aber für diese eine besondere Brisanz, und das gilt ebenso für die Fertilitätsbehandlung. Von der TCM-Welt ist dieses Risiko bisher kaum wahrgenommen worden, obwohl dazu eine beachtliche Menge an Daten, vorwiegend aus der chinesischen Literatur, vorliegt. Für eine Arzneidroge, nämlich Coptidis rhizoma (Huanglian), ist in einer großen Studie aus Taiwan gezeigt worden, dass Kinder im Alter von durchschnittlich 14,9 Jahren vermehrt Tumoren entwickelten, wenn die Mütter in der Schwangerschaft diese Droge eingenommen hatten. Doch Daten aus epidemiologischen Studien am Menschen oder aus Langzeit-Carcinogenitätsstudien am Tier, die den Goldstandard darstellen, sind für die chinesische Medizin die Ausnahme. In der Regel ist man gezwungen, auf In- vitro- oder In-vivo-Daten aus Mutagenitäts- oder Gentoxizitätsstudien zurückzugreifen, um das cancerogene Risiko einzuschätzen. Diese sind nur bedingt auf die therapeutische Situation in der Schwangerschaft übertragbar.
Es werden vorliegende Daten aus Mutagenitäts- oder Gentoxizitätstestungen für 30 schwangerschaftsrelevante Drogen dargestellt. Die Resultate sind überwiegend negativ, teilweise widersprüchlich, teilweise auch positiv. Unter den Testverfahren ist eine Hierarchie zu beachten. Ein positiver Gentoxizitätstest bedeutet nicht gleich, dass ein signifikantes Cancerogenitätsrisiko bestehen muss. Viele Lebensmittel enthalten ebenfalls Inhaltsstoffe, für die gentoxische oder cancerogene Eigenschaften nachgewiesen wurden. Idealerweise sind für eine Risikobestimmung auch antimutagene Effekte zu berücksichtigen, und es ist eine Quantifizierung des Risikos vorzunehmen. Dafür fehlen im Bereich der chinesischen Medizin allerdings derzeit die Voraussetzungen. Im Zweifelsfall ist, und das gilt besonders für die Schwangerschaft, der Grundsatz „safety first“ zu beachten. Für die 30 schwangerschaftsrelevanten Arzneidrogen wird eine Einschätzung des gentoxischen Risikos vorgenommen. Ferner werden Drogen mit besonderem gentoxischem bzw. cancerogenem Risiko aufgeführt, von deren Anwendung in der Schwangerschaft abzuraten ist. Eine derartige Einschätzung ist teilweise subjektiv und im Fluss befindlich und wird sich sicherlich durch die Generierung neuer Daten in der einen oder anderen Richtung ändern müssen. Für eine Beurteilung der Schwangerschaftsrisiken der chinesischen Arzneitherapie hat sich in Deutschland die Arbeitsgruppe Sicherheit der Chinesischen Arzneitherapie in der Schwangerschaft (ASCAS) gebildet.
Abstract
Among the various risks that have to be taken into consideration when drugs are used for the treatment of pregnant mothers is that of genotoxicity. Of course, the problem is not significant to pregnant mothers alone, but it is particularly critical for this group of patients as well as for those undergoing fertility treatment. Hitherto, the world of Traditional Chinese Medicine has hardly been aware of this risk at all, although there is a significant amount of data available, mostly in Chinese publications. With regard to one particular medicinal, namely Rhizoma Coptidis (Huanglian), an extensive study conducted in Taiwan provided evidence that children of mothers who had taken this drug during pregnancy tended to develop tumours when they reached the age of 14.9 years on average. However, data taken from epidemiological studies on humans or from long-term carcinogenicity studies on animals, which represent the “gold standard”, are the exception in Chinese Medicine. As a rule, one is obliged to resort to in-vitro of in-vivo data from mutagenicity or genotoxicity studies in order to be able to assess the carcinogenic risk. These data can only be applied to a limited extent to therapeutic situations during pregnancy.
The article presents data available from mutagenicity or genotoxicity studies of 30 drugs that are of relevance to treatments during pregnancy. The results are predominantly negative, partly contradictory and partly positive. It is to be noted that there is a hierarchy to be observed in test procedures. A positive genotoxicity test does not necessarily mean that there must be a significant carcinogenic risk. There are many foods that also contain substances which have been shown to have genotoxic or carcinogenic properties. Ideally, to assess the risk accurately, anti-mutagenic effects also need to be considered, and the risk must be clearly quantified. At present, however, in the field of Chinese Medicine the prerequisites for such assessments are missing. In the case of doubt, and this is particularly true with regard to treating patients who are pregnant, one must be guided by the principle of “safety first”. For the 30 medicinal drugs that are relevant to pregnancy, an estimation of the genotoxic risk is made. In addition, a list is given of the drugs that represent a particular genotoxic and/or carcinogenic risk and whose use is not to be recommended at all with patients who are pregnant. An estimation of this kind is to an extent subjective, it is liable to change and will have to be revised in one direction or another when further data becomes available. In Germany a work group, Arbeitsgruppe Sicherheit der Chinesischen Arzneitherapie in der Schwangerschaft (ASCAS) has been created to provide a judgement on the risks that Chinese medicinal drugs represent to pregnant mothers.
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Dieser Artikel basiert auf einem Vortrag des Autors beim Wissenschaftlichen Kongress der SMS „Chinesische Medizin im klinischen Alltag - Grundlagen, Anwendung & Wissenschaft“ vom 3. bis 5. Oktober 2014 in der Evangelischen Akademie Tutzing.
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Dr. med. Axel Wiebrecht, Arzt für Allgemeinmedizin. Ab 1982 Ausbildung in Akupunktur und Qigong bei Rhada Thambirajah, DÄGfA (Diplom A und B), AGTCM u.a., Hospitationen in der Klinik Kötzting und im Xiyuan-Krankenhaus, Beijing. Ab 1999 Ausbildung in Chinesischer Arzneitherapie (CA) bei Barbara Kirschbaum und Walter Geiger, Diplom. Seit 1994 niedergelassen in eigener Praxis für Allgemeinmedizin, Chinesische Medizin, Chirotherapie und westliche Naturheilverfahren in Berlin. Seit 2004 Erster Vorsitzender des Centrums für Therapiesicherheit in der Chinesischen Arzneitherapie. Regelmäßige Veröffentlichungen und Vortragstätigkeiten zu Sicherheitsfragen der CA. Mitglied der Arbeitsgruppe Sicherheit der CA in der Schwangerschaft.
Ein Erratum zu diesem Beitrag ist unter http://dx.doi.org/10.1007/s00052-015-0066-7 zu finden.
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Wiebrecht, A. Mögliche Gentoxizität chinesischer Arzneidrogen und Konsequenzen für die Schwangerenbehandlung. Chinese Medicine 30, 21–37 (2015). https://doi.org/10.1007/s00052-015-0053-z
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DOI: https://doi.org/10.1007/s00052-015-0053-z
Schlüsselwörter
- Chinesische Arzneitherapie
- Schwangerschaft
- Schwangerschaftsrisiko
- Gentoxizität
- Mutagenität
- Cancerogenität