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eople in Hong Kong with dietary restrictions could be unwittingly ingesting animal ingredients, including those banned by religious laws, in the form of everyday medicines. A new British study found that undeclared products of animal provenance are present in numerous common medications taken globally – and, like Britain, Hong Kong has no official requirements when it comes to the labelling of ingredients of animal origin. There are some cases in which medicines themselves are sourced directly from animals – blood thinner Heparin can come from pigs, for example, while some popular brands of oestrogen are made from pregnant mare’s urine. But more frequently, problem ingredients only crop up in the administered form of a drug, such as a tablet, often in the shape of fillers, binders and capsules. The three most common are lactose, used mainly as a filler, which comes from cow’s milk, and is traditionally extracted using rennet from calves’ stomachs; gelatin, used to make capsules, and traditionally made from the skin and bones of cows and pigs; and magnesium stearate, used as a lubricant in tablet manufacturing and to make tablets soluble, and traditionally made from rendered animal fat. According to an article (“Suitability of Common Drugs for Patients Who Avoid Animal Products”) published recently on the website of the medical journal BMJ, these three ingredients in particular are present in 74 of 100 of the most commonly used medications in Britain, including painkillers such as aspirin and paracetamol, and common medications to deal with high blood pressure, heart disease and stomach conditions. Co-author of the article Kinesh Patel, research fellow in the Wolfson Unit for Endoscopy at St Mark’s Hospital in Harrow, London, says the most popular drugs and their ingredients are very similar in Hong Kong; many large drug brands are global, and companies naturally prefer to make a single version of a drug and distribute it globally rather than catering for local markets with specific versions. The biggest issue, Patel found in his research, conducted with Kate Tatham, research fellow in the Section of Anaesthetics, Pain Medicine and Intensive Care at Imperial College, Chelsea and Westminster Hospital in

gelatin made from impure bones can itself be pure, but of course not everyone knows this, and there can be differences of opinion between various certifying authorities within of the most commonly used a specific religion. medications in Britain A flu vaccination contain animal products campaign in Scotland last year was delayed because of concerns among Muslims about pork gelatin in the vaccine. Saudi Arabia and Malaysia have even collaborated on a scheme to make gelatin from camels. According to Hong Kong’s chief imam Muhammad Arshad, medicines containing non-Halal ingredients are allowed in certain circumstances. “If the medicine is a basic need and life-saving then it could be used, on condition that there is no alternative medicine available. If it is not a basic need, just for a Vegetarians or people with dietary restrictions could be small sickness or improvement unknowingly consuming animal products through in a condition, then it is not allowed for a Muslim to use common medicines, writes Richard Lord it if he knows it is made of non-Halal items.” The tragedy is that, as Patel says, “all of this is entirely unnecessary”. Clear labelling would sort it out to a certain extent; substituting vegetarian alternatives for the most common animal products would sort it out entirely. Rennet from moulds and plants including soybeans can be used to extract lactose, for example, while vegetarian sources of gelatin and magnesium stearate are also available. “As time moves on, manufacturers will find it easier to go vegetarian treatments because they’re pharmaceutical products,” in it, so it’s OK’. But a lot of automatically,” says Patel. “If concerned about possible the spokesman adds. vegetarians don’t think that. you go to a hospital now, you’ll animal ingredients is at its most Kalpana Bhende, family Drug companies are not obliged find that no latex gloves are used acute when it comes to dietary physician at Hong Kong’s to talk about the manufacturing because some people have prohibitions based on religion; Matilda International Hospital, processes they use.” allergies, so we can move on followers of faiths as diverse as says that awareness of the issue Like Britain, Hong Kong does and eradicate problems. Islam, Judaism, Hinduism, is low in the city. not force drug companies to Regulations can change.” Buddhism and Jainism all “I have never encountered acknowledge where these The only potential issue is potentially have to avoid some any concern regarding this issue ingredients come from. cost: “Lactose manufacturers animal ingredients. from any patient, and hence “There are no particular would be up in arms, but the “You wouldn’t think that never encountered any requirements for labelling amount of lactose in a capsule is problems with people not taking people would stop taking a the ingredients of animal minuscule – fractions of a gram – drug that they need,” says Patel, their medication.” origins in registered so it’s unlikely to make much Of course, the problem is that “but then Jehovah’s Witnesses pharmaceutical products,” difference to the cost in the who are going to die still refuse they might do so without their says a Hong Kong Department long term.” blood transfusions [which doctor knowing. of Health spokesman. In the meantime, better “People lie to their doctors all followers of the Christian When ingredients of labelling would help everyone – denomination believe the Bible the time,” says Patel. “They stop animal origin are used in those with dietary restrictions, prohibits]. There are some very taking their drugs and lie about pharmaceutical products, and those who’d rather just dogmatic adherences.” it, even drugs that are really manufacturers are only forced know what’s in the medications Confusing the picture important – I’ve heard of it to provide evidence that they they’re putting inside their further, there’s not always happening with organ-rejection have taken measures to bodies. The presence of animal agreement within specific medication. We’ve got to make minimise the risk of products, says Patel, “isn’t a religions such as Islam or sure people don’t have a reason transmission of communicable scandal itself, but the lack of Judaism about what’s allowed to stop taking their medicine – diseases to people. labelling is. It should be pretty and what isn’t. A 1995 World otherwise it’s not doing anyone “The Department of easy to find out what’s in a Health Organisation conference any good.” Health will remain vigilant on drug”. As it stands, it really isn’t. of Jewish and Muslim scholars The problem of people the global development of decided, for example, that discontinuing with medical labelling requirements for


A tough pill

to swallow

London, is that the possible animal origin of ingredients is rarely marked on drug packaging or information leaflets; and even when potentially problematic ingredients are listed, crucial information about how they were obtained often isn’t. Lactose, for example, was found in 49 of the 100 drugs tested; only eight of them declared the use of calf rennet. When the researchers contacted the makers of the 10 most popular that didn’t specify, four confirmed the use of calf rennet, one of a vegetarian alternative – and five didn’t reply at all. That, says Patel, means that patients concerned about the ingredients of a drug often can’t even turn to the manufacturer for information. “A lot of manufacturers we discussed this with didn’t understand the question and didn’t see the problem. They’d say: ‘Lactose doesn’t have rennet

Manufacturers we discussed this with … didn’t see the problem KINESH PATEL (ABOVE), RESEARCHER


Penicillin allergy or a rash judgment? ................................................ Dr Ray Ng Penicillin is one of the most important antibiotics we can prescribe for chest, throat and skin infections. The advantages of penicillin are that it is safe to use during pregnancy and breastfeeding, and is well tolerated in children. It is found in benzylpenicillin V, which is given as an injection. It is loosely related to amoxicillin, an oral antibiotic. A familiar antibiotic may be co-amoxiclav/augmentin, which contains amoxicillin and clavulanic acid. But some people are allergic to the drug. Symptoms may vary from a mild skin rash to a severe chain reaction within the body called anaphylaxis. Anaphylaxis cases caused by true penicillin allergy occurred at a rate of one to five per 10,000 cases of penicillin treatment, according to a review paper by Sanjib Bhattacharya of the Bengal School of Technology which was published in the Journal of Advanced Pharmaceutical Technology and Research in 2010. There is no published data on rates of penicillin allergy in Hong Kong. Two of Hong Kong’s leading allergy specialists, Dr

Lee Tak-hong, head of the Allergy Centre at the Hong Kong Sanatorium and Hospital, and Dr Adrian Wu Young-yuen, head of the Centre for Allergy and Asthma Care, have not found an increased prevalence of penicillin allergy in any specific ethnic population. Both Lee and Wu agree there is no evidence to confirm hereditary factors play a major role – if one of your parents is known to have a penicillin allergy, this does not necessarily increase your chances of developing it. If you are allergic to penicillin, doctors are obliged to err on the side of caution and note it on your medical record. This is because even when the initial allergic response is relatively minor, subsequent exposure to the antibiotic can trigger a severe anaphylactic reaction which can be fatal. If the doctor is unable to prescribe penicillin for you, this can restrict your choices, and less effective antibiotics may need to be used to deal with common infections. In cases such as recurrent tonsillitis, I rotate between different antibiotics to reduce the chances of drug resistance, where the antibiotic simply loses effectiveness. If the patient has a smaller number of nonpenicillinbased antibiotics to select from, resistance may arise more easily. A 2001 study in JAMA, led by Dr Alan Salkind of the University of Missouri-Kansas City School

of Medicine, said only 10 to 20 per cent of patients who selfreported penicillin allergy were found to be truly allergic. Patients I have seen over the years have reported an allergy to penicillin in a number of ways: • An event reported by a parent because they were too young to remember it. • The antibiotic causing a relatively mild reaction such as vomiting and diarrhoea. • An anaphylactic reaction causing a severe skin rash and serious symptoms within an hour of taking the antibiotic. There are two main types of allergic drug reactions, depending on the onset of presentation. With the immediate type, the reaction usually occurs within an hour of exposure and comprises an itchy skin rash called hives, swelling of the lips and tongue, difficulty breathing, dizziness and chest palpitations, abdominal pain and diarrhoea. These reactions on first exposure to penicillin are not life-threatening, but can be on subsequent exposure, as the immune response can unleash a more severe attack. The delayed type of reaction can occur on day seven of treatment, and even a few days after completing the course of antibiotic. The rash that appears can manifest in different forms. Therefore, it is not easy for doctors, let alone the patient, to tell whether they have a genuine penicillin allergy. If you have been presented with one of these scenarios in the past, consider taking some tests. The standard test for penicillin allergy involves skinprick testing (introducing the

allergic substance/allergen by scratching the skin) and intradermal testing (injecting the allergen just beneath the skin surface). A positive result would confirm you should not take penicillin. In the case of a negative result, this would then be followed by a controlled “provocation” test in a clinical setting with oral doses of penicillin to truly ensure that you are not allergic to the drug. You should wait four weeks after a severe allergic reaction before arranging a test, as the immune response may under-respond to testing. You should also stop taking oral antihistamines for at least one week to reduce the chances of getting a false-negative result. It is known that patients can “lose their allergy over time”. Wu states that the risk of penicillin allergy can reduce to less than 15 per cent after 10 years of avoidance. But it is still prudent to be retested before it is deemed safe for future courses of penicillin. Of all the drug allergies, penicillin allergy is the most common. It is encouraging that nowadays I am seeing fewer patients insisting on antibiotics for relatively minor viral infections, which reduces the risk of resistance for themselves. For patients who have been labelled with penicillin allergy, it is worth getting tested, so your antibiotic options are less limited in the future. Dr Ray S. H. Ng is a member of the Royal College of General Practitioners (Britain). He practises as a family physician in Central.

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