To determine the patterns of use, knowledge, and attitudes toward complementary and alternative medicine (CAM) among pharmacists. Anonymous self-administered survey. 61st International Congress of International Pharmaceutical Federation (FIP), Singapore Traditional Chinese Medicine (TCM) Research Symposium, and retail and hospital pharmacies in Singapore. Pharmacists attending the FIP Congress, TCM Symposium, and pharmacists working in retail and hospital pharmacies. Frequency of use of different types of CAM by demographic attributes, knowledge scores, and attitudinal scores. Of the 430 surveys received, 420 fit the criteria for inclusion. Of the pharmacists, 84.3% reported use of some form of CAM in their lifetime. CAM was used for chronic and acute conditions. There was no difference in use of CAM based on gender and income. The mean score on the knowledge test was 7.23 of 10. Of the pharmacists, 72.6% were moderately satisfied with CAM and 79.4% indicated they would recommend CAM to family and friends. They received information on CAM from books/magazines (64%), friends/family (35.7%), and the Internet (31.4%). Eighty-one percent (81%) of pharmacists felt they had inadequate skills and knowledge to counsel patients on herbal medicine and 90.5% felt the professional curricula should have more components on CAM. The use of CAM among pharmacists is widespread and prevalent. The increased use of CAM necessitates the need for more education. Pharmacists acknowledge that CAM may have a place in health care and accept their role as information providers. There is also a need for reliable sources of information on CAM.

Context. The use of complementary and alternative medicine (CAM), particularly herbal medicine and their derived products, have been increasing. However, sporadic reports of serious adverse effects associated with the use of these products have become a source of concern. Spontaneous adverse event reporting may be used to monitor the safety of these products. Objective. The objectives of this study is to analyze and describe the patterns of adverse events associated with the use of Chinese Proprietary Medicine, other complementary medicine and health supplements (termed CAM products) in the Singapore Pharmacovigilance database from 1998 to 2009 and to highlight areas of safety concerns. Methods. Adverse events associated with CAM products reviewed by the Vigilance Branch of the Health Sciences Authority for the period 1998–2009 were collated and analyzed. The following information was extracted and collated: patient demographics, type and indication of CAM products, system-organ class affected, seriousness of the adverse event, route of administration, hospitalization status, outcome of adverse event, concomitant use of conventional medicine, adulterant testing and profession of the reporter. Results. In the period 1998–2009, 627 cases of adverse events due to CAM products were reported. Most of these 627 cases (80.2%) were found to be serious and most of the patients used CAM products for sexual performance enhancement (291, 46.4%), to relieve pain such as joint and neck pain (36, 5.9%) and for slimming purposes (27, 4.3%). Of the 627 cases, endocrine disorders constituted 22.5% and central nervous system disorders constituted 20.6%. Liver was the main organ involved in the serious cases. Twenty-two fatalities were reported and hepatotoxicity was responsible for the deaths of 10 patients during the study period. Conclusions. In conclusion, 627 adverse event reports associated with CAM products had been successfully analyzed and described. They constituted ∼3.8% of the total number of adverse events reported from 1998 to 2009. Outbreaks of severe hypoglycemia in 2008 and 2009 were associated with the use of adulterated and illegal sexual performance enhancement products. Further work to confirm the hepatotoxicity of implicated CAM products is warranted. Reporting of suspected adverse events is strongly encouraged even if the causality is not confirmed because any signs of clustering will allow rapid regulatory actions to be taken. The analysis of spontaneously reported adverse events is important in monitoring the safety of CAM products and helps in the understanding of the benefits and risks associated with the use of such products.

A tadalafil analogue and hydroxyhomosildenafil were isolated from a herbal product marketed for erectile dysfunction. The structure of the tadalafil analogue was elucidated using LC-UV, high resolution MS, ESI-MS/MS, IR, and NMR. The compound was determined to be (6R,12aR)-2-amino-6-(1,3-benzodioxol-5-yl)-2,3,6,7,12,12a-hexahydropyrazino[1′,2′:1,6] pyrido[3,4-b]indole-1,4-dione. This compound should be included as a target compound when screening for adulterants in herbal products. This is the first published paper on a tadalafil analogue and hydroxyhomosildenafil found as adulterants of a herbal product.