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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5856_Библиотеки_им_академика_М_И_Перельмана

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436 Farsad Nadjafi and Hartwig Schulz
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zones worldwide), Iran is a rich source of medicinal plants, some of which have been used in traditional medicine for centuries. The flora of Iran is very rich with almost 8000 species and, together with Turkey, these countries have the highest plant diver­sity and percentage of endemic plants (more than 2000 species) in the Middle East and West Asia (Ghahreman and Attar, 1999). It is estimated that nearly 13% of Iran’s plant flora (850–1000 species) are used as herbs in the traditional and ethno-medicine of the country (Bagheri and Reghan, 1994). Culti
­vation of herbs has a long history in Iran and the cultivation of some of them, like saffron, goes back to 3000 years ago (Koocheki,
2013). Cultivation of herbs in Iran is mostly done by local smallholders. According to the statistics of the Iranian Ministry of Agricul­ture, the cultivation area of medicinal plants in 2015 was about 171,463 ha (Salehi Sar­doei, 2022). Various herbs and spices are cultivated in different parts of the country such as coriander (Coriandrum sativum), tar­ragon (Artemisia dracunculus), fennel (Foe- niculum vulgare), dill (Anethum graveolens), cumin (Cuminum cyminum), black cumin (Ni-
gella sativa), damask rose (Rosa × damasce­na), saffron (Crocus sativus), blue mallow (Malva sylvestris), savory (Satureja horten­sis), anise (Pimpinella anisum), spearmint (Mentha spicata), and henna (Lawsonia iner­mis). The farmers used their own selected
propagation materials and the vast geo
­graphical distribution and different climatic conditions resulted in a rich genetic diver­sity of land races with different growth and quality characteristics. The cultivation and postharvest methods in these agricultural systems are based on traditional knowledge and are very labor-intensive (Fig. 15.1). Women have an important role in the collec­tion and processing of herbs. The products are mostly sold in local markets but rarely used by the pharmaceutical and food indus­tries, as they often do not meet the required standards. The reason is that the farmers use traditional processing methods like natural drying that may cause hygiene problems.
In recent years, the development of
medicinal plant industries and export markets
has significantly increased the demand for standardized herbal raw materials. These in­creased demands have led to the industrial cultivation of some aromatic and medicinal plant species such as cumin, peppermint, lemon balm (Melissa officinalis), coriander, damask rose, fennel, saffron, and tarragon, as well as introduced some new herbs such as Stevia rebaudiana and Aloe vera into the country’s agricultural systems (Fig. 15.2). As acreage expanded, so did the need for mech­anization and improved varieties, especially in terms of yield, resistances against drought, pests, and diseases, salt tolerance as well as quality.
Among the medicinal and spice plants, saffron has the largest area with almost 100,000 ha (Salehi Sardoei, 2022). Although the cultivation and harvesting of saffron require a lot of labor, the farmers are very interested in growing this plant species. The reason is its low water requirement and high economic income to be obtained from this crop. In 2014, 135 t of saffron were exported from Iran and it is estimated that the produc­tion volume in 2022 will reach more than 300 t (Salehi Sardoei, 2022). Damask rose is another plant that is extensively cultivated in Iran. Together with Turkey and Bulgaria, Iran is the largest producer of damask rose in the world. This species had a cultivation area of 18,000 ha in 2016. More than 85% of the cultivation area is located in Fars, Kerman, Isfahan, and East Azerbaijan provinces (Sale­hi Sardoei, 2022). The livelihood of many farmers in these regions is completely related to the cultivation and processing of this plant. Despite the large number of processing com­panies in the country, industrial production is mainly focused on rose water, which is a cheap product, while valuable products like essential rose oil, rose concrete, and rose ab­solute are produced only in very low amounts. This is mainly due to traditional concepts of the industry and low investment in new dis­tillation and extraction technologies in recent years. Cumin is another spice plant cultivated mostly in dryland agricultural systems of the country. The area of this plant under cultivation and production in Iran has significantly in­creased in recent years. In 2020, the cultivation
The Current Situation 437
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438 Farsad Nadjafi and Hartwig Schulz
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area was nearly 18,000 ha with more than 12,000 ha cultivated in Razavi Khorasan Pro­vince alone (Sefidkon, 2021). Coriander is also produced in Iran mostly for seed produc­tion and the spice industry; the cultivation area was nearly 7000 ha in 2021 and located mainly in Hamadan Province. Ninety-five percent of the production is exported to countries such as Pakistan, Germany, and the United Arab Emirates (Salehi Sardoei, 2022).
In Iran only 54 species are cultivated, while most of the medicinal plants (>95%) used in the country are collected from the wild (Mashayekhan et al., 2016). It is esti­mated that 40% of rural families in Iran live in poverty and rely on medicinal plant col­lection for their livelihood. Medicinal plants can provide a significant source of income for rural people in Iran especially through the sale of wild collected material, which contributes 10% to the total income of poorer households in the northeastern part
of Iran (Mashayekhan et al., 2016). Some wild collected medicinal plants of the coun­try that are well known in the international market are tragacanth (Astragalus gum- mifer), galbanum gum (Ferula gummosa), asafoetida (Ferula assa-foetida), and licorice (Glycyrrhiza glabra). Due to increased harvesting and unsustainable harvesting methods, many medicinal plant species are currently threatened in the country. The plants are mostly exported and introduced in the markets as raw and unprocessed ma­terials. There exist some licorice extraction companies with a production capacity of 18,350 t in 2021, of which 95% is exported (Salehi Sardoei, 2022).
Research and education
With the development of the medicinal plant industry, the need for scientific information
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and expert personnel in this field had increased. Research and education related to medicinal plants and natural products in Iran are man­aged by the following three ministries: the Ministry of Science, Research and Technology; the Ministry of Health; and the Ministry of Agriculture. The Ministry of Health is respon­sible for education at graduate level and research related to traditional medicine and pharma­cognosy. The Ministry of Science, Research and Technology is responsible for establishing scientific and technological bases in the field of medicinal and aromatic plants in areas such as agriculture, phytochemistry, biology and pro­cess engineering, etc. and for training experts in these fields. This Ministry has also created a National Network for Research and Technol­ogy of Medicinal Plants of Iran to improve the collaboration between laboratories, promote cooperation between industry and research in­stitutes, and organize scientific and technical conferences and workshops related to medicinal plants (https://en.mpnet.ir/, accessed 19 April
2023).
Figure 15.3 shows an overview of the
situation of education and research in the field of medicinal plants in 2014 and 2015. The number of scientific papers, the number of companies in science and technology parks, the number of journals that published articles
on medicinal plants, and the research in uni­versities increased from 2014 to 2015. Since standards in the field of medicinal plants were largely lacking in Iran, the responsible organ­izations developed appropriate standards in cooperation with universities, research insti­tutes, and industrial centers.
One of these standards, which was of particular importance to the country, is the national standard GAP (Good Agricultural Practices of Medicinal and Aromatic Plants). In addition, the number of companies associ­ated to universities has been increased, refer­ence laboratories have been installed, and more entrepreneurial offerings for medicinal plants have been developed (Fig. 15.4).
The revival of Traditional Iranian/Persian Medicine (TIM/TPM) and its use in the coun­try’s healthcare system was followed in recent years in medical universities. Figure 15.5 shows the situation of TIM/TPM and pharmacognosy in the universities during 2014 and 2015. Development of traditional medicine was not only pursued in universities, but also special­ized clinics were established to serve the public. The number of these clinics that serve TIM/ TPM was seven in the year 2015 (unpublished data of the National Council for Science and Technology Development of Medicinal Plants and Traditional Medicine).
PhD researches on the subject of MPs
Knowledge-based companies in science and
Academic journals (specialized & general)
publishing articles on MPs
Scientific articles on MPs (in ISI citation
Fig. 15.3. Education and research situation in the field of medicinal plants (MPs) in Iran in 2014 and 2015. (Unpublished data of the National Council for Science and Technology Development of Medicinal Plants and Traditional Medicine.)
technology parks
MP entrepreneurship centers
MP-related theses (×100)
databases) (×100)
2015 2014
0
10 20 30 40 50 60 70 80
Number
440 Farsad Nadjafi and Hartwig Schulz
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Standards on MPs
Entrepreneurship packages on MPs
Reference laboratories on MPs
University-based companies on MPs
0 20 40 60 80 100 120 140
Number
Fig. 15.4. Innovation and technology of medicinal plants (MPs) in Iran during 2014 and 2015. (Unpub­lished data of the National Council for Science and Technology Development of Medicinal Plants and Traditional Medicine.)
Graduated in Pharmacogonosy
Graduated in ITM
PhD students in Pharmacogonosy
PhD students in ITM
Faculty members in Pharmacogonosy
Faculty members in ITM
2015 2014
2015 2014
Fig. 15.5. The situation of Traditional Iranian Medicine (TIM) and pharmacogonosy fields in the medical universities in Iran during 2014 and 2015. (Unpublished data of the National Council for Science and Technology Development of Medicinal Plants and Traditional Medicine.)
The trend toward herbal medicine, medicinal plants as well as the use of traditional medi­cine medical services has led to the continous growth of herbal products industries in the country. In 2015, already 350 medicinal plant companies existed in Iran and from them, 183 companies produced herbal waters, plant ex­tracts, and essential oils. It should be said that most of them are selling herbal waters due to
Industry
0 100 200 300 400 500
Number
the high national consumption and good mar­kets in Arab countries (unpublished data of the National Council for Science and Technol­ogy Development of Medicinal Plants and Traditional Medicine). Figure 15.6 shows the number of herbal products and licenses issued to manufacture herbal medicines and other plant-based products during 2014 and 2015. To support the medicinal plant industries, the government placed 56 herbal drugs under in­surance coverage.
The Current Situation 441
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Number of plants used in herbal and traditional
Approved licenses for traditional medicine
Approved licenses for essential oils and extracts
Fig. 15.6. The situation of herbal products in Iran during 2014 and 2015. (Unpublished data of the National Council for Science and Technology Development of Medicinal Plants and Traditional Medicine.)
National policy-making processes aiming
to improve the market for medicinal plants
medicine products
products
Herbal drugs under insurance coverage
Approved veterinary drugs
2015 2014
Approved licenses for herbal products
0 200 400 600 800 1000 1200 1400 1600
Number
resulting in vomiting, diarrhea, coma, or other toxic reactions. In this way, however, early humans were able to develop a huge know-
Due to the large number of government organizations involved in the issue of medicinal plants, in order to improve coordination among these organizations and ministries and to define national strategies, the National Coun­cil for Science and Technology Development of Medicinal Plants and Traditional Medi­cine was established at the Vice Presidency of Science and Technology in Iran. This Council has prepared the national document on medicinal plants and traditional medicine, which defines the country’s strategies in this area. All ministries and governmental organiza­tions are obligated to perform their duties within the framework of these strategies.
ledge about edible materials and natural medicines. Subsequently, humans invented fire, learned how to make alcohol, developed religions, achieved technological break­throughs, and learned how to develop new medicines. All the different forms of Trad­itional Medicine such as Traditional Chinese Medicine (TCM), Ayurveda, Kampo, Tradi tional Korean Medicine (TKM), Traditional Per­sian Medicine (TPM), and Unani use natural products and have been practiced around the world for hundreds or even thousands of years, and they have developed into properly regulated systems of medicine. In their vari­ous manifestations, they have certain short­comings, but they are still a valuable part of human knowledge (Fabricant and Farnsworth,
Adaptation of Traditional Persian
Medicine Products to European
Market Needs
2001; Alves and Rosa, 2007).
Persia was a center of academic know­ledge in ancient times and became the first world empire in history, stretching at those times from Bulgaria to Pakistan and from
Using natural products as medicines must have been an enormous challenge for early humans and it is very likely that they often ingested poisonous plants in search of food,
Egypt to the Caucasus. The experience and knowledge of Greece, Egypt, Babylon, India, and also China could thus enrich TPM and develop it over the last 4000 years.
442 Farsad Nadjafi and Hartwig Schulz
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During the Middle Ages and the follow­ing centuries in Europe, mainly monks, ex­perienced women, and later pharmacists practiced the art of healing by means of nat­urally obtained extracts and preparations. This Traditional European Medicine (TEM) was enriched from the 15th century onward by the discovery of America and India with new plants and healing methods. Today, multicomponent mixtures and their natural substances are still in the focus of modern pharmaceutical research. In this context, scientists specialized in various disciplines are working closely together to find new ap­plications for plant constituents in comple­mentary medicine or to rediscover trad­itional knowledge with the techniques and methods available today on the basis of cur­rent studies (Bunse et al., 2022).
Thus, in the Western world, phytother­apy became the culmination point for the emergence of today’s classical medicine. Today, nearly a quarter of all modern medi­cines are derived from natural products, which thus represent a resource for primary care, but also have become very important for innovation and discovery of new active substances. As can be demonstrated by the discovery of artemisinin to combat malaria, the extensive knowledge of natural products is very promising for the future, and it is therefore expected that modern analytical techniques will be a very important tool to identify other pharmaceutically relevant ac­tive compounds in plants endemic to Iran (Wu, 2009).
In order to reorganize and support the worldwide application of Traditional Medicine systems, the World Health Organization (WHO) has published various policy papers aiming to strengthen quality assurance, safety, proper use, and efficacy, in particular through the regulation of traditional medical products. In this context, the importance of training, skill development, services, and reliable therapies is also clearly emphasized (WHO, 2015). More than 100 million Europeans are currently users of TCM, with one-fifth using TCM regularly and preferring healthcare including TCM. There are many more TCM users in Africa, Asia, Australia, and North America.
In modern times, it is often forgotten that TEM and TPM have a common heritage based on the four elements doctrine, the so­called “humoral medicine”. Various medi­cinal plants known in Europe, such as sage (Salvia officinalis), fennel (Foeniculum vul- gare), and lovage (Levisticum officinale), had already been mentioned by Avicenna and are later found in various herbal books on herbal remedies of monastic medicine. In Europe, Persian physicians were long regarded as role models, and many elements of TPM were incorporated into European healing practice in the 13th century. Avicenna in particular is considered the “father of mod
­ern medicine” because he was the first who introduced clinical trials to experimentally test medicines for their individual effective­ness of natural healing substances. Import­ant approaches to health prevention can also be taken from various Islamic writings such as the Taqwim al-Sihha (Tacuinum sani- tatis) written by Ibn Butlan, in which indi­vidual food materials were assigned to the four elements (warm, cold, moist, dry) and in this way the different health effects of a food were presented for the first time.
In recent years, medical systems such as TCM and Ayurveda are attracting more and more attention in the Western world, where the demand for inner balance and a holistic view of body and mind has increased signifi­cantly. In this context, numerous vitality and wellness organizations have emerged that have developed individual concepts from these two traditional systems and adapted them to the Western way of life. In addition to the respective herbal therapies, one of the main goals is a change of the nutritional pattern based on Avicenna’s approach that a balanced diet using valuable food components has a significant impact on human health. Today, it is widely recognized among health
­care providers that access to a healthy diet, optimally adapted to our living conditions, significantly strengthens our immune system and reduces the risk of diabetes and cardio­vascular disease, including inflammation, ele­vated cholesterol, high blood pressure, and poor sleep. The main emphasis of this “food as medicine” concept is put on the consumption of a variety of herbs and spices, legumes,
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nuts and seeds, fruits and vegetables, while the concept of conventional medicine is based primarily on technological medical ad­vances to treat diseases with various syn­thetic drugs. However, the concept of “food as medicine” does not always work equally well for all people, which is why the individ­ual case must be carefully examined. In many cases, however, it is advisable to carry out the change in diet with the help of dietary supplements and in conjunction with appro­priate conventional medical treatment.
The marketing of phytopharmaceuti­cals based on endemic species is difficult because these plant species must first be approved by the European authorities, and this process is usually time-consuming and costly. To enable inclusion in the European Pharmacopoeia (Ph.Eur.), it may therefore be advantageous to first cultivate the rele­vant species in Europe in order to increase awareness in individual European countries. Corresponding studies were conducted by Bomme et al. (2006) on the introduction of traditional Chinese medicinal plants to the European market, for example to compare possible quality differences of plants from experimental cultivation in Germany and corresponding imported plants from China. Detailed botanical species identification using DNA sequence and fingerprint ana­lyses was performed in the cultivation of 16 selected Chinese medicinal plant species. In addition, the harvesting technique and various active ingredients were determined. Through this controlled and documented cultivation, the relevant data for inclusion in the Ph.Eur. with regard to drug safety and general quality requirements could be collected (Bomme, 2001).
Before the introduction of Western medicine in the 16th century, TCM was the predominant form of medical care in China (Dong, 2013). Like TPM, TCM is based on thousands of years of medical practice and experience, from which its efficacy and effectiveness are derived. It is generally note­worthy that today traditional medical systems and modern medicine are increasingly converging, and it has become possible to determine the pharmacology as well as the mechanisms of action of numerous endemic
medicinal plants in TPM and TCM with the help of modern technology. With the under standing of life sciences, it was thus possible to make the traditional medical systems more understandable for modern medicine (Tu et al., 2002; Zhang and Li, 2011; Zhang et al., 2012; Dong, 2013; Haidan et al., 2016).
Quality assessment
Reliable quality control of medicinal plants, which have been collected and used world­wide for the pharmaceutical industry, has always been one of the main concerns of the WHO. Therefore, internationally accepted guidelines for assessing the quality of the in­dividual plant raw materials were estab­lished that can be used in each country to set up individual quality specifications of the medicinal drugs. These guidelines were de­veloped to promote the proper use and de­velopment of traditional medicine and, in this context, to ensure an objective descrip­tion of the quality of individual pharmaceut­ical products. According to the WHO (2000), the following specific objectives represent the most important guidelines:
-
harmonization of recognized and most
important concepts applied in Trad­itional Medicine;
elaboration of key issues in the develop-
ment of methods for research and evaluation in Traditional Medicine;
improving quality and importance of re-
search in the eld of Traditional Medi­cine; and
provision of appropriate evaluation
methods to facilitate regulatory devel­opment and registration in Traditional Medicine.
In order to ensure high quality, safety, and efficacy of medicinal plants, most of which come from wild collections, it is first import­ant to reliably identify the respective plant species. In this context, particular attention should be paid to the current botanical names (genus and species), but also syn­onyms and vernacular names, of the plant parts used for the individual preparations,
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as well as detailed instructions for agricul­tural production and collection conditions according to the good agricultural practice of the respective country. For quality control, different sources can be used, such as the in­dividual WHO quality control methods (WHO, 1998b) for medicinal drugs and the WHO monographs of selected medicinal plants (WHO, 1999).
When researching and evaluating herbal medicinal products for which there is no long history of use or that have not been researched at all, the “WHO research guide
­lines for the evaluation of safety and effi­cacy” should be regarded in detail. In the case of well-documented traditional uses of herbal medicinal products, the procedure can be simplified and it is mostly sufficient to follow a reduced number of procedures for conducting research and evaluating safety and efficacy according to the relevant WHO guidelines (WHO, 1993, 1998a).
Whereas in the past the term “quality” was described primarily as product quality (efficacy, composition, taste, shelf life, etc.), for some years we must also ensure that suitability value, ecological quality, social and sociocultural value, and nutritional con­venience quality are guaranteed.
Furthermore, particularly in the food sector including food supplements, there has been an enormous increase in labels with regard to aspects of fair trade, regional­ity, organic cultivation, and sustainability.
The individual quality of medicinal and aromatic plants offered on the market, as well as extracts and distillates isolated from them, is usually specified by different param­eters, using different physical, chemical, mi­crobial, and sensory test methods (described by the International Organization for Stand­ardization (ISO) and various national/inter­national pharmacopoeia). For the respective products (e.g., teas, drugs, spices, essential oils, and solvent extracts) usually also com­pany-internal specifications exist. In add­ition to the classical sum parameters such as density, refractive index, optical rotation as well as various titrimetrically determined key parameters, nowadays mainly chromato­graphic methods such as gas chromatog­raphy (GC) and high-performance liquid
chromatography (HPLC) are used for qualita­tive and quantitative analyses. In addition, vibrational spectroscopic methods are in­creasingly applied especially for rapid and mostly nondestructive characterization of plants and the extracts obtained from them. In most cases, it is possible to determine the botanical origin of the plant material (spe­cies, chemotype) under investigation and to detect reliably possible adulterations and im­purities.
Contaminants
The European Union has created a very com­plex set of regulations for medicinal prod­ucts, including in particular various regula­tions, guidance documents of the European Medicines Agency (EMA), monographs, pharmacopoeias, and other specific regula­tions of the national health authorities. All these legal provisions also apply to herbal medicinal products, which must therefore meet the same quality, safety, and efficacy requirements as all other medicinal prod­ucts (Steinhoff, 2019).
However, there are some specific things to consider due to the natural origin of herbal raw materials that mainly relate to their production and quality control. In add­ition, since medicinal plants can be exposed to various environmental influences, special legal requirements for their purity must be observed. The Ph.Eur. therefore mentions tests for pesticides, heavy metals, and mi­crobial impurities, as well as mycotoxins, in the general monographs for herbal drugs and herbal drug extracts under defined con­ditions. In addition to these general mono­graphs, individual monographs for a variety of herbal drugs and for some extracts may also contain individual rules for the absence or limitation of certain contaminants. The individual methods for determining these contaminants are also described in more de­tail in specific chapters of the Ph.Eur. The analytical methods used in quality control of herbal plants and the related products such as essential oils must generally be validated according to individual criteria that are also described in the Ph.Eur. in detail.
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Currently, the Ph.Eur. contains a list of about 70 plant protection products (PPPs) that are considered relevant in phytopharma­ceutical raw materials and an individual limit value is provided for each of these substances. Generally, with consistent application of the
Guideline on Good Agricultural and Collection Practice (GACP) for Starting Materials of Herbal Origin (EMA, 2006), the responsible health
authorities may permit waiving the cost­intensive pesticide analyses.
The list of PPPs is continuously updated de­pending on the individual approval status and adapted to the respective risk assessments made by the European Food Safety Authority (EFSA). Detailed information on the substances and their permitted maximum residue levels in the re­spective products can be found on the website of the European Commission (https://food.ec.
europa.eu/system/files/2021-12/pesticides_ ppp_app-proc_guide_phys-chem-ana_chem­subst.pdf, accessed 27 April 2023).
Use of plant protection products
In case of suspicion of other PPPs not listed, the Ph.Eur. refers to the EU Regulation No. 396/2005 on pesticide residues in food (European Parlia­ment and Council of the European Union, 2005). Provided that the individual batches as well as the standards of GACP (EMA, 2006) can be fully documented, the responsible health authorities will waive the usally mandatory testing of PPPs.
The respective analytical methods ap­plied to determine PPPs must also be docu­mented, according to the documents published by the European Commission. In practice, sev­eral methods may be used, but they must be de­rived from the official “S19 method of the Ger­man Research Society (DFG)”. According to guidance of the EMA’s Committee for Herbal Medicinal Products (HMPC) for preparation of the application dossier, it is sufficient to cite these official methods validated on different herbal matrices (EMA, 2016a).
Heavy metals
The general monograph entitled Herbal Drugs of the Ph.Eur. (Council of Europe, 2016) es-
tablishes the individual limits for cadmium (1.0 ppm), lead (5.0 ppm), and mercury (0.1 ppm). These limits are mandatory “unless otherwise specified in an individual mono­graph or unless otherwise justified and ap­proved.” Because certain herbal drugs may have naturally occurring higher levels of cer­tain heavy metals, there are several exemp­tions in the respective individual mono­graphs with higher limits for cadmium (e.g., tormentil and willow bark) and for lead (Ice­land moss and stinging nettle root). The Ph.Eur. also states that “herbal drugs used for the preparation of extracts may, in justi­fied cases, exceed the limits for heavy met­als specified in the monograph provided that the resulting extract meets the require­ments for heavy metals” (Council of Eur­ope, 2016).
In addition, the pharmacopoeia pre­sents modern techniques for the determin­ation of heavy metals in herbal drugs and herbal drug preparations, such as atomic ab­sorption spectrometry (AAS), inductively coupled plasma atomic emission spectrom­etry (ICP-AES), or inductively coupled plasma mass spectrometry (ICP-MS).
Polycyclic aromatic hydrocarbons
Medicinal plants may be contaminated with polyaromatic hydrocarbons (PAHs) taken up from contaminated soil or air. In addition, PAHs can also enter herbal drugs during dry­ing or roasting processes by direct application of open fire. For the food sector, Commission Regulation No. 1881/200619 (Commission of the European Communities, 2006) sets the following maximum levels for PAHs in food supplements, dried herbs, and dried spices (except cardamom and smoked capsicum): benzo(a)pyrene, 10.0 μg/kg; sum of the four PAHs (benzo(a)pyrene, benz(a)anthracene, benzo(b)fluoranthene, chrysene), 50.0 μg/kg. The currently available information on possible sources of PAH occurrence in herbal preparations, such as smoking, roasting, drying, or environmental effects, has been presented in a reflection paper published by the EMA’s HMPC (EMA, 2016b). This paper describes not only the effects of PAHs on huma n