Revised: 1 March 2005

Publications

Advice to doctors regarding patients who have taken Herbs Health Multistress capsules

Herbs Health Multistress capsules have been found to be adulterated with the corticosteroid betamethasone.

Background

In August 2004 Medsafe received a report of corticosteroid-induced side effects in a patient taking Herbs Health brand of Multistress capsules.

Testing has indicated that Herbs Health brand of Multistress contains betamethasone in a dose per capsule of approximately 1.6mg; this is equivalent to about 11mg of prednisone. However, it is possible that the amount of betamethasone in each individual capsule may vary considerably.

According to the Herbs Health Multistress package the recommended daily dose is 1 capsule per day or as directed by a health professional.

Although distribution of this product has now ceased, consumers may still have personal supplies of this product.

Because of the risks associated with chronic corticosteroid use, including the risk of adrenal suppression after stopping treatment, the Director-General of Health has issued a privileged statement on this issue. Consumers have been advised to continue taking the Herbs Health Multistress capsules until they have seen their doctor for review. Consumers are also advised to see their doctor if they have recently stopped taking Multistress.

Medsafe's Advice for Doctors:

1. For patients still taking Herbs Health brand of Multistress capsules, it is recommended that before stopping the capsules, an assessment should be made of each individual patient's risk for adrenal suppression:
   • Doctors should estimate each patient's total corticosteroid exposure by determining the patient's daily intake of the Multistress capsules (and any other steroid products), and the total duration of use. Patients who have been taking this product continuously for more than three weeks, or have been taking more than the recommended dose, are more likely to be at risk of adrenal suppression.
   • However, regardless of the estimated exposure to betamethasone, it is important that all patients are also examined for clinical signs of corticosteroid excess (e.g. plethoric moon-face, hypertension, easy bruising, purple abdominal striae, truncal obesity, hirsutism).
   • In situations of doubt, a short Synacthen test may be performed. This can be arranged with the local laboratory or endocrinology unit.

   If a patient has any of the risk factors identified above, the patient should be transferred to an equivalent dose of prednisone and the Herbs Health Multistress capsules should be stopped. The dose of prednisone should be gradually reduced to zero.
   
   If a patient has no risk factors for adrenal suppression, i.e. short duration of use and the absence of clinical signs of corticosteroid excess, the Multistress capsules can be stopped immediately. However, all patients should be advised to seek medical advice if they become unwell.

2. For patients who have recently stopped Multistress capsules after prolonged use, doctors should consider the potential for acute adrenal insufficiency, particularly in the presence of intercurrent illness or stress (including surgical procedures).
   • Doctors are reminded that the symptoms of acute adrenal insufficiency include malaise, muscle weakness, mental changes, muscle and joint pain, desquamation of the skin, dyspnoea, anorexia, nausea and vomiting, fever, hypoglycaemia, hypotension and dehydration.
   • If acute adrenal insufficiency is suspected, oral steroid replacement should be initiated. However, if a patient presents with signs of adrenal crisis, intravenous hydrocortisone should be administered and specialist advice should be sought immediately.

Please report any patients with corticosteroid excess from Herbs Health Multistress to the Medsafe Compliance Team on 04 4962176.