REVIEW A Review of Traditional Remedies of Ciguatera Fish Poisoning in the Pacific Shilpa Kumar‐Roiné, 1,2,3 H. Taiana Darius, 4 Mariko Matsui, 1,2,3 Nicolas Fabre, 1 Mohamed Haddad, 1 Mireille Chinain, 4 Serge Pauillac 3 and Dominique Laurent 1 * 1 Université de Toulouse, UPS; UMR 152 (Laboratoire de Pharmacochimie des Substances Naturelles et Pharmacophores Redox), 118, rte de Narbonne, F‐31062 Toulouse cedex 9, France 2 Institut de Recherche pour le Développement; UMR‐152; F‐98848 Noumea, New Caledonia 3 Institut Pasteur de Nouvelle‐Calédonie, Laboratoire des Biotoxines, BP61, F‐98845 Noumea, New Caledonia 4 Institut Louis Malardé, Laboratoire des Micro‐algues Toxiques, BP30, F‐98713 Papeete, Tahiti, French Polynesia Ciguatera fish poisoning (CFP) is an illness caused by eating tropical coral fi sh contaminated with ciguatoxins (CTXs). The clinical management of patients with CFP is generally supportive and symptomatic in nature as no antidote exists. Of the many drugs prescribed, several have been claimed to be effi cient in small, uncontrolled studies, but the outcomes of treatments with these medicines are often contradictory. In New Caledonia, traditional remedies are commonly employed in the treatment of CFP and of the 90 plant species catalogued as useful in CFP, the most popular herbal remedy by far is a decoction prepared from the leaves of Heliotropium foertherianum Diane & Hilger (Boraginaceae). Other important plants used in the treatment of CFP include Euphorbia hirta L. (Euphorbiaceae) and Vitex L. sp. (Lamiaceae). This review focuses on the evidence for effi cacy of these species and pharmacological studies which support their use. Other plants used in CFP and the conventional treatment of CFP are also discussed briefly. Copyright © 2011 John Wiley & Sons, Ltd. Keywords: Ciguatera fish poisoning; conventional drugs; folk remedy; Heliotropium foertherianum; Euphorbia hirta; Vitex trifolia; pharmacological activities. INTRODUCTION Among the existing seafood‐borne poisonings, Ciguatera fish poisoning (CFP) is one of the most common forms of ichtyosarcotoxism in the Pacific, Indian and Caribbean regions (Friedman et al., 2008; Laurent et al., 2005; Lehane and Lewis, 2000; Lewis, 2001, 2006; Lewis et al., 2000). Though generally endemic to tropical and sub‐ tropical islands and coastal regions, CFP cases are now more and more reported in inland areas and in temperate countries due to international seafood exportation (Moulignier et al., 1995; Ng and Gregory, 2000; Sadovy, 1997), tourism (Bavastrelli et al., 2000; de Haro et al., 2003; Johnson and Jong, 1983) and global warming incidences (Raikhlin‐Eisenkraft and Bentur, 2002). Though largely under‐reported (Barbier and Diaz, 2003), today the frequency of CFP is, nonetheless, estimated to between 50000 to 100000 cases per year (Fleming et al., 2006). While the mortality due to CFP is low (typically <0.1%), this malady manifests itself by a variable combination of gastrointestinal, neurological and cardiovascular symptoms, differing from person to person in intensity and duration (Farstad and Chow, 2001; Lehane and Lewis, 2000; Pearn, 1994). This leads to an elevated morbidity and has important socio‐economic impacts on island populations (Glaziou and Legrand, 1994; Laurent et al., 2005; Lewis, 1992; Olsen, 1988). The marine neurotoxins named ciguatoxins (CTXs) are predominantly responsible for CFP. These toxins are produced by certain strains of benthic dinoflagellates of the genus Gambierdiscus (Bagnis et al., 1980; Yasumoto, 2005). The CTXs are transferred up to man via the marine food chain from the microalgae to herbivorous and then to carnivorous coral fishes. At the same time, these toxins undergo an oxidation process concomitant with an increase in toxicity up the chain (Lewis and Holmes, 1993). Gambierdiscus are also known to produce another class of neurotoxins called the maito- toxins (MTXs). Due to their poor ability to accumulate in fish flesh and low oral potency in mice, it is believed that MTXs do not play any significant role in human intoxication (Holmes et al., 1990; Yasumoto et al., 1976). All CTXs (molecular weight 941–1000 Da) possess a ladder‐shaped polyether backbone (Nicholson and Lewis, 2006; Yasumoto and Murata, 1993) consisting of highly oxygenated long chain alkyl compounds, in which most of the oxygen atoms occur as cyclic ether linkage that form 13–14 rings. These rings are fused into a mostly rigid, ladder‐like structure (Fig. 1). The structural differences between the congeners mainly arise from the terminal substituents at A and L‐ring. Heat‐resistant, fat‐soluble these polyheterocyclic toxins bind with high affinity to receptor site 5 of voltage‐sensitive sodium channels (VSSC) (Bidard et al., 1984; Lombet et al., 1987). The typical clinical features of CFP include acute gastroenteritis (nausea, vomiting, diarrhoea and ab- dominal pain) within 6–12 h of contaminated fish * Correspondence to: Dr Dominique Laurent, UMR152 IRD‐Université, Pharmacochimie des Substances Naturelles et Pharmacophores Redox, Chemin de l'Arahiri, PK 3.5, Arue BP529, 98713 Papeete, Tahiti, French Polynesia. E-mail: dominique.laurent@ird.fr PHYTOTHERAPY RESEARCH Phytother. Res. 25: 947–958 (2011) Published online 2 February 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ptr.3396 Copyright © 2011 John Wiley & Sons, Ltd. Received 02 June 2010 Revised 25 November 2010 Accepted 29 November 2010