Source 出处 · Neiwaishang Bianhuo Lun · Doses are not given here: they are set by a licensed practitioner for the individual.
Safety. Zhu Sha An Shen Wan is recorded in Neiwaishang Bianhuo Lun, the thirteenth-century work of Li Gao (Li Dongyuan), and it belongs to a category this library has not covered before: formulas that settle by weight rather than by nourishment or by clearing. The category name is not metaphorical. The chief ingredient is cinnabar, zhu sha, which is mercuric sulfide, and the rest of the formula is ordinary herbal material arranged around it: huang lian drains fire, sheng di huang and dang gui nourish and move the blood, zhi gan cao harmonises. The classical reading is that when heart fire is exuberant and the blood has nothing to hold it, the spirit has nothing to rest on, and the presentation is irritability, palpitations and sleeplessness.
This library will not repeat that as a claim. What it will do is state plainly what the chief ingredient is, because that is the part of the entry a reader is entitled to. Cinnabar is mercury sulfide. It is far less soluble in water than other mercury compounds, and the traditional processing, shui fei or levigation, grinding under water and collecting the finest fraction, removes part of the more soluble portion. Neither fact makes it inert. Mercury is a neurotoxicant and a nephrotoxicant, inorganic mercury accumulates in the kidney, and mercury poisoning from cinnabar-containing preparations is reported in the clinical literature. Heating cinnabar is a separate hazard, and heat is precisely what the traditional instruction avoids. This is also why the same caution recurs in this library wherever zhu sha appears: not in pregnancy, not for children, not for people with impaired kidney or liver function, and not as something taken over time. Several jurisdictions restrict or prohibit mercury compounds in medicines, and a product bought in one place may not be lawful in another.
The second caution is berberine. Huang lian is a berberine-containing herb; berberine inhibits CYP3A4, CYP2D6 and P-glycoprotein in human studies, which is a real question for anyone taking a medicine with a narrow therapeutic range, and it displaces bilirubin, which is why berberine-containing preparations are raised in connection with neonatal jaundice and G6PD deficiency. Sheng di huang and shu di huang are two different materials prepared from the same root and cannot be substituted for one another. Zhi gan cao carries the licorice caution: sustained daily intake can produce a mineralocorticoid-like state of sodium and water retention, potassium loss and raised blood pressure, and it is worse rather than better alongside diuretics, digoxin or corticosteroids.
The clinical point is the one that matters most and is easiest to skip. Irritability and sleeplessness have a differential diagnosis and it is not a short one: anxiety and depressive disorders, thyroid disease, obstructive sleep apnoea, restless legs, circadian disruption, caffeine, alcohol, and medicines including antidepressants, corticosteroids, beta-agonists and decongestants. There is a specific misclassification risk inside this picture. Agitation together with a reduced need for sleep is also how mania presents, and reading that as fire and pressing it down with a heavy sedating formula is an error in the opposite direction from the one intended. New agitation with disturbed sleep in an older person is delirium until proven otherwise, and delirium is a symptom of something. Agitation with chest pain, breathlessness, focal neurological signs or altered consciousness belongs to emergency care, not to a formula. Chronic insomnia is treated first with cognitive behavioural therapy for insomnia, which holds up better over time than any medicine this library could name. This library does not claim that Zhu Sha An Shen Wan calms the spirit, induces sleep, or treats insomnia, palpitations, anxiety or any named disease.
朱砂安神丸著录于十三世纪李杲（李东垣）《内外伤辨惑论》，属于本库此前未收的一类：**以「重」镇之，而不以补、不以清**。这个类别名称不是比喻。方中主药是**朱砂，即硫化汞**，其余是围绕它安排的寻常药味：黄连泻火，生地黄与当归养血和血，炙甘草调和。古典的读法是：心火亢盛、阴血不足，则神无所依，表现为心烦、心悸与不寐。
本库不会把这个读法当作主张来复述。本库要直说的是主药是什么 —— 这是读者有权知道的那一部分。**朱砂是硫化汞**。它在水中的溶解度远低于其他汞化合物，而传统炮制「**水飞**」（在水中研磨、收取极细粉）能去掉一部分可溶的部分。这两个事实都不使它变成惰性物质。**汞是神经毒物，也是肾毒性物质**，无机汞在肾内蓄积，而**与含朱砂制剂相关的汞中毒在临床文献中有病例报告**。**加热朱砂是另一重风险**，而传统做法恰恰是避免加热的 —— 这也是为什么本库凡遇朱砂必重述同一条：**孕期、儿童、肝肾功能受损者不用，也不作长期服用之物**。多个司法辖区对药品中的汞化合物有限制或禁止，一地在售的产品在另一地未必合法。
第二条提示是小檗碱。**黄连是含小檗碱的药味**；人体研究中**小檗碱抑制 CYP3A4、CYP2D6 与 P-糖蛋白**，对服用治疗窗窄的药物者是一个实在的相互作用问题；并且它**置换胆红素**，这正是含小檗碱制剂在新生儿黄疸与 G6PD 缺乏语境下被提出的原因。**生地黄与熟地黄是同一来源经不同加工的两味药，不可互代**。炙甘草带着甘草这条提示：**长期每日摄入可致类盐皮质激素综合征**（钠水潴留、失钾、升压），与利尿剂、地高辛或糖皮质激素合用更重而非更轻。
临床上的要点是最要紧、也最容易被跳过的那一条。**心烦与不寐有一张鉴别清单，而且不短**：焦虑与抑郁障碍、甲状腺疾病、阻塞性睡眠呼吸暂停、不安腿、昼夜节律紊乱、咖啡因、酒精，以及包括抗抑郁药、糖皮质激素、β 受体激动剂与减充血剂在内的药物。这副图景里还有一个具体的误判风险 —— **烦躁加上睡眠需求减少，也正躁狂的表现**；把那当作「火」而以重镇之品压下去，是朝与意图相反方向走的错误。**高龄者新出现的烦躁伴睡眠紊乱，在排除之前按谵妄处理**，而谵妄是某件事的症状。烦躁伴胸痛、呼吸困难、局灶神经体征或意识改变，属于急救，不属于方剂。慢性失眠的一线治疗是**失眠认知行为治疗（CBT-I）**，其效果的持久性优于本库能举出的任何药物；**本库不声称朱砂安神丸能安神、助眠，或治疗失眠、心悸、焦虑或任何具体疾病**。